Psychiatric hospital treatment of children and adolescents in New South Wales, Australia: 12-year trends

Abstract

Background
It is preferable that children and adolescents requiring in-patient care for mental health problems are managed in age-appropriate facilities. To achieve this, nine specialist Child and Adolescent Mental Health Services (CAMHS) in-patient units have been commissioned in New South Wales (NSW) since 2002.

Aims
To examine trends in child and adolescent in-patient admissions since the opening of these CAMHS units.

Method
Analysis of separation data for under 18-year-olds to CAMHS, adult mental health and paediatric units for the period 2002 to 2013 in NSW, comparing districts with and without specialist CAMHS units.

Results
Separations from CAMHS, adult and paediatric units rose with time, but there was no interaction between time and health district type (with/without CAMHS unit). Five of eight health districts experienced increased separations of under 18-year-olds from adult units in the year of opening a CAMHS unit. Separations from related paediatric units increased in three of seven health districts.

Conclusions
Opening CAMHS units may be followed by a temporary increase in separations of young people from adult units, but it does not influence the flow of patients to non-CAMHS facilities in the longer term.

Declaration of interest
None.

Copyright and usage
© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Full text

Psychiatric hospital treatment of children and
adolescents in New South Wales, Australia:
12-year trends
Philip Hazell, Titia Sprague and Joanne Sharpe
Background
It is preferable that children and adolescents requiring in-patient
care for mental health problems are managed in age-
appropriate facilities. To achieve this, nine specialist Child and
Adolescent Mental Health Services (CAMHS) in-patient units
have been commissioned in New South Wales (NSW) since 2002.
Aims
To examine trends in child and adolescent in-patient
admissions since the opening of these CAMHS units.
Method
Analysis of separation data for under 18-year-olds to CAMHS,
adult mental health and paediatric units for the period 2002 to
2013 in NSW, comparing districts with and without specialist
CAMHS units.
Results
Separations from CAMHS, adult and paediatric units rose
with time, but there was no interaction between time and
health district type (with/without CAMHS unit). Five of eight health
districts experienced increased separations of under
18-year-olds from adult units in the year of opening a CAMHS unit.
Separations from related paediatric units increased in three of
seven health districts.
Conclusions
Opening CAMHS units may be followed by a temporary
increase in separations of young people from adult units, but it
does not influence the flow of patients to non-CAMHS facilities
in the longer term.
Declaration of interest
None.
Copyright and usage
© The Royal College of Psychiatrists 2016. This is an open
access article distributed under the terms of the Creative
Commons Non-Commercial, No Derivatives (CC BY-NC-ND)
licence.
In the UK, revision to the Mental Health Act applying to children
and young people admitted to hospital for the treatment of mental
illness requires that hospital managers ensure that ‘the patient’ s
environment in the hospital is suitable having regard to his age
(subject to his needs)’.
1
Chapter 36 of the Code of Practice to the
Mental Health Act specifies that children and adolescents receiv-
ing in-patient care for mental illness should have: appropriate
physical facilities; staff with the right training, skills and knowl-
edge to understand and address their needs as children and young
people; a hospital routine that will allow their personal, social and
educational development to continue as normally as possible; and
equal access to educational opportunities as their peers, in so far
as that is consistent with their ability to make use of them,
considering their mental state.
1
There is an expectation that under
18-year-olds will be managed by Child and Adolescent Mental
Health Services (CAMHS) specialists, or at least that their treating
team will have access to CAMHS expertise. Admission of a person
under 16 years of age to an adult unit with persons aged 18 years
and older is now considered a reportable ‘serious untoward
incident’. Psychiatrists surveyed in the UK reported adverse
experiences of young people admitted to adult mental health
units such as witnessing a completed suicide and being assaulted
by older patients.
2
Admission of young people with mental health
problems to paediatric wards raised concern about safety to the
patient owing to the limited capacity to restrict access to the
means for self-harm, and risks posed by the patient to others
owing to the limited capacity to manage dysregulated behaviour.
2
Strategies to improve access to specialist CAMHS care include
the development of intensive community treatment services
(ICTS),
3–5
more efficient use of specialist CAMHS in-patient
resources through greater bed occupancy and shorter lengths of
stay, and the establishment of new CAMHS in-patient units.
6
In
New South Wales (NSW), the hospitalisation of children and
adolescents for mental health reasons is governed by NSW Health
Policy PD2011_016, ‘Children and Adolescents with Mental
Health Problems Requiring Inpatient Care’. The policy states
that children under 12 years requiring acute mental health in-
patient care should be admitted to a paediatric ward or to a
combined child and adolescent mental health facility within a
children’s hospital, whereas the preferred option for children aged
12–17 years is admission to a specialist CAMHS unit. Children
aged 12–15 years for whom a specialist CAMHS bed is not
available may also be admitted to paediatric wards. Other patients
under 18 years for whom a specialist CAMHS bed is not available
may be admitted to adult acute mental health wards. No lower age
limit is specified for such admissions, but the expectation is that
the admission should be brief. Since 2002, nine acute CAMHS
specialist in-patient units have been opened in NSW. The purpose
of this paper is to report trends in the mental health hospitalisa-
tion of under 18-year-olds in local health districts (LHDs) which
have or have not opened a CAMHS unit, with specific attention to
the pattern of separations from non-specialist CAMHS facilities.
Method
We extracted from the NSW state-wide mental health database
separation data for under 18-year-olds from specialist CAMHS in-
patient units, acute adult mental health in-patient units and
paediatric medical units for the period January 2002 to December
2013. Data were extracted in June 2014. There were a total of
22 724 separations from 17 different LHDs in the overall data-set.
One LHD was part of an interstate network and these data
(n=109) were excluded. Data from the paediatric unit of one LHD
were missing; however, the number of missing cases is assumed to
1
BJPsych Open (2016)
2, 1–5. doi: 10.1192/bjpo.bp.115.000794

be negligible based on number of separations from other units
within the same LHD. In total, separation data from 17 NSW
LHDs (n=22 615) were available for analysis.
Separations from each type of unit (CAMHS, adult, paediatric)
were plotted by LHD in 12 monthly blocks by calendar year to
determine the pattern over time. LHDs were classified according
to whether they had ever contained a CAMHS unit or not: LHDs
1–7 inclusive contained a CAMHS, adult and paediatric unit,
whereas LHDs 9–17 inclusive did not have CAMHS units
(supplemental Table DS1). There were some exceptions to this
pattern of classification, including LHD 10 which was analysed as
though it contained a CAMHS unit because of its close
geographical proximity to a CAMHS unit within a neighbouring
LHD. Additionally, two CAMHS units were established in
children’s hospitals which together constitute an LHD in its own
right (LHD 8). Adult and paediatric units in LHDs 3, 9 and 10
host overflow from these two CAMHS units. Hence, LHDs 1
through 10 inclusive were classified as Ever-CAMHS, whereas
LHDs 11 through 17 inclusive were classified as Never-CAMHS.
Sensitivity analyses were run excluding data from LHDs 3, 9 and
10 to ensure that their inclusion as Ever-CAMHS had not biased
the results.
Data were analysed using IBM SPSS Statistics Version 22.0.
Analyses conducted included descriptive statistics, and two-way
repeated measures analysis of variance with sphericity assumed.
For descriptive analyses, we noted the date of opening for each
new CAMHS specialist in-patient unit (n=9) and examined the
flow of under 18-year-olds to adult acute mental health units and
paediatric units in the respective LHD in the years prior to and
following the opening of each unit.
For inferential statistics, admissions per calendar year for
individual LHDs formed the units of analysis. For admissions to
adult units and paediatric units, we computed linear, quadratic
and cubic trend to determine the difference in slope between
Never-CAMHS and Ever-CAMHS LHDs.
NSW Health did not require ethics approval for the project as
it comprised an audit of de-identified data released to a unit of
the NSW Ministry of Health for the purpose of health service
management and evaluation.
Results
Total separations for under 18-year-olds from mental health
facilities increased by 258% from 759 in 2002 to 2723 in 2013.
For comparison, from 2002 to 2013 the population in NSW aged
0–19 years increased by 4.5% from 1.78 million to 1.86 million.
7
The proportion of those admitted to adult acute mental health
units declined in that period from 71% to 43% but there was a net
increase in the number of under 18-year-olds admitted to adult
acute mental health units (Fig. 1). The proportion of those
admitted to paediatric medical units for mental health reasons
declined slightly in that period from 22% to 20% but there was a
net increase in the number of patients admitted to paediatric
medical units for mental health reasons (Fig. 1). In the Ever-
CAMHS LHDs, the proportion of those admitted to adult acute
mental health units declined in the same period from 66% to 35%,
whereas the proportion of those admitted to paediatric units
declined from 25% to 18%.
For the period 2002–2013, the mean age of patients admitted
to CAMHS units was lower than that for children and adolescents
admitted to adult acute mental health units (14.60 years (range
4–17) v. 15.82 years (range 11–17)) and higher than those
admitted to paediatric medical units for mental health reasons
(13.01 years (range 0–17)). Males made up 30% of paediatric
admissions, 33% of CAMHS admissions, and 41% of admissions
to adult acute mental health units. Average length of stay was 6.99
days for adult units, 7.38 days for paediatric medical units and
19.03 days for CAMHS units. Frequencies of diagnoses for the
overall sample are presented in supplemental Table DS2.
Nine specialist acute CAMHS in-patient units opened during
the period January 2002 to December 2013, ranging in capacity
from 6 to 12 beds. To investigate trends in child and adolescent
admissions to adult mental health units in NSW, we conducted a
two-way repeated measures analysis of variance with year and
LHD type as independent variables. Mauchly’s test indicated that
the assumption of sphericity had been violated. However, we
elected to report results with sphericity assumed, as the Mauchly’s
test can be oversensitive. There was a significant effect of time on
admissions to adult units, F(11,154)=2.20, P=0.02. There was no
significant time by LHD-type interaction, F(11,154)=0.55, P=0.87.
Figure 2 depicts the admissions to adult units for Ever-CAMHS
0
200
400
600
800
1000
1200
1400
2002 2003* 2004* 2005* 2006 2007 2008* 2009* 2010 2011* 2012* 2013*
Total under 18 years admissions
Year
CAMHS
Adult
Paediatric
Fig. 1 Total admissions (n=22 615) for under 18-year-olds to in-patient CAMHS, adult acute mental health and paediatric medical units for mental
health reasons in NSW from 2002 to 2013. Data are comprised of 16 local heal th districts (LHDs). Asterisks indicate the year in which a new CAMHS
unit opened.
Hazell et al
2

(n=9) and Never-CAMHS (n=7) LHDs. The difference in slope for
LHD type was not found to be statistically significant for linear,
F(1,14)=0, P=0.99, quadratic, F(1,14)=2.40, P=0.14, or cubic trends,
F(1,14)=4.53, P=0.05. Analyses were rerun suppressing data from
LHDs 3, 9 and 10 as they were classified as Ever-CAMHS on the
assumption they accepted overflow admissions from a neighbouring
LHD. Re-analysis did not alter the findings.
We repeated the analyses for admissions to paediatric medical
units. Again, Mauchly’s test indicated that the assumption of
sphericity had been violated, but we elected to report results with
sphericity assumed. Whereas mean admissions appear somewhat
higher overall in LHDs hosting a CAMHS unit than those without,
the difference did not reach statistical significance, F(1,13)=3.85,
P=0.07. The main effect of time was statistically significant,
F(11,143)=2.31, P=0.01, but the time by LHD-type interaction was
non-significant, F(11,143)=0.26, P=0.99 (supplemental Fig. DS1).
The difference in slope for LHD type was not found to be
statistically significant for linear, F(1,13)=0.05, P=83, quadratic,
F(1,13)=0.01, P=0.94, or cubic trends, F(1,13)=0.33, P=0.58. Analyses
were rerun suppressing data from LHDs 3, 9 and 10 as they were
classified as Ever-CAMHS on the assumption they accepted overflow
admissions from a neighbouring LHD. Re-analysis did not alter the
findings.
In the year of opening for CAMHS units (data analysable for
eight LHDs), the number of admissions to related LHD acute
adult mental health in-patient units compared with the previous
year increased by more than 5% for five units, remained stable for
two units and decreased by more than 5% for one unit (Table 1).
The increases observed exceeded the statewide trend in admissions
(see supplemental Table DS3). In the year subsequent to opening,
admissions to adult units (data analysable for seven LHDs)
increased by more than 5% for four units and decreased for three
units. The net effect on admission to adult acute mental health
units in the year of opening of a CAMHS unit and 1 year either
side (data analysable for seven LHDs) was an increase from 348 to
484 admissions followed by a fall to 401 admissions. It took a
further year (data analysable for six LHDs) for admissions to fall
back to baseline levels.
Admissions of children and adolescents to related LHD
paediatric medical units for mental health reasons (data analysable
for seven LHDs) increased greater than 5% in three units,
remained stable for one unit and decreased for three units in the
year of opening (Table 2). The increases observed exceeded the
statewide trend in admissions (supplemental Table DS4). In the
year subsequent to opening, admissions increased for three units,
remained stable for two units and decreased for two units. The net
effect on admission to paediatric medical units in the year of
opening of a CAMHS unit and 1 year either side (data analysable
for six LHDs) was a decline from 143 to 130 to 111.
Table 1 Number of under 18-year-olds admissions to adult
acute mental health in-patient units pre- and post-opening of a
CAMHS unit within the surrounding LHD
LHD
2 years
prior
1 year
prior
Year of
opening
1 year
post
2 years
post
1 –– 35 34 23
2 159 263 251 ––
392828371
↓
55
4251712
↓
15
↓
14
5384858
↑
29
↓
29
6423061
↑
62
↑
–
7 153 133 209
↑
154
↑
120
8a 51 32 41
↑
50
↑
67
8b 39 6 20
↑
20
↑
32
Note: Arrows depict an increase or decrease of >5% relative to the year prior to
CAMHS unit opening.
0
10
20
30
40
50
60
70
80
90
100
2002 2003* 2004* 2005* 2006 2007 2008* 2009* 2010 2011* 2012*
2013*
Mean admissions
Year
Ever CAMHS
Never CAMHS
Fig. 2 Mean yearly under 18-year-olds admissions per LHD to adult acute in-patient units by LHD type. Asterisks indicate the year in which a new
CAMHS unit opened.
Table 2 Number of child and adolescent admissions to
paediatric medical units pre- and post-opening o f a CAMHS un it
within the surrounding LHD
LHD
2 years
prior
1 year
prior
Year of
opening
1 year
post
2 years
post
1 –– – 27 28
2 79 100 114
↑
––
3432
↓
33
4475651
↓
22
↓
22
5415342
↓
35
↓
24
6768
↑
14
↑
–
7 –– 85 142 162
8a – 10 10 11
↑
11
8b 32 15 17
↑
26
↑
17
Note: Arrows depict an increase or decrease of >5% relative to the year prior to
CAMHS unit opening.
3
Psychiatric hospital treatment of children and adolescents in NSW

Discussion
The net number of patients under 18 years receiving hospital care
for mental health problems in NSW has risen considerably since
2002. Bed capacity in specialist CAMHS in-patients units in NSW
has increased, but even in 2013 more patients under the age of 18
received hospital care for a mental health problem outside the
CAMHS units than within them. The NSW rate of 43% of child
and adolescent mental health admissions going to adult units in
2013 compares with 8% across the UK National Health Service in
2008–2009,
1
19% in Norway in 1993,
8
and 31% in Ireland in
2011.
6
Comparable data from other countries are difficult to find,
although it is clear from descriptive studies that under 18-year-
olds are admitted to adult psychiatric units in, for example, Italy,
9
New Zealand
10
and Sweden.
11
Psychiatrists surveyed in the UK
reported a number of factors contributing to the difficulty in
accessing specialist CAMHS beds including increase in referrals,
decreased capacity of social care, decreased in-patient capacity,
decreased community CAMHS capacity, changes in commission-
ing arrangements, change in clinical need or complexity of
patients and decreased capacity for intensive outreach.
2
In five of eight instances, the opening of a specialist CAMHS
in-patient unit in NSW was followed by an unintended short-term
increase in the number of under 18-year-olds admitted to acute
adult mental health in-patient units in the district. An increase in
admissions to paediatric medical units was only seen in three of
seven districts, and the net effect was a decline in admissions to
paediatrics. It may be expected that admission rates to CAMHS
units would be low in the first calendar year of opening because
generally they will not be open for a full 12 months. In addition, it
takes the units months, and sometimes years, to recruit sufficient
staff; hence beds may not be fully occupied for some time after
opening. However, these factors per se do not explain the
temporary surge in admissions to adult units. We speculate that
anticipation of the opening of a specialist CAMHS in-patient unit
raises the expectation that in-patient care will form part of the
overall mental health care of under 18-year-olds with mental
illness and that demand for such service outstrips the capacity of
the CAMHS unit, leading to overflow admissions to adult units. It
is possible that a similar phenomenon has occurred in the UK.
Although the rates of child and adolescent admissions to adult
units have been favourable compared with NSW, there was in
2013 an upswing in the number of under 18-year-olds treated on
adult mental health wards.
12
The upswing occurred despite an
increase in specialist CAMHS bed numbers from 1128 in 2006 to
1264 in January 2014, and an improvement in bed occupancy.
12
Our analyses found no significant difference between trends
over time in admissions of children and adolescents to adult
mental health units between LHDs with Ever-CAMHS and Never-
CAMHS. Similarly, our analyses found no significant difference
between trends over time in mental health admissions to
paediatric medical units between LHDs with Ever-CAMHS and
Never-CAMHS. These findings argue against the opening of
CAMHS units having a long-term favourable or unfavourable
impact on admissions to non-CAMHS facilities. Although a
smaller proportion of all juvenile mental health admissions were
to non-specialist CAMHS in 2013 than in 2002, the absolute
number of admissions to non-specialist CAMHS has risen steadily
over the period. In response to a similar situation in the UK, the
Royal College of Psychiatrists has made recommendations to
reduce the burden on in-patient services of providing mental
health care to children and adolescents.
2
The first is to address
pressures on other government sectors such as education and
social welfare that have ‘knock on ’ effects on health services.
Second is the strengthening of community CAMHS services.
Third is the establishment of ICTS to facilitate early discharge
from hospital and planned intensive home treatments. Fourth is
financial incentives to encourage community and in-patient
CAMHS to work more effectively in partnership. Fifth is the
establishment of partnership and safeguarding boards to promote
interagency cooperation to mitigate against delayed discharges
and delayed admissions. Sixth is investment in crisis services for
vulnerable and high‐risk children and young people. It is possible
that the establishment of ICTS would be a more effective strategy
for reducing admissions of under 18-year-olds to acute adult
mental health in-patient services than creating more specialist
CAMHS beds, as it removes the expectation of admission to
hospital. Between the year prior and the year following the
establishment of an ICTS for adolescents in the Lothian region
of Scotland, the number of under 18-year-olds admitted to adult
mental health wards dropped from 20 to 7.
3
Median length of stay
in the region’s specialist adolescent mental health unit also
decreased, from 40 to 30 days. However, reviews of the relative
effectiveness of ICTS conclude that there are insufficient quality
data to determine whether this form of treatment is a viable
alternative to in-patient care.
2,4,5
Limitations
A study of this nature is dependent on the accuracy of the data
that are entered into the state-wide database. During the period of
interest there have been adjustments to the boundaries of health
districts, meaning that possible admissions to some adult and
paediatric medical units have been attributed to different LHDs at
different times between 2002 and 2013. To our knowledge, this
would have only affected a few small hospitals such that the
overall error in a sample of this size would be minimal. We have
not made adjustments for the few (n=68) patients whose episode
of care involved treatment both by an acute adult mental health
unit and a CAMHS unit, as the number is too small to impact on
the findings and conclusions. The decision of where to locate
CAMHS in-patient units in NSW was strategic. As such, factors
that influenced the location of the units such as perceived unmet
need may also have influenced the flow of admissions. If those
factors are specific to NSW, the findings of the study may not
generalise to other jurisdictions.
Implications of the study
These data indicate that in the first year or so after opening a
specialist CAMHS in-patient unit it is likely that child and
adolescent admissions to acute adult mental health units in the
surrounding region will increase. Directors of mental health
services need to be aware of this phenomenon and communicate
it to service providers and consumers, otherwise newly opened
specialist CAMHS in-patient units may be perceived to have failed
in their purpose. In NSW at least, the opening of CAMHS units
has not influenced the longer term flow of patients to non-
CAMHS facilities. CAMHS units appear to fulfil an additional as
opposed to replacement role in the care pathway for young people
with mental illness. The reduction of admissions of under 18-year-
olds to adult units requires strategies in addition to an increase in
specialist CAMHS bed capacity.
Philip Hazell, BMedSc, MBChB, PhD, FRANZCP, Cert Accred Child Psychiatry (RANZCP),
Conjoint Professor of Child and Adolescent Psychiatry, The University of Sydney,
Sydney, NSW, Australia; Titia Sprague, MBBS, MPH, MBA, FRANZCP, Cert Accred Child
Psychiatry (RANZCP), NSW Ministry of Health, Sydney, NSW, Australia; Joanne Sharpe,
BAppSc (OT), NSW Ministry of Health, Sydney, NSW, Australia
Correspondence: Philip Hazell, Discipline of Psychiatry, Sydney Medical School,
Rivendell, Thomas Walker Hospital, Hospital Road, Concord West, NSW 2138, Australia.
Email: philip.hazell@sswahs.nsw.gov.au
First received 23 Apr 2015, final revision 8 Oct 2015, accepted 25 Nov 2015
Hazell et al
4

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