Trends in admissions to a child and adolescent neuropsychiatric inpatient unit in the 2007–2017 decade: how contemporary neuropsychiatry is changing in Northwestern Italy

Psychopathological problems of the teenagers are growing in Italy as well as in the rest of Western world [1, 2]. A number of reports indicate that teenagers display worldwide increasing rates of conduct problems and other externalizing disturbances, such as abuse of drugs or alcohol [3, 4], depression [5‐7], self-injurious or life-threatening behaviour [8]. Despite their incidence appear unchanged, also the prevalence of eating disorders is increasing in childhood and adolescence due to the long duration of illness [9].

The increase of adolescence psychopathology is crucial because it impairs the current social and relational functioning of the youth with possible consequences for his/her family adjustment, personality development, and academic career [2]. It may represent a concrete risk for long-lasting impairment of mental and also physical health in adulthood [3]. Internalizing and externalizing disorders in adolescence may often produce vicious circles with serious consequences. For instance, the reduction of sleep caused by internet addiction, substance abuse or alcohol can cause deterioration of social relations, conduct disorders, anxiety disorders or major depression [10], increasing also the suicidal ideation [11]. Research also supports the association between the abuse of cannabis or other "light" drugs and the development of psychotic disorders such as schizophrenia [12]. Moreover, the emotional and relational stress in adolescence may cause an increase in BMI which is related to the development of obesity in adulthood [13]. Last but not least, bullying is linked to abnormalities in personality development, to syndromes such as ADHD, to issues of affective-relational development [14], and it can be a cause of suicide [15].

The psychopathological expressions of the adolescents require specific therapeutic and management approaches which differ from those of early childhood psychiatry. Often the adolescents display physical characteristics which are similar to those of the adults and their psychopathological expressions are often characterized by self-harming or violent behaviours [2]. It is for this reason that despite the existence of effective therapies the use of coercive means is still a relevant problem in adolescents’ management [16].

Frequently, the increase in the use of emergency services to manage the adolescents with a mental disorder is also consequent to the sense of impotence of the family in containing the adolescent offspring. The contemporary changes in social and relational dynamics leading to a reduction of the role of authority in the familial relationships may have contributed to contemporary inability of parents in establishing relations of authority and hierarchy to contain the adolescent on the affective and regulatory side of the parenting relationship [17].

Current literature evidences that the parents are often thwarted to build and manage a relationship with their children also because personal problems [18]. Sometimes the family is also the bearer of psychopathology through physical or psychological abuse, neglect and parenting inability [19, 20]. Family conflicts, distortion of communication, and intra-family stress predispose to internet addiction [21]. A lack in parenting skills is also linked to somatization [22], eating disorders [17] and borderline personality [23].

Clinicians perception support rise in psychopathological diagnoses and inpatients admissions among adolescents [1]. At the best of our knowledge no study reports consistent data confirming this trend in the last decade. Data reporting about large cohort studies have been recently published to describe the rising of adolescents’ problems in the last decade [5‐7], nevertheless at the best of our knowledge no study reported the description of inpatient hospital treatments in the same period.

The present paper reports the picture of 11 years of observation of the inpatient admissions into a Neuropsychiatric Inpatient Service of an Italian paediatric hospital showing the trend of inpatient admissions with respect to the sex and age of admission, diagnosis and the length of inpatient stay. A better insight into this phenomenon may be useful for planning future organization of child and adolescent therapeutic services and also to adopt prevention strategies involving paediatricians, families and child and adolescent psychiatrists.

All the admissions to the Neuropsychiatric Inpatient Service of the Regina Margherita Paediatric Hospital (OIRM) in Turin over the eleven years 2007–2017 were examined. This service has a function of hub for the northwest region of Italy called “Piedmont and Valle D’Aosta” (PIVA), where it has been the only neuropsychiatric inpatient service through 2017. The region includes urban, industrial, and rural areas, and is home to about 4.5 million people.

The available data consisted in: diagnosis at discharge, patient age and gender at admission, number of admissions for each month of the year, and length of hospitalization.

Inclusion criteria: they were considered in the data elaboration 1. all the hospital admissions with a minimal duration of 2 days (48 h); 2. the admissions for which the neuropsychiatric diagnosis at admission was confirmed at discharge. The 48 h stay for admissions is the time-limit for the administration of the hospital for asking reimbursement to health authorities. Admissions with shorter duration are invalidated.

The results of these analyses indicate that major changes have occurred in the utilization of child neuropsychiatric inpatient services over the past 10 years at a large paediatric hospital that served as the only inpatient service for an area with about 4.5 million people. The data are not an effective indicator of the total incidence of child neuropsychiatric disorders in the community, but they represent valid indicator of those requiring inpatient treatment in a specialized psychiatric and neurologic (neuropsychiatric) service in this region due to disorders’ severity or to the inability of the territorial services to manage it in security.

Hospitalizations for psychiatric disorders have significantly increased, and, in parallel, those for neurological conditions have decreased. Patient age and length of stay in the hospital have significantly increased.

A necessary premise in the interpretation of these data is that care for paediatric neurologic and psychiatric disorders is managed in Italy as a unitary medical discipline called child neuropsychiatry. Clinicians are trained in both child neurologic and psychiatric disorders, and neuropsychiatric services, including inpatient, outpatient and day-hospital, are addressed to both categories of disorders.

The first evidence obtained by the data analysis is that the age at admission is progressively increasing from the beginning (2007) to the end (2017) of the observation in favour of adolescent admissions with respect to children admissions. This probably doesn’t mean that the new infant and children cohorts evidence a decrease in neuropsychiatric morbidity, since literature suggests a global increase of neurological and psychiatric disorders in infancy [26].

As a consequence of the priority rules for hospitalization the mean age of inpatient admissions has been probably influenced by the need to contain disruptive or self-damaging behaviours which are highly prevalent in the adolescent population [2].

The increasing proportion of adolescents’ inpatient admissions accounts for the significant decrease in the number of hospitalizations for younger children. Nevertheless, the number of hospitalized adolescents did not increase significantly. It is the increase in the length of hospitalization, rather than the number of adolescent hospitalizations, that accounted for the changes in inpatient service composition. Among the possible factors contributing to this increase in the length of hospitalization, there may be the severity of adolescent psychopathology and the difficulty to arrange for outpatient treatment [5].

The first hypothesis could be supported by the increasing rate of depression, self-damaging or life-threatening acts in adolescent general population evidenced by literature [5, 8]. In our sample the number of inpatient treatments for depression was significantly higher in the last period (2012–2017) with respect to the previous one (2007–2011). This may suggest that the depressive psychopathology is increasing in severity and it needs longer periods of treatment with respect to the past.

The second may be related to a possible inadequacy of the neuropsychiatric outpatient services, whose resources or organization may not be completely updated with respect to the containment of the rising severe adolescent psychopathology [27]. On the other hand, it may be also related to the family difficulty in the management of the adolescents expressing psychopathology. As mentioned in the introduction the changes in social and relational dynamics with a reduction of the role of authority in the familial relationships may have contributed to a difficulty of parents in establishing relations of authority and hierarchy [16] to contain the adolescent. Moreover, the family is often unprepared to face with the new forms of psychopathological expression of the adolescents, related or not to the new technologies. This may account for the clinicians’ difficulty in organizing secure hospital discharge into the origin family, and give reason of the recently underlined overuse of community treatment in Italian reality [28].

Another evidence is the progressive gender differentiation, with an increase of female inpatient admissions. This underlines that the depressed female adolescents progressively occupied the inpatient service, excluding the children and also male adolescents. Moreover, female adolescents generally display a higher need for long inpatient treatments. Based on the available data only speculation is possible. The largest diagnostic group in our sample is represented by the eating disorders that are prevalent in female gender (n = 216, 91%) and request long periods of inpatient treatment [9]. Nevertheless, the diagnosis of eating disorders do not significantly increase in the observed period. It is most possible that the quality of female depression is different from that of male subjects, thus requiring longer inpatient stay. Female sex is generally more prone to depression with respect to the male one [6, 7], and also it more frequently displays personality features which indicate a liability towards depressive disorders [29]. Nevertheless, the relative increase in frequency and length of depressive episodes in female adolescents in our sample may be also due also to social and environmental changes of contemporary society: the high prevalence and in some cases the increase of physical or sexual abuse [30], stalking and sexting [31], bullying [32], and prostitution [33]. Moreover, when the abuses are intra-familial or strictly related to the social environment they may represent also a severe obstacle in organizing the demission at home [2, 34].

The final evidence regards the reduction of inpatient treatments for neurological disorders with respect to psychiatric disorders. The authors don’t believe that this means an absolute reduction of neurologic disease, that literature estimates in growth [26]. It is very possible that the subjects with neurological problems have been admitted to paediatric wards because they are more easily manageable without a specific organization and structural containment. Moreover, it is possible that clinicians estimated dangerous to admit in the same ward agitated and disruptive adolescents with infants and young children affected with neurological disorders. Of fact, the evidence suggests a transition of the neuropsychiatric ward to a more strictly psychiatric function in the last few years.