There has been a notable shift in paediatric admissions in Ireland. This has coincided with a widespread shortage of specialist placements for children facing behavioural, psychiatric, and child protection challenges, leading to an over-reliance on the placement of these children in hospitals.
Whilst paediatric social admissions (PSA) are not a novel concept, they have gained increased attention and significance in recent years. A paediatric social admission is one where a child is admitted to the hospital but not for a medical reason. They often have complex care needs secondary to their medical or disability diagnoses.
There is growing concern about the continued use of acute paediatric hospitals to care for children with complex disabilities, mental health, and child protection needs. The Ombudsman for Children’s Office suggested that in 2020, 18 children were admitted to paediatric hospitals in Ireland, and 10 children in 2021 for reasons beyond their medical needs.
We often face ethical, moral, and practical dilemmas when presented with the need for a paediatric social admission.
The social admission leads to the child’s social circumstances being conceptualised as a medical diagnosis. This results in a clinical response rather than one aimed at addressing the underlying cause. These cases are challenging. Let’s consider some of the risks and protective factors driving PSAs.
Identifying patient profiles
Children with Complex Disabilities
The Ombudsman for Children’s Office (OCO) shared the case of ‘Jack‘ in its 2020 report, providing a glimpse into the challenges faced by children with complex disability having limited access to specialist placements.
‘Jack’ was in a serious road traffic accident in another country when he was three years old. This left him with life-altering physical and intellectual injuries that required constant care and supervision. After his mother removed him from the foreign hospital, he was admitted to a hospital in Ireland for ongoing treatment. There, she disclosed that she could not meet Jack’s care needs at home.
Despite being deemed medically fit for discharge in August 2017, Jack lived in limbo between two hospitals for two and a half years due to delays in disability services and social services arranging a specialist placement for him.
This case underscores the struggles many children with complex disabilities encounter, often arriving at the paediatric ED in crisis when their families can no longer provide safe care at home.
Children with mental health needs
Many young people present to EDs for urgent assessment because of difficulty accessing specialist Child and Adolescent Mental Health Services (CAMHS), and a lack of appropriate psychiatric placements for children adds pressure to acute hospitals.
In 2019, 14% of all child and adolescent mental health patients were treated in approved adult hospitals.
A lack of out-of-hours crisis services means that the ED is the only place for children who experience a crisis to go, whether it relates to mental health, parenting, or other psychosocial stressors. Becasue paediatric emergency departments are accessible out-of-hours they become the de facto place of safety with access to immediate support.
Children with child protection needs
A review of the Irish police services’ use of Section 12 of the Child Care Act revealed poor interagency collaboration between police, social services and other organisations. Section 12 allows Irish police to enter a home without a warrant and remove a child to safety if there is a serious and immediate risk to the health or safety of the child. Public paediatric hospitals serve as the de-facto place of safety when this happens.
In 2014, 71% (397) of emergency removals of children by police occurred out-of-hours or at weekends. Although most incidents occurred at the family home, 5% occurred in a hospital or medical facility. In almost one-quarter of cases, the child was taken to the paediatric hospital as the initial designated place of safety because there was no foster or emergency accommodation available or when family members were unable or unwilling to help.
Navigating Paediatric Social Admissions
Conventional medical practice tends to view social concerns from a disease-centric perspective, neglecting to analyse the patient’s broader social context.
While medical expertise is needed from a diagnostic perspective, multidisciplinary perspectives should be sought to alleviate systemic issues impacting the discharge planning process, like inadequate community support or a safe discharge destination. We need to recognise that the child is located within a social structure that allows interaction between many contributing factors.
adapted from Andrew and Powell, 2015
The literature at a glance
It is unclear how many children like ‘Jack’ arrive at the door of paediatric hospitals without placement in appropriate disability, foster or mental health facilities. Paediatric social admissions, unlike social determinants of health (SDOH) and adverse childhood experiences (ACEs) is under-researched. We rely on ‘Jack’s’ case as an example of what can go wrong when state agencies fail to communicate with each other.
Admitting children with social problems to an acute hospital does not address the underlying social issues. The risk of displacement from their birth family when they are discharged increases for children admitted to the hospital for prolonged periods. A 2006 publication on newborns hospitalised for over six months found that parents struggled to maintain their child’s high care needs, and 23% of infants lost contact with their birth parents. The same happens with parents caring for acutely unwell children.
We don’t know how paediatric social admissions impact families. To prevent cases like ‘Jacks’ becoming a regular occurrence we must first define the issue of PSAs and understand their prevalence.
There is an intersection between between a child’s biological, psychological, and social environments. In a 2014 study, one-quarter of children were discharged to a non-home environment, such as residential care, foster care, or a medicalised placement, with child protection services involved with over one-third of prolonged hospital admissions.
Many social factors affect the management of paediatric cases in tertiary paediatric hospitals. They lead to professional, legal, and moral judgments about the child’s safety, risk levels and family coping abilities. This can be ethically challenging for clinicians managing cases without a standardised framework. These children are in the acute setting for protracted periods, from six months to years. During this time, they cannot access normal routines, education, or family life. Social admissions infringe on the rights of a child.
Professionals dealing with paediatric social admissions need to understand social determinants of health and adverse childhood events. More ACEs can lead to increased rates of common childhood illnesses.
Social factors such as the parent/child relationship, family structure and family resources also influence health. Just 20% of a person’s health and general well-being is related to access to care and the quality of services. The physical environment impacts the other 80%. How a child develops through their lifespan can be connected to factors such as education, family support, parental income, community safety and physical environment.
What can clinicians do?
Acknowledging the challenges associated with paediatric social admissions begins with documenting social issues and assessing their social history with the same level of detail as their medical history. To understand the individual, familial, hospital, and broader environmental impacts on why social admissions occur, ED practitioners must understand the risk and protective factors that contribute to paediatric social admissions in clinical decision-making. Risk factors should act as potential red flags and be assessed against protective factors.
To advocate for children and their families effectively, clinicians need an alternative theoretical framework to contextualise social issues. They also need skills in working with families in crisis and awareness of alternatives where social concerns exist.
Key messages
Consider social determinants of health and document these in a child’s clinical notes.
Children who experience extremely long hospitalisations have complex illnesses and comorbidities, with substantial risk for mortality. They have a higher rate of displacement rate from their families after discharge so a multidisciplinary approach is the best way of addressing their needs.
Appoint a lead professional at the start who is confident in dealing with complex cases and understands the principles of interagency work. They can assume a ‘coordinating role’.
It’s okay to ask for help when dealing with such complex cases.
References
Carter Anand, J. (2009) ‘Paediatric social admission to hospital’ International Pediatrics 24(20):56–64
Ombudsman for Children (2020). Jack’s Case: How the HSE and Tusla, Child and Family Agency, Provided for and Managed the Care of a Child with Profound Disabilities, Dublin: Author. (Available at: https://www.oco.ie/library/ombudsman-for-children-launches-report-on-jacks-case/)
Ombudsman for Children (2022). Jack’s Case: One Year On. Dublin: Author.
McNicholas, F. 2018. Child & adolescent emergency mental health crisis: a neglected cohort. Irish Medical Journal 111, pp. 841.
Rooney, L., Healy, D., & McNicholas, F. (2021). The Garda SÃochana and Child Mental Health: An Investigation of pathways to crisis mental health care. Department of Child and Adolescent Psychiatry, UCD & Policing Authority. Available at: https://www.policingauthority.ie/assets/uploads/documents/The_Garda_S%C3%ADoch%C3%A1na_and_Child_Mental_Health_FINAL.pdf
Shannon, G. (2017). An Audit of the exercise by An Garda SÃochána of the provisions of Section 12 of the Child Care Act 1991. Available at: https://www.drugsandalcohol.ie/27362/1/Audit%20of%20Section%2012%20Child%20Care%20Act% 201991.pdf
Health Service Executive (HSE), 2019. Delivering Specialist Mental Health Services 2019 Available at: https://www.hse.ie/eng/services/publications/mentalhealth/hse-mental-health-division-delivering-specialist-mental-health-services.pdf
Shannon, G. 2017. Audit of the exercise by An Garda SÃochána of the provisions of Section 12 of the Child Care Act 1991. Available at: https://www.drugsandalcohol.ie/27362/1/Audit%20of%20Section%2012%20Child%20Care%20Act%201991.pdf
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