No doubt I will make myself unpopular (again) with some of our psychiatric colleagues by speaking out in this way about the use of locked psychiatric units in the treatment of children with eating disorders, but we have had several recent transfers to Kartini Clinic instigated by parents who disagreed with their treatment team’s insistence that their child be admitted to their regional locked psychiatric unit.  The parents visited the unit and were scared by what they saw.

There is a long history in this country of children with anorexia nervosa being sent to locked inpatient pediatric/adolescent psychiatric units for treatment, and it is still being done in some major metropolitan areas.  Incredibly some of the largest, most sophisticated cities have some of the weakest systems in place for treatment of children with eating disorders.

Now, I must first point out that there are good reasons for psychiatric units to be locked.  This goes down poorly with a lay audience, of course, especially when we are talking about children, but the reasons for locking a unit have to do with safety, not with “imprisonment”.  And while it is good to be safe and keep young patients from harm, I still think it is the wrong approach for almost all children with eating disorders.

Why?

  1. By their very nature such units exclude parents.  Even very good psychiatric units do not typically invite the parents to freely visit their own child or be a part of therapeutic interventions of any kind. Rarely are there any parent or sibling support groups.  Sometimes the treatment team will have never even met the parents.  I think it is fair to say this model is the very opposite of family-based treatment, whether a la Lock and Le Grange or a la Kartini.

  1. Rarely are psychiatric staff trained in medical stabilization.  This may mean they are uncomfortable with kids who require tube feeding on their unit; they may not understand how to manage refeeding syndrome or do orthostatic vitals; they may not make complete weight restoration a priority (!) and may follow, in fact, the long tradition of not “forcing” kids to eat, in the interest of “collaboration”.

  1. The overwhelming majority of these units are not exclusively for children with eating disorders, but rather include children and adolescents with such disparate diagnoses as schizophrenia and other psychotic disorders, various highly behaviorally disruptive disorders, drug using behaviors, even early criminal behaviors. Can you imagine a frightened 12 year old with restricting anorexia in such a milieu?

Are there some kids who could benefit from a psychiatric unit?  Yes, there are.  They would be: those with severe psychiatric disorders requiring separation from their families, those needing complex psych medication interventions, and those with severe self-harm behaviors and/or suicidal thoughts and actions.

This may be an old tradition in some places still, but in my opinion it is a bad one.  Times have changed.  Families are not the problem they were once viewed as being, instead evidence shows they are at the core of the solution.