Relational stressors as predictors for repeat aggressive and self-harming incidents in child and adolescent psychiatric inpatient settings

Abstract

This study examined whether relational stressors such as psychosocial stressors, the therapist's absence and a change of therapist are associated with repeat aggressive or self-harming incidents in child and adolescent psychiatric inpatient care. The study data were derived from critical incident reports and chart reviews of 107 inpatients. In multinomial regression analysis, patients with repeat aggressive or self-harming incidents were compared with patients with single incidents. Results suggested that a higher number of psychosocial stressors and a change of therapist, but not the therapist's absence are predictors for repeat aggressive and self-harming incidents. There was a high prevalence of therapist's absence during both, single and repeat, incidents. Repeat aggressive incidents were common in male children and adolescents with disruptive behavior disorders. Repeat self-harming incidents were common in adolescent females with trauma-related disorders. Patients with repeat aggressive or self-harming incidents had a higher number of abnormal intrafamilial relationships and acute life events than patients with single incidents. Interventions to reduce a change of therapist should in particular target children and adolescents with a higher number of psychosocial stressors and/or a known history of traumatic relational experiences. After a first incident, patients should have a psychosocial assessment to evaluate whether additional relational support is needed.

Nonsuicidal Self-Injury: Management on the Inpatient Psychiatric Unit

“…Similarly, adolescents with four or more psychosocial stressors or known familial trauma are highly likely to engage in repeated self-harm or aggression on the inpatient unit, especially when undergoing a change in therapist or when their usual therapist is not available (Ulke, Klein, & von Klitzing, 2014). This may be because of staffing turn-over, therapist vacation, or resident rotation in a teaching hospital.…”

“…Self-harming patients who are hospitalized often have a prolonged length of stay with a resultant increased likelihood of therapist turn-over. One practical suggestion offered by Ulke et al (2014) is to provide at-risk patients with a strong working relationship with two therapists thus minimizing the risk of changing therapists during their hospitalization. In an academic teaching setting, this would involve an active relationship with the unit attending psychiatrist or a staff PMHNP—roles not subject to frequent turn-over.…”