Issues in acute care and extended treatment converge in the biopsychosocial model. A comprehensive model ensures that all essential areas of functioning are addressed.⁵,⁶ The biological view recognizes that a youngster may be vulnerable to certain kinds of disorders because of inherited characteristics or physical trauma or illness. Common heritable features include difficult temperament, learning disabilities, attention deficit and hyperactivity, certain developmental delays and disorders, psychosis, mood disorders and emotional reactivity, and substance abuse. Patients who have a family history of mood disorder or substance abuse are not necessarily destined to manifest such disorders, but they may be more genetically predisposed than other youngsters to developing such problems under certain environmental circumstances. A patient with a schizoaffective disorder can be made aware of the potential for problems with thinking and affect management, begin to take responsibility for monitoring changes in thinking and moods, and develop plans for minimizing the effects of the illness. Similarly, patients with learning disabilities and developmental disorders, for example, Asperger syndrome, can be helped to understand and accept their vulnerabilities and limitations, and then develop coping and compensatory mechanisms for managing their problems. This approach allows patients to feel less guilt and shame and to acquire a greater sense of control over their lives. Another aspect of the biological view is a respect for the role of psychotropic medication in providing relief from the severity and frequency of many symptoms and allowing for greater accessibility to treatment. Child and adolescent patients are capable of learning that medications do not usually “cure” problems, but, rather, aid in helping patients manage their symptoms and vulnerabilities.

The psychological point of view recognizes that young people have a personal history and that some events and experiences may have affected them profoundly. Various forms of trauma including emotional, physical, and sexual abuse are common, and they vary in their intensity and the degree they have been repeated. Many youngsters have experienced developmental difficulties and academic failures. Others have become unhappy with their bodies and aspects of their personalities. Lack of peer acceptance and rejection in romantic relationships have an enormous impact on adolescents and are often the precipitants for self-destructive behavior. Divorce and the deaths of loved ones contribute to a young person’s vulnerability to self-esteem problems and the development of attitudes of futility and despair. One’s interpretation of experiences is also central to the development of psychiatric problems and also to their amelioration. How patients view themselves, the life events they have experienced, and their relationships with others are critical to a diagnostic understanding and treatment of the symptoms and problems they present.

Finally, the youngster’s development occurs in a familial, cultural, and social context. This context may contribute resources and strengths along with challenges and difficulties. In addition, youngsters are likely to return to their environments, and even if they do not will certainly continue to be strongly influenced by their family and social origins. Achieving an understanding of the family system, including the extended family and multigenerational family patterns and events, is important in developing a sense of the context of the patient’s problems. It is also crucial to engage the family members as participants in the diagnostic process and in accepting a sense of responsibility for successful outcome. A common challenge is how to create such a feeling of participation without stimulating an atmosphere of guilt and blame about past events and patterns of behavior. Creating defensiveness or self-hatred in parents invariably leads to self-protection rather than increased collaboration in problem solving.

The choice of level of care depends on the goals of intervention. Does the child or adolescent need the shorter intervention of acute care, which aims at immediate safety, or the longer intervention of residential care, which aims at solving long-standing problems that have resisted outpatient and brief hospital treatment?

Acute care inpatient units tend to be general units, with multiple diagnostic categories treated on one unit. Residential inpatient units are likely to be more specialized, with specific units for eating disorders, trauma, post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), and personality disorders. Residential care has a long and rich history with much written and clinical experience to guide the design of residential hospitals and other forms of residential care. The case is less clear with acute inpatient care. No extensive clinical literature provides a model of how acute care units are best designed for the patients they serve. The acute care unit as it now exists has evolved in response to rapidly decreasing third-party payments. Over the last decade lengths of stay have fallen from an average of 12 days to an average of 4 days.⁷ The changes have been driven by financial realities and not by clinical knowledge or design. The section on acute care will focus on how the authors think such a unit should best be designed and run in order to attain maximum treatment benefit.

What constitutes a clinically well-designed acute care unit for children and adolescents? What treatment modalities should be included? What staff training constitutes the minimal level of competence for nursing staff on an acute care unit? What clinical phenomena or psychiatric disorders are best treated in acute care settings? What is the acceptable milieu on an acute care unit? In answering these questions, consideration needs to be given to one of the primary difficulties of acute care units: patients with all diagnoses are admitted to acute care unit. A typical acute care unit may have at any one time suicidal patients, sexual offenders, trauma victims, substance abusers, people with personality disorders, those with eating disorders, psychotic patients, aggressive and assaultive children, or foster care children needing placement—all on a single 15-bed or 20-bed unit. That multiple diagnoses are served on one unit require particular attention to admission criteria, staff skills training, and unit design and milieu.

A well-designed acute inpatient program at minimum provides the following: patient safety; diagnostic understanding of a case; family intervention; sustained contact with outpatient providers if appropriate; medication management; and treatment modalities aimed toward helping patients understand, on a developmentally appropriate level, the various contributions to their admission. Equally important, the acute care unit provides discharge planning such that the patient moves smoothly from the unit to the next appropriate level of care.

The acute care admission is considered part of a continuum of care: a brief inpatient intervention can serve to diagnose a new-onset illness, clarify the diagnosis in a patient who has decompensated, redirect the course of a patient’s care, or stabilize a patient to prepare the return to outpatient care or to move on to longer-term residential treatment. Ionescu and Ruedrich proposed such a model for adults.⁸ The unit is likely to serve best those mental illnesses that respond to medication and brief psychosocial interventions. The acute care unit will be less effective in those illnesses that require extensive psychosocial or behavioral interventions, for example, eating disorders, personality disorders, OCDs, and substance use disorders.