9.9 Treatment options and inpatient care

Choosing treatment and indications for inpatient care

Choosing the treatment

• Diagnosis identifies the evidence-based options, while formulation, severity, development, comorbidity and preference decide how they are used.

• Choose the intervention and the setting together, so the setting gives the care and safety needed with the least restriction.

• Similar behaviour can need different treatment: a child who cannot follow classroom language needs communication support, whereas coercive family interaction may call for parent training.

• Before counting a treatment as tried, check whether it was actually delivered and used.

• Match the work to developmental ability rather than a rigid age cut-off.

• Treat comorbidities in the order that best supports engagement and safety, because attention deficit hyperactivity disorder does not always rule out therapy for anxiety.

• Weigh family resources, culture, practical barriers and the young person's own priorities.

Formats of treatment

• NICE allows individual or group cognitive behavioural therapy for children and young people with social anxiety, because the advice against routine group therapy applies only to adults.

• Check the product licence as well as the guideline, since off-label prescribing can be appropriate with a clear rationale, discussion and monitoring.

Consent, assent and confidentiality

• Explain treatment at the child's level and invite them to take part, even when someone else gives legal consent.

• Competence or capacity applies to the particular decision, not to the young person as a whole.

• Explain confidentiality and its limits early, including sharing information for safety.

• Establish who holds parental responsibility, and involve the young person in deciding how far the family takes part.

• One parent's consent may be enough for ordinary treatment, but serious disagreement over significant treatment needs careful review and often legal advice.

Monitoring and treatment that is not working

• Review setting and intensity as needs change, because day or intensive community treatment may make admission unnecessary.

• When appointments are missed, ask about access, family circumstances, safeguarding and the young person's wishes, and adapt the plan rather than withdrawing care.

• Before calling a treatment a failure, review the diagnosis, comorbidity, dose or intensity, duration, adherence, adverse effects and changes at home or school.

Indications for admission

Admission is right when the safety, medical monitoring, treatment or assessment a child needs cannot be provided less restrictively.

• For eating disorders, NICE says no absolute body mass index or weight threshold decides admission, nobody is admitted solely for psychological treatment, and nobody is discharged solely because weight has improved.

• Psychiatric admission after self-harm follows its own indications, separate from the need for a general hospital bed.

• Limited evidence about routine admission does not show that admission is harmful or unnecessary for every young person.

Costs of admission

• Admission can disrupt attachments, schooling, friendships and ordinary autonomy, and some wards reinforce harmful behaviour.

• Set clear objectives, keep education and relationships going, support independence and review restrictions.

• Keep the stay as short as clinically appropriate, driven by active planning rather than a fixed duration.

Distance from home

• Distance limits family participation and coordination with school and community teams.

• A 2020 Children's Commissioner report found that just over a fifth of admitted children were more than 50 miles from home, and adult out-of-area figures do not apply to children.

• For an unavoidable out-of-area placement, name responsible practitioners in the home area and on the ward, and transfer closer to home when possible.

• NICE requires the placement, care plan and discharge plan to be reviewed at least every three months.

Legal authority for admission

Admission, treatment and restrictive arrangements may each need separate legal authority under the relevant jurisdiction's law.

Competence and refusal in England and Wales

• Assess Gillick competence below 16, and decision-specific capacity under the Mental Capacity Act at 16 and 17.

• Valid consent from a competent or capacitous young person can authorise informal admission without parental consent.

• Section 131(4) stops a parent's consent overriding a capacitous 16- or 17-year-old's refusal of informal psychiatric admission.

• When a competent under-16 refuses, the Code warns against relying on parental consent, so consider the Mental Health Act criteria and legal advice on court authority.

Scope of parental responsibility

• The English Mental Health Act Code uses the scope of parental responsibility to judge what a parent can authorise for a child who lacks competence.

• That judgement weighs age, maturity, invasiveness, resistance, previous wishes and the parent's ability to act in the child's interests.

• Parental consent alone does not authorise a deprivation of liberty for a 16- or 17-year-old who lacks capacity.

Detention and the courts

• The Mental Health Act has no minimum age, but its criteria and safeguards still apply.

• Courts can authorise treatment and override some refusals, and the Court of Protection can act for 16- and 17-year-olds within its powers.

• In an emergency, give necessary treatment under the applicable emergency authority while arranging urgent legal advice.

Jurisdictions

• The Mental Health Act 2025 amends the 1983 Act, but Royal Assent does not commence every provision.

• Section 52, commenced in April 2026, concerns review of notification duties for under-18 admissions and does not yet replace the existing rule.

What the ward must provide

• Section 131A requires an environment suitable for an under-18's age, informal or detained, and managers must consult appropriate expertise.

• Care includes trained and vetted staff, education, family involvement and monitoring of nutritional, cardiovascular and metabolic health.

• An adult ward is not automatically unlawful but must be exceptional and individually justified, with transfer planned.

• Never move a child merely because their behaviour affects other young patients.

• In England, notify the Care Quality Commission without delay once an under-18 has spent more than a continuous 48 hours on an adult psychiatric ward.

• Government policy opposes placing under-16s on adult wards.

• Review every restrictive intervention for necessity, proportionality, alternatives and environmental causes.

Discharge planning

• Start discharge planning at admission, with the young person, family and community team.

• For eating disorder admissions, NICE requires a review within one month of whether inpatient care is still needed.

• Plan return to education with a named school or college worker, and agree early warning signs and crisis contacts.

• Send the general practitioner discharge letter within 24 hours, and coordinate transition when the young person nears adult services.

Apply any shorter current service standard.

Evidence based interventions and care pathways

Evidence and formulation

• Evidence-based practice combines research evidence, clinical expertise and the young person's preferences with developmental and family assessment.

• Diagnosis identifies relevant treatments, and formulation explains how to apply them to the young person's needs and circumstances.

• Match setting and intensity to severity, safety and the intervention needed. High risk may need direct specialist access without first failing lower-intensity treatment.

First-line approaches by presentation

Repeated self-harm

• Dialectical behaviour therapy adapted for adolescents (DBT-A) has the strongest trial evidence for repeated self-harm with emotional dysregulation and emerging borderline features.

• DBT-A trains emotion-regulation and distress-tolerance skills.

• The National Institute for Health and Care Excellence (NICE) suggests considering DBT-A for these young people.

Delivering the pathway

• Child, parent and teacher reports often differ, so explore what happens in each setting rather than deciding one informant is wrong.

• Before changing a plan that is not working, review diagnosis, comorbidity, intensity, duration, access and adherence.

• Unreported adverse effects or practical barriers can resemble treatment resistance.

• Seek the young person's assent even when another person gives legal consent.