Understanding caregivers’ perspectives on adolescent psychiatric admission and re-admission

ABSTRACT

Background:

In India, adolescent psychiatric hospitalization is influenced by clinical, familial, and systemic factors. Caregivers’ perspectives on admission decisions remain underexplored, particularly in low-resource settings.

Aim:

To explore the perceived need for inpatient admission or re-admission of adolescents with mental illness, as expressed by their primary caregivers.

Methods:

A qualitative descriptive study was conducted at a tertiary Child and Adolescent Psychiatric Centre in India. Twenty-six primary caregivers of adolescents (13–18 years) were interviewed using a validated semi-structured guide, and the data were analyzed thematically.

Results:

Thematic analysis identified several themes: factors influencing admission/re-admission, caregiver burden, family and home dynamics, social withdrawal and inadequate school support, adolescent coping strategies, and treatment-related challenges such as medication side effects and inadequate aftercare.

Conclusion:

Caregiver-perceived admission drivers are multifactorial. Strengthening community services, caregiver psychoeducation, and adolescent-friendly aftercare is essential to reduce preventable hospitalisations.

INTRODUCTION

Adolescent mental health is a global priority: the World Health Organization (WHO) estimates mental health conditions cause 16% of disease burden in youth aged 10–19, with suicide the fourth leading cause of death among 15–19-year-olds.[1] India, with over 243 million adolescents, faces a particularly acute challenge, with the National Mental Health Survey (2015–2016) reporting a 7.3% prevalence of mental disorders in this group.[2]

Hospitalization decisions are shaped by family dynamics, caregiver burden, and systemic barriers, not symptom severity alone. Caregivers as primary decision-makers offer unique insights into gaps in community care. Despite the growing literature on quantitative predictors of readmission, qualitative data on caregiver perspectives remain sparse, particularly from India. This study aimed to explore these perspectives to inform adolescent mental health service improvement.

MATERIALS AND METHODS

Study setting, design and participants

The study was conducted at the Child and Adolescent Psychiatric Centre (CAP), National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, a tertiary mental health care institution in India. The participants comprised 26 primary caregivers of adolescents aged 13–18 years who had been admitted to the CAP inpatient facility for either first-time or repeated psychiatric hospitalization. A qualitative descriptive design was adopted to gain in-depth insights into caregivers’ perspectives and decision-making regarding hospitalization. Primary caregivers, including parents or guardians, who had lived with the adolescent for at least six months and were involved in decisions related to admission were included in the study. Participants were recruited using convenience sampling.

Ethical considerations

The study was approved by the Institute Ethics Committee (Approval No -DO/BEH.Sc.Div./2024-25. Dated – 15/07/2024). Written informed consent was obtained from all participants prior to data collection. Confidentiality and anonymity were maintained throughout the research process. Audio files and transcripts were stored securely with access limited to the research team.

Data collection

In-depth semi-structured interviews lasting 30–45 minutes were conducted in a private setting within the CAP ward during October–November 2025, using an expert-validated interview guide covering reasons for admission, caregiving experiences, treatment history, and expectations from hospitalization. The gender of the interviewer was considered during the interview process. Participants were informed in advance about the gender of the interviewer and their verbal consent was obtained regarding their comfort with the interviewer. Interviews were conducted only after the participant expressed willingness and comfort to proceed.

Adolescents’ clinical data were extracted from medical records; caregiver demographics collected via structured proforma. Interviews were audio-recorded, transcribed verbatim in the participant’s preferred language, and cross-verified for accuracy.

Data analysis

Thematic analysis was conducted inductively using ATLAS.ti (2020–2024). Trustworthiness was ensured through prolonged engagement, peer debriefing, and member checking. Data saturation was reached at the 22^nd participant; four additional interviews confirmed saturation (n = 26).

RESULTS

Adolescents had a mean age of 15.09 years (SD = 1.38); 72.7% were male, and mean educational level was 9^th–10^th standard. Caregivers had a mean age of 47.95 years (SD = 3.73); 54.5% were female, 72.7% were graduates, 68.2% were urban residents; 54.5% were fathers and 45.5% were mothers.

Participant characteristics

OCD was the most frequent diagnosis (n = 13), followed by depression (n = 4); others included attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), and dissociative disorder. Most had 2–5 years of illness; 43% had insidious onset, and 12 had hospital stays exceeding one month.[3,4,5]

Five adolescents were re-admitted; 15 showed good medication adherence, and 7 had poor adherence consistent with non-adherence as a key readmission predictor.[6,7]

Sample characterization using the Nursing Care Dependency Level (NCDL), Children’s Global Assessment Scale (CGAS), and Global Assessment Scale (GAS) (for description only, not as outcomes) indicated most adolescents required supervision (40–70% dependency), with moderate-to-severe functional impairment (CGAS 41–50).

Thematic analysis

Six major themes and subthemes emerged from the interviews [Table 1]:

Table 1.

Themes and sub-themes derived from the primary caregivers’ interviews

MAJOR THEMES	SUB THEMES
Factors Influencing Admission and Readmission Decisions	Worsening of Symptoms
	Unmanageable Behaviour at Home
	Ineffectiveness of Previous Treatment
	Decline in Academic Performance
	Risk of harm
	Co-morbidities
	Incomplete recovery
The Burden of Care: Emotional and Psychological Challenges	Feelings of helplessness and stress
	Guilt and self-doubt
	Burden of care
The Ripple Effect on Family and Home Dynamics	Family relationships
	Siblings and extended family dynamics
Learning and social engagement	Learning and Social Engagement
	Social Withdrawal and Isolation
	School support and challenges
Caregivers’ perspective on adolescent’s coping strategies	Coping mechanisms observed
	Adolescents’ resistance to help
Challenges and concerns in mental health treatment	Medication side effects
	Hospitalization as a last option

Theme 1: Factors influencing admission and re-admission

Subtheme 1.1: Worsening of Psychiatric Symptoms- Caregivers reported an escalation in symptoms such as irritability, aggression, hallucinations, and suicidal ideation, which became unmanageable at home. A caregiver stated:

“She stopped sleeping for days, would scream suddenly, and said someone is watching her. We couldn’t handle it anymore.” (Participant 4).

Subtheme 1.2: Ineffectiveness of Previous Treatment- Several caregivers described poor response to outpatient care and medications, with relapses after initial improvement.

“He was on medicines but skipped doses often. We tried to manage at home, but it got worse again.” (Participant 11).

Subtheme 1.3: Academic Decline and School Refusal- Caregivers expressed concern about their child’s deteriorating academic performance, inability to focus, and refusal to attend school.

“She would sit with her books but not write a single word. Then she started refusing to go to school altogether.” (Participant 15).

Subtheme 1.4: Risk of Harm to Self or Others- Admission was sought when adolescents displayed violent behaviour or suicidal thoughts.

“He broke the glass window in a rage. I was scared for his younger sister.” (Participant 9).

Subtheme 1.5: Comorbid Conditions and Incomplete Recovery- Multiple diagnoses and unresolved past episodes were cited as contributing factors.

Theme 2: The burden of care

Subtheme 2.1: Emotional Distress and Fatigue - Many caregivers reported feeling helpless, anxious, and physically exhausted due to the constant supervision required.

“It’s like walking on eggshells every day. We don’t know what will trigger her next.” (Participant 2).

Subtheme 2.2: Disruption of Family Routine and Well-being- The caregiving burden often extended to neglect of personal health, professional commitments, and strained spousal relationships.

“We take turns sleeping at night. My job is at risk, but I can’t leave him alone.” (Participant 19).

Theme 3: Family and home dynamics

Subtheme 3.1: Parental Conflict and Disagreement- Disagreements regarding treatment decisions and caregiving responsibilities were common.

“My husband thinks he will grow out of it. I think he needs help. We keep arguing about this.” (Participant 7).

Subtheme 3.2: Sibling Impact- Siblings were often left neglected or emotionally affected by the adolescent’s behavior.

“My younger son is scared of his sister. He hides in his room when she shouts.” (Participant 20).

Theme 4: Social support and engagement

Subtheme 4.1: Withdrawal from Peer Group and School- Caregivers reported a progressive withdrawal from social and academic life.

“He stopped going out to play. He doesn’t speak to his friends anymore.” (Participant 13).

Subtheme 4.2: Stigma and Lack of Understanding in School- Some schools were reluctant to support or accommodate the child’s needs.

“The school said they couldn’t handle him and asked us not to send him until he’s better.” (Participant 16).

Theme 5: Adolescent coping strategies

Subtheme 5.1: Avoidance and Withdrawal- Many adolescents exhibited prolonged social isolation, sleeping through the day or avoiding communication.

Subtheme 5.2: Resistance to Treatment- Non-adherence to medication, skipping therapy, and denial of illness were commonly reported.

“He threw away his tablets. He doesn’t believe anything is wrong.” (Participant 21).

Theme 6: Challenges in mental health treatment

Subtheme 6.1: Concerns about Medication Side Effects- Parents frequently expressed concern about long-term use of psychotropics.

“She’s gaining weight rapidly. I’m afraid the medicines are too strong.” (Participant 17).

Subtheme 6.2: Inadequate Aftercare and Continuity- Caregivers found it difficult to access consistent follow-up, especially those from outstation areas.

“We live far away and cannot come for reviews every two weeks. Sometimes the doctor is also changed.” (Participant 22).

DISCUSSION

The findings reveal a complex interplay of clinical, familial, and systemic factors driving caregiver decisions to seek adolescent psychiatric admission. Worsening symptoms, unmanageable behavior, academic decline, risk of harm, and treatment non-adherence were the most commonly cited reasons for admission, consistent with prior literature.[5,6,8,9,10] Caregiver burden was prominent: 50% reported significant stress and helplessness, aligning with Blader et al.[11] who identified parental stress as a key admission driver. Family dysfunction and sibling distress were also frequently reported,[12] whereas social withdrawal (59%) and poor school support (41%) reflected broader systemic gaps.[9] Adolescent treatment resistance and medication side effects further complicated management and increased re-admission risk.[7,13] These findings underscore that caregivers resort to hospitalization as a last option when outpatient and community services prove inadequate a pattern documented across settings.[4,14] Notably, this study contributes an Indian context-specific perspective largely absent from existing literature, where caregiver-level factors and systemic barriers unique to low- and middle-income countries are underexplored.

Limitations

This study was conducted in a single tertiary care setting with a small sample size using convenience sampling, limiting generalizability. Findings reflect only the perspectives of caregivers, without triangulation from adolescents or clinicians. Self-report bias and social desirability may have influenced responses.

CONCLUSION

Caregivers’ decisions for adolescent psychiatric admission are driven by a complex interplay of clinical severity, caregiver burden, family disruption, and systemic barriers. Hospitalization is typically sought as a last resort when community-based care has failed. These findings highlight the critical need to strengthen outpatient services, provide structured caregiver psychoeducation, integrate mental health support in schools, and develop adolescent-friendly aftercare pathways to reduce preventable admissions and improve long-term outcomes.

Declaration regarding the use of generative AI

The authors attest that there was no use of generative artificial intelligence (AI) technology in the generation of text, figures, or other informational content of this manuscript.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.