Mental health is complex in neurotypical people. Throw in autism, intellectual and developmental disabilities and the complexities grow. Then there is the random use of drugs to try to address mental health and behavioral issues. Drugs can either mitigate problems, make them more severe, or add new issues or problems.
With autistic people that have trouble communicating how they feel, you have to do a lot of body language interpretation. Mental health problems can arise when intelligence is greater than the ability to communicate.
Self-injurious behavior is a form of self-medication. This really hit home to me by an experience with my son. My son had never engaged in self-injurious behavior up until he was 17. At 17, we found ourselves with him coming out of a state mental hospital on acute hospital dosage of drugs and entering into a residential school. He was not happy with either. The drugs were causing many side effects including hand tremors, freezing, running his hands through his hair, constipation, and facial muscle control problems where smiles looked like a grimace. He was not his generally “happy go lucky self”. I say that kind of in jest but compared to other autistic people, Thomas has a general good ability to roll with things and not have what is going to happen spelled out. He started hitting himself in the face and the upper thighs, deep bruises. Dropping the dosage down eventually brought him back to his normal self, but the self-injurious behavior continued (though not the deep bruises). He learned that it got attention and uses it to escape unwanted tasks. This is an example where you have the side effects of a drug morphed into a new problem.
Another similar thing can happen with wetting the bed and drugs making bladder control a problem or being so drowsy as to being unaware. Drug(s) can be changed to try to stop this side effect but the person can learn that the bed wetting gets a certain reaction they find rewarding even if they do not like the wet feeling.
Injurious to Self or Others
Autistic people can go through the same mental health issues as other people. Self-injurious behavior can be severe depression, suicidal, refusing to eat, property destruction that can cause self-injury like breaking windows and in the case of being a child and/or having intellectual disabilities along with running away. Running away can be dangerous to a person if they do not understand how to navigate traffic and can be victims of strangers. There other conditions which may not be intentionally self-injurious that can lead to the need of a mental health hold like Pica, the eating of non-food items, often toys.
Injurious to others is aggressive behavior that injures others, assault. This is usually targeted at parents, teachers and caregivers. Mothers usually get most of it. This can include assault against strangers. Depending on the intelligence of the autistic person, reaction of the stranger, and the decisions of first responders, the assault can either lead to a mental hold or arrest.
Though the codes/laws go by different number designations in different states, the description of “injurious to self or other” is the reason for forced hospitalization for mental health reasons and is consistent across the states. In California, mental health holds go by 5150 (3 day hold), 5250 (court ordered 2 week hold), 5270 (court ordered hold can be an indeterminate length).
Police, psychiatric doctors, state/county mental health departments, or courts can order a mental health hold. Courts will almost always follow the advice of a psychiatrist or state/county mental health department and not act on their own.
Most mental holds start by having to call 911. Depending on the situation, it can be better to call your county’s mental health unit. It is a good telephone number to have before a situation occurs. Police vary in their ability to deal with mental health issues.
Police are very reluctant to call for a mental hold because it is not a criminal offense and the paper work involved. They will transport or usually call for an ambulance. If transported to a hospital by police, the person will be handcuffed and transported in the back seat of the police car. In an ambulance, the person is transported on a gurney strapped down. Depending on agitation, they may receive a sedative. With a child and what the conditions are, it may be possible for someone else to transport them with the police following behind. Regardless a person must be admitted through the hospital’s emergency room ambulance entry. This can only be done by the police or by an ambulance. This bypasses the emergency room waiting room.
Some counties have special mental health units that will go out into the field. There can also be police specially trained to deal with mental health issues. It is possible children with Autism could be taken to a mental health office or mental health facility. With my son, we have experienced just about all different types of intake situations. Not that this will happen to you, but twice, we have been in locked down emergency mental psychiatric wings of a hospital. We are talking about prisoners with shackled arms and legs, orange jumpsuits, and about 5 armed sheriffs leading them to a cell. Picture me and my 12 year old son sitting in a padded rectangle room with a concrete “bed” in the middle and a small window in a steel door. Actually the movies are realistic about these units.
At admittance, the situation will be evaluated by county mental health workers as to whether the situation warrants a hold and then to find a psychiatric bed in either a child or adult unit. The evaluation will include an interview with a parent usually the mother. If the reason for a hold is “injurious to self or others” do not be surprised if questions are asked as to whether or not there is any spousal abuse happening in the family, especially if this is the first time. Fathers can expect some suspicion from the mental health investigator as to whether they are abusive.
Finding the psychiatric bed is what can take the longest or not happen at all. If a bed is found, the person put on hold will be transported by ambulance to the psychiatric unit. If a bed is not found a person can either be released with an action plan (explained later), or continued to be held at the hospital.
What Hospitals Do Not Want You to Know
Ok, here is what hospitals do not want you to know. If you believe that a person will continue to be a danger to themselves or others and the action plan is not adequate to address this, then you can refuse to accept to take back the person. This is regardless of whether or not a psychiatric bed is found. The person must have come through the emergency room.
The person is eventually moved out of the emergency room and into a hospital bed. The hospital will continue to try to find a psychiatric bed.
My son from a very early age had been admitted to just about every children’s psychiatric unit in our area and one of them he was admitted to twice. At a local hospital psychiatric unit the stay is usually about a week, maybe two. If a longer psychiatric hold is necessary, a person will be moved to a larger psychiatric facility. In California, the large psychiatric hospital of “last resort’ is College Hospital in Longbeach and Cerritos. The one in Cerritos has five wings, one of which is for children. My son has been in it twice.
Mental Health Hold Story
A story to put this all together. In one week my son busted out 4 bus windows, escaped from one of those windows, broke a bone in his ankle, sent both him and his 1 on 1 to the emergency room, assaulted four other people, and traveled 45 miles away from home and was gone for 7.5 hours. It wasn’t until that Monday, when he started melting down going to school and asked for the police that we called the police and asked for a hold. He was handcuffed and taken to the emergency room of a hospital. An emergency doctor already knew him as well as a prior attempt by him to escape the hospital with about 8 people trying to hold him down and sedate him. He was sedated. Local children’s psychiatric hospitals were called. All refused to take Thomas. He had been to all of them before. He was moved out of the emergency room after about a week and into a long term hospital care bed where he was confined to his room with a 1 on 1 for three months. He received schooling at the hospital. The hospital continued to try to find a bed for Thomas in a psychiatric ward.
We refused to take him back as there was no plan other than hospitalization or a group home placement. The hospital administration was unhappy with us, but was more unhappy with the state’s social services because they could not find an appropriate placement for him. College Hospital at the time would not take Thomas because they had a medically fragile patient in their children's ward and having already had prior experience with Thomas, knew about his behaviors. Eventually, the medical fragile patient was released and College Hospital agreed to take Thomas.
Our local hospital couldn’t wait to get him out and had an ambulance drive him down the state of California in no time. Thomas was at College Hospital for about 2 plus months before a suitable placement was found for him. It was probably good that College Hospital waited for the fragile patient to be released because Thomas had some behaviors and had to be put in a temporary seclusion room where he promptly ripped out the dry wall of one wall.
Courts and Mental Health Holds Longer than 3 Days
Because Thomas’ mental hold in the hospitals went for so long, we went through all the steps of the various hold lengths. A 3 day hold requires no court appearance. After the 3 day hold, a court approved hold is required for an additional 2 week hold. Longer holds require probate court oversight because the individual who is put on hold loses their rights temporarily to make decisions for themselves. The court appoints a public defender to represent the person on hold during hearings. Your state’s social service will have both a lawyer and a social worker at the hearing. There may also be a representative from the hospital. While parents are not required to appear in court, it does help the court to hear from the parents. Generally, these proceedings are not contiguous and more procedural. The court generally grants a 2 week hold. The longer or indefinite mental health holds follow the same above procedures but there will be periodic reports and court hearings.
Action plans are made with social service workers or county mental health workers. An action plan is a plan of action that outlines how a person with mental health issues, injurious behavior to self and others or elopement will be treated. The plan should have an assessment of the issues. The action can be a release back to the home with support services and how they will be provided, or on the other end a group home situation. If one of the behaviors is injurious to other people, there must be a plan that takes into account the safety of others involved. This can be hard because aggression to others is usually targeted at family members.