Use of seclusion and restraint in children and adolescents. Council on Scientific Affairs, American Medical Association

Restraint in paediatrics: A delicate balance

Patient restraint in health care is currently under intense review. There are two disparate groups that should be considered. First, infants and young children are commonly restrained while undergoing simple medical procedures such as venepuncture or immunisation, and this practice may be better framed as 'hugging' not 'holding'. Second, there is a distinct but significant group of children and adolescents with serious psychiatric or organic illness with behavioural disturbances necessitating restraint, who are the primary focus of this paper. Nevertheless, the balance between restraining any young person in health care and causing preventable harm is delicate: any form of child restraint, whether physical, chemical or seclusion, merits ethical reflection and should be undertaken judiciously. All clinicians should prioritise the dignity and privacy of the young person while weighing the vulnerability of this cohort of patients.

Restraint and the Question of Validity

Restraint as an intervention in the management of acute mental distress has a long history that predates the existence of psychiatry. However, it remains a source of controversy with an ongoing debate as to its role. This article critically explores what to date has seemingly been only implicit in the debate surrounding the role of restraint: how should the concept of validity be interpreted when applied to restraint as an intervention? The practice of restraint in mental health is critically examined using two post-positivist constructions of validity, the pragmatic and the psychopolitical, by means of a critical examination of the literature. The current literature provides only weak support for the pragmatic validity of restraint as an intervention and no support to date for its psychopolitical validity. Judgements regarding the validity of any intervention that is coercive must include reference to the psychopolitical dimensions of both practice and policy.

The relationship between seclusion and restraint use and childhood abuse among psychiatric inpatients

Seclusion and restraint (S/R) is a controversial topic in the field of psychiatry, due in part to the high rates of childhood physical and sexual abuse found among psychiatric inpatients. The trauma-informed care perspective suggests that the use of S/R with previously abused inpatients may result in retraumatization due to mental associations between childhood trauma and the experience during S/R. Thus, though one would expect to see efforts on the part of inpatient psychiatric facilities to limit S/R of previously abused inpatients, research suggests that trauma victims may be more likely to experience S/R. The current study sought to clarify this possibility by examining whether presence or absence and chronicity of childhood sexual and physical abuse differed among three groups of adult inpatients (N = 622) residing at a mid-Western state psychiatric hospital. These groups are empirically derived on the basis of dramatic differences in the patterning of their exposure to S/R over the course of hospitalization. Results of Chi-square and Kruskal-Wallis tests suggest that the classes did not significantly differ in presence or absence and chronicity of childhood sexual or physical abuse when male and female inpatients were analyzed separately. However, among the class of inpatients who experienced the most instances of S/R, 70% of the members have histories of childhood abuse. Implications for inpatients, clinicians, and policy makers are discussed.

Errorless Compliance Training to Reduce Extreme Conduct Problems and Intrusive Control Strategies in Home and School Settings

The present case study involved intervention for a 7-year-old boy with a history of extreme aggression and noncompliance. Given the severity of his behavioral difficulties, his parents used highly coercive consequences, including physical restraint, which significantly compromised the parent—child relationship. The authors used errorless compliance training, a success-based, noncoercive intervention strategy to assist the mother in obtaining child cooperation without need for physical intervention. Although initial intervention attempts were ineffective because of the poor quality of the mother—child bond, systematic adjustments to the intervention eventually produced substantial improvements in child compliance in the home. Concurrent use of the intervention in the child’s classroom led to meaningful gains in classroom compliance. Anecdotal reports from the mother after intervention suggested widespread improvements in prosocial behavior and the parent—child relationship. The study findings provided support for use of errorless compliance training as a home and school-based alternative to interventions that require punitive or coercive consequences to suppress severe antisocial behavior.

Children's mental health emergencies--part 2: emergency department evaluation and treatment of children with mental health disorders

OBJECTIVE

The emergency physician should be familiar with the wide spectrum of pediatric mental health emergencies because they are commonly encountered in emergency medical practice.

METHODS

A review of the literature was done in order to develop an approach for dealing with children presenting with mental health disorders in the emergency department (ED).

RESULTS

Children' mental health emergencies have a wide spectrum from behavioral disturbances to major depression. An approach to the issues involved in caring for these patients is discussed which acknowledges the essential role of the emergency physician and the importance of integrating ED care with multidisciplinary services.

CONCLUSIONS

The actions and directions taken in the ED are a crucial part of the child's long-term care and treatment. The ED evaluation and management of pediatric mental health emergencies may vary depending on the complaint and includes differentiation from organic etiologies, medical stabilization, and occasionally in depth psychosocial interview.

Learning from tragedy: a survey of child and adolescent restraint fatalities

OBJECTIVE

This descriptive study examines 45 child and adolescent fatalities related to restraints in residential (institutional) placements in the United States from 1993 to 2003.

METHOD

The study team used common Internet search engines as its primary case discovery strategy to determine the frequency and the nature of the fatalities, as well as the characteristics of the children and the adolescents involved.

RESULTS

Male children and adolescents were over-represented in the study sample. Thirty-eight of the fatalities occurred during or after a physical restraint, and 7 fatalities occurred during the use of mechanical restraints. Twenty-eight of the deaths occurred in a prone restraint. In 25 of the fatalities, asphyxia was the cause of death.

CONCLUSION

In the 23 cases in this study where information is available, none of the child behaviors or conditions that prompted the restraint would meet the standard of danger to self or others: the commonly accepted criteria for the use of a restraint. The study points to deficiencies in fatality reporting, recommends reporting fatalities to established state child fatality review boards, and reinforces that restraints be governed by strict protocol and monitoring. The study also urges caution to policymakers in substituting or changing restraint procedures based on the incomplete data reported in this study.

Characterizing aggressive and noncompliant behaviors in a children's psychiatric inpatient setting

This study was conducted to evaluate aggression and noncompliance among child psychiatric inpatients in relation to demographic, clinical, and hospitalization characteristics, including the use of restraints and seclusion. Eighty six children (10.8+/-2.4 years old, 67% male) consecutively admitted to an inpatient psychiatric unit were rated weekly using the Modified Overt Aggression Scale (MOAS) and the Disruptive Behavior Rating Scale (DBRS) between November 1, 2002 and June 30, 2003. Moderate to high correlations were observed between the four types of aggression (verbal, and physical against self, others, or objects) and noncompliant behavior. In hierarchical regression analyses, only mental retardation emerged as a significant predictor of aggression and noncompliance. Aggression and noncompliance were associated with different characteristics of inpatient treatment. Aggressive behavior was significantly associated with the use of restraints and seclusion, and noncompliant behavior with length of hospitalization and number of psychiatric medications at time of discharge. Modifying milieu interventions for youths with mental retardation, and adapting behavioral interventions empirically proven to target noncompliance may be effective loci for reducing aggression in child psychiatric inpatient units.

Restraint use for psychiatric patients in the pediatric emergency department

BACKGROUND

Restraint of children and adolescents with psychiatric problems has generated controversy. Restraint may be defined as methods used to restrict movement or normal access to one's body. Published data to guide restraint practice are limited.

OBJECTIVE

To examine frequency of restraint use and patient demographics and chief complaints associated with restraint use in our pediatric emergency department.

METHODS

We retrospectively reviewed the pediatric emergency department records of children (age <18 years) who underwent emergency psychiatric evaluation in an urban general hospital from January 2001 to December 2002. Factors associated with restraint use were determined using multivariate logistic regression.

RESULTS

Data were available for 1125 (82%) of 1371 patients who underwent emergency psychiatric evaluation; 76 (6.8%) of 1125 patients were restrained: 37 physical, 19 with medication, and 20 both. Study patients were mean age 13.1 years, 50% girls, 54% blacks, 19% Latinos, and 18% whites; 80% had public insurance. Boys were restrained more often than girls (8.7% vs. 5.2%, P = 0.02). Age, insurance, and race were not associated with restraint use. Patients admitted for inpatient psychiatric care were restrained more frequently than those discharged home (9.9% vs. 3.9%, P < 0.001). In multivariate logistic regression, sex was not associated with restraint use. Restraint use was associated with chief complaints of visual hallucinations (odds ratio, 5.29), out-of-control behavior (odds ratio, 4.65), hyperactivity (odds ratio, 2.26), and admission to a psychiatric facility (odds ratio, 2.40).

CONCLUSIONS

Approximately 1 in 15 children undergoing psychiatric evaluation were restrained. This is the first study to elucidate correlates of restraint practice in the pediatric emergency department. Further studies examining indications for restraint and comparing methods of restraint are needed.

The use of seclusion in emergency medicine

INTRODUCTION

Little is known about the use of seclusion in emergency departments (EDs) across the country. The primary purpose of this study was to determine the extent of the use of seclusion in EDs in the United States. The secondary purpose was to describe seclusion use in EDs.

METHODS

A survey consisting of questions about the use of seclusion, hospital information, complication rate and related procedures was mailed to a random sample consisting of 20% of the US ED medical directors. The survey was re-mailed to the nonresponders who were also contacted by phone and faxed. The results of the survey were inputted into the SPSS program (SPSS, version 10, Chicago, IL).

RESULTS

The survey was returned by 443 of the 1015, or 43.6% of the ED medical directors in the United States who had been selected. Of the valid 442, 123 (25.6%) use seclusion in their ED. The most frequent reason for not using seclusion was physical plant issues (212 of 422, 50.2%). Most used direct visualization (102 of 187, 54.5%) of seclusion rooms that were locked (54 of 120, 45.0%) and that were overwhelmingly located within the ED (112 of 117, 95.7%). The most frequent reason for placing a patient in seclusion was violence (122 of 126, 96.8%). Both adults (123 of 126, 97.6%) and children (41 of 126, 32.5%) were placed in seclusion rooms. The most frequently reported complication was the patient's getting out of the seclusion room (32 of 106, or 30.1%). Patients were also given chemical restraints (79 of 113, 69.9%). The physician almost always ordered the seclusion room (124 of 125 cases, 99.2%), but the patient was commonly placed in the room by a nurse (109 of 122, 89.3%); generally, the staff had formal training (99 of 122, 81.1%). The use of seclusion was correlated with the number of ED beds (F=32.0, df=1, P=.003), ED volume (F=37.7, df=1, P=.001), number of hospital beds (F=22.6, df=1, P=.001), having a psychiatric unit (F=24.7, df=1, P=.001) and teaching EDs (F=10.8, df=1, P=.001).

CONCLUSION

Seclusion rooms are used in a minority of EDs across the country. It also identified many outstanding concerns with complications, use in children, addition of chemical sedation, training and seclusion policy.

The use of restraint for pediatric psychiatric patients in emergency departments

OBJECTIVE

To identify current practice and staff education regarding the use of restraint in emergency departments for children undergoing psychiatric evaluations and to compare restraint practice and education in emergency medicine residencies (EMRs) and pediatric emergency medicine fellowships (PEMFs).

METHODS

A self-administered survey regarding staff and resident education and the use of restraint for emergency pediatric patients undergoing psychiatric evaluation was mailed to the directors of EMRs and PEMFs. Main outcome measures included frequency of restraint use, staff trained in restraint use, favored positions for physical restraint, and agents regularly used for chemical restraint.

RESULTS

Forty-one percent (48/118) of EMRs and 66% (33/50) of PEMFs completed the survey. The great majority of both EMRs and PEMFs report use of physical and chemical restraint in 5% or less of pediatric psychiatric patients. Forty of 47 EMRs and 29 of 32 PEMFs have formal policies on physical restraint use. Far fewer programs have formal policies for chemical restraint (13/33 EMRs and 5/28 PEMFs). A large percentage of both EMRs and PEMFs do not teach their trainees about the application of restraints (EMR = 52%, PEMF = 82%) or the appropriate situations in which to use restraint (EMR = 35%, PEMF = 64%). However, EMRs were more likely than PEMFs to teach about both appropriate restraint application and appropriate situations for their use (RR = 2.6, 1.2-5.8 and RR = 1.8, 1.1-2.9, respectively). The supine position was the position favored by both groups for physical restraint. Therapeutic holding was infrequently used, mostly for younger children. Seventy-two percent of EMRs and 85% of PEMFs used chemical restraint in children. Benzodiazepines and butyrophenones were the most commonly used agents. However, butyrophenones were often misclassified as phenothiazines by both EMRs and PEMFs.

CONCLUSION

Restraint, both physical and chemical, is a widely, but uncommonly used, intervention for pediatric psychiatric patients in emergency departments. Many EMRs and PEMFs do not teach residents about restraint.

Seclusion use with children and adolescents: an Australian experience

OBJECTIVE

To summarize the current state of knowledge on the use of seclusion and restraint with children and adolescents and to report the findings of an exploratory study to identify factors that place a child or adolescent at increased risk of seclusion during their admission.

METHOD

Literature searches were undertaken on MEDLINE, CINAHL and PsycINFO databases. Articles were identified that focused specifically on seclusion and restraint use with children and adolescents or contained material significant to this population. The study reports findings from a retrospective review of patient charts, seclusion registers and staffing from an Australian acute inpatient facility.

RESULTS

The data available in regard to seclusion use in this population is limited and flawed. Further research is needed on the use and outcomes of seclusion and restraint and on alternative measures in the containment of dangerousness. Both the literature and this study find that patients with certain factors are at increased risk of being secluded during an inpatient stay. These factors include being male, diagnoses of disruptive behaviour disorder and a previous history of physical abuse. Staffing factors did not show a relationship to the use of seclusion.

CONCLUSIONS

There are patient factors that predict increased risk of seclusion; these factors and their interrelationships require further elucidation. Further research is also needed on the outcomes, both positive and negative, of seclusion use and of alternatives to seclusion.

Faulty assumptions associated with the use of restraints with children

TOPIC

The use of restraints in nursing and other professions has a long and troubling history, particularly in psychiatric settings. No research evidence has demonstrated restraints to be therapeutically effective. A number of faulty assumptions appear to support the continued practice of this unproven and potentially dangerous intervention.

PURPOSE

To present and refute several faulty assumptions using the empirical literature and theory, and to discuss alternatives based on the developmental-ecological theoretical framework for responding to crises in children.

SOURCES

Extant empirical literature.

CONCLUSION

Alternatives to restraints must be investigated and developed to replace the current reactive, crisis-management orientation of practice.