Mechanical restraints as positive reinforcers for aggression

Factors associated with the use of mechanical restraint in a mental health hospitalization unit: 8-year retrospective analysis

WHAT IS ALREADY KNOWN ABOUT THE TOPIC?: Our present understanding of mechanical restraint is heterogenous, largely due to the important differences between countries/regions. In Spain, the use of this restrictive practice is not regulated, nor is its use protocolized. Previous studies that have investigated the impact of organizational factors and changes in these protocols are often short and not conducted within a framework designed to establish a long-term plan for reducing the use of mechanical restraint. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: We demonstrate that the implementation of administrative and protocol changes in our psychiatric unit significantly reduced the use of mechanical restraint, thus laying the foundations for a regulatory framework. Our analysis shows that the profile of patients who require mechanical restraint is highly variable, but that certain clinical and institutional aspects within the framework of a long-term plan for the reduction in mechanical restraint can be targeted with long-lasting positive effects. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Organizational changes focussed on training staff, promoting family support and requiring the registration and close monitoring of episodes empower the role of the nursing staff in the prevention, monitoring and regulation of mechanical restraint. ABSTRACT: Introduction Mechanical restraint is a controversial restrictive practice to manage agitation or violent behaviour. Numerous studies have evaluated the factors and organizational changes that influence on mechanical restraint, but only for short time periods. None of those studies have assessed the effects of measures applied within the framework of a long-term plan to reduce the use of mechanical restraint. Given the lack of specific legislation in Spain, more data are required for its proper regulation. Aim/Question To evaluate the risk factors associated and the impact of specific measures designed to minimize the application of mechanical restraint in an acute mental health unit over an 8-year period and previous observation of 5 years. Methods Cross-sectional study based on a retrospective analysis of mechanical restraint records. We compared admissions requiring ≥one episode of restraint versus admissions not requiring this coercive measure. Results Between 2007 and 2014, 412 admissions (12%) required mechanical restraint. The data show that the measures applied in the previous five years had significantly reduced the total hours of restraint per semester. The factors associated with admissions requiring mechanical restraint were involuntary, unscheduled and longer admissions. The best predictor of restraint was involuntary admission (OR = 6.37), followed by the diagnosis of personality disorder (OR = 5.01). Discussion Identification of the factors associated with mechanical restraint would allow for early detection strategies. Our results provide additional evidence on the usefulness of organizational changes to reduce coercive measures, even in a country without specific legislation. Implications for Practice Organizational changes, such as staff training and increased family support during admission of episodes of mechanical restraint, can reduce the use of this measure. These measures also give the nursing staff greater responsibility in terms of their role in registering and monitoring the restrictive practice, thus helping to prevent or minimize the use of mechanical restraint.

Direct observation in a large-scale randomized trial of parent training in children with autism spectrum disorder and disruptive behavior

A direct observation strategy (Standardized Observation Analogue Procedure, SOAP) was used in a large-scale randomized trial of parent training versus parent education in young children with autism spectrum disorder (ASD) and disruptive behavior. The 16-minute SOAP, modified from an earlier version of this same measure, included parentchild interaction to assess child behavior in a clinical laboratory setting. Despite study entry criteria for all child participants requiring moderate levels of disruptive behavior in this project, 126 of 168 children with complete SOAP data at baseline showed no disruptive behavior on this measure. Although the primary purpose of the study was to determine whether the SOAP could detect differences between the two conditions (i.e.,parent training (PT) and parent education (PE)), baseline observation data was not consistent with parent ratings at baseline or subsequent follow up visits, leaving little room to demonstrate improvement with this observation measure. This and the challenging, time-consuming and resource intensive effort involved in using such a measure in a large randomized scale trial, raises fundamental questions about the validity of the SOAP as an outcome measure in such a study. Further consideration related to the feasibility and practicality of using direct observation as a primary measure in larger scale efforts overall are also discussed.

Use of a Direct Observational Measure in a Trial of Risperidone and Parent Training in Children with Pervasive Developmental Disorders

A Structured Observational Analog Procedure (SOAP), an analogue measure of parent-child interactions, was used to assess treatment outcome in children with Autism Spectrum Disorder and serious behavior problems. It served as a secondary outcome measure in a 24-week, randomized trial of risperidone (MED; N=49) versus risperidone plus parent training (COMB; n=75) (ages 4-13 years). At 24-weeks, there was 28 % reduction in child inappropriate behavior during a Demand Condition (p=.0002) and 12 % increase in compliance to parental requests (p=.004) for the two treatment conditions combined. Parents displayed 64 % greater use of positive reinforcement (p=.001) and fewer repeated requests for compliance (p<.0001). In the analysis of covariance (ANCOVA), COMB parents used significantly more positive reinforcement (p=.01) and fewer restrictive statements (p<.05) than MED parents. The SOAP is sensitive to change in child and parent behavior as a function of risperidone alone and in combination with PMT and can serve as a valuable complement to parent and clinician-based measures.

Reducing and eliminating restraint of people with developmental disabilities and severe behavior disorders: an overview of recent research

This paper provides a brief overview of the most recent research (1999-2009) on restraint reduction and elimination efforts in the literature and also examines the characteristics of restraint along with the risks and benefits. Some earlier papers were included in this review because of their importance to the topic. The results of this literature review are discussed in terms of implications for practitioners and researchers.

Restraints and the code of ethics: An uneasy fit

This article examines the use of physical restraints through the four broad principles of ethics common to all helping professions. It asks whether the continued use of physical restraints is consistent with ethical practice through the lens of those principles. It also examines where the necessity to use restraints in the absence of empirically supported alternatives leaves professionals in terms of conflicts between ethical principles and makes recommendations for changes in education and clinical practice. It concludes that an analysis through a bioethics lens demonstrates that the use of restraints as a tool in psychiatric settings is a complex and multifaceted problem. Principles of ethics may often be in conflict with each other in instances where patients must be physically restrained.