Review of Restraint Data in a Residential Treatment Center for Adolescent Females

Patterns of change in restrictive measures in residential care: Trauma-informed staff training benefits children and youth who need it the Most

BACKGROUND

Implementation of trauma-informed staff training is promising to reduce restrictive measures (restraints, seclusions, and time-outs) used to address problem behaviors in youth in residential care. Previous mixed results may be explained in part by the heterogeneity in the use of restrictive measures among youth.

OBJECTIVE

The objective was twofold: (1) to examine whether heterogeneity in the initial number of restrictive measures experienced by youth, before implementing trauma-informed staff training, moderates the effect of the training and (2) to explore whether children and youth's characteristics are associated with the number of restrictive measures.

PARTICIPANTS AND SETTING

A trauma-informed staff training was implemented in 44 residential care units in Quebec, Canada.

METHODS

This study used administrative data. The sample (n = 297 youth) was divided into three subgroups based on the number of restrictive measures experienced in the six-month period prior to the training: 1) absence or low (52 % of the sample); 2) moderate (23 %); 3) high (25 %).

RESULTS

The use of restrictive measures was compared between the subgroups. Main and interaction effects were all significant. None of the slopes for groups 1 and 2 were significant. In contrast, significant decreases from T1 were observed at T2 (-0.18 (0.02), p < .000) and T3 (-0.22 (0.02), p < .000) in group 3. Several children and youth's characteristics distinguished groups.

CONCLUSIONS

Implementation was more beneficial to youth who experienced a high number of restrictive measures. Training opportunities can lead to positive changes in measures used to address problem behaviors in youth.

Prevalence and correlates of restrictive interventions in an Irish child and adolescent psychiatric unit: a 4-year retrospective study

BACKGROUND

There has been a global effort to reduce the use of restrictive interventions (RIs) in healthcare settings. In order to reduce unnecessary RIs, it is essential to understand their use in mental health settings. To date, there have been few studies examining the use of RIs in child and adolescent mental health settings, with no such studies in Ireland.

AIMS

The purpose of this study is to examine the prevalence and frequency of physical restraints and seclusion and to identify any associated demographic and clinical characteristics.

METHODS

This is a 4-year retrospective study of the use of seclusion and physical restraint in an Irish child and adolescent psychiatric inpatient unit from 2018 to 2021. Computer-based data collection sheets and patient records were retrospectively reviewed. Eating disorder and non-eating disorder samples were analysed.

RESULTS

Of 499 hospital admissions from 2018 to 2021, 6% (n = 29) had at least one episode of seclusion and 18% (n = 88) had at least one episode of physical restraint. Age, gender and ethnicity were not significantly associated with rates of RI. Unemployment, prior hospitalization, involuntary legal status and longer length of stay were significantly associated with higher rates of RIs in the non-eating disorder group. Involuntary legal status was associated with higher rates of physical restraint in the eating disorder group. Patients with a diagnosis of eating disorder and psychosis had the highest prevalence of physical restraints and seclusions respectively.

CONCLUSIONS

Identifying youth who are at greater risk of requiring RIs may allow early and targeted intervention and prevention.

Physical restraint of children and adolescents in mental health inpatient services: A systematic review and narrative synthesis

Physical restraint is regularly used in children and adolescent mental health care, often as a reactive behaviour management strategy. Physical restraint has been associated with physical injury, but psychological consequences are poorly understood. The aim of this systematic review was to examine physical restraint of children and adolescents in inpatient mental healthcare services. Healthcare databases were searched to identify English language publications discussing anyone aged ≤18 years who had experienced physical restraint as a mental health inpatient. No date restrictions were applied. Sixteen quantitative studies are included within this review. Most studies are retrospective in nature. Publications were appraised using the Critical Appraisal Skills Programme quality assessment tool. Common characteristics associated with children and adolescents who experience physical restraint include age, gender, diagnosis, and history. Most studies associate physical restraint with the management of aggression. Findings suggest that it may be a combination of patient (intrinsic) and environmental (extrinsic) factors which ultimately lead to children and adolescents experiencing restraint. This review confirms that little is known about children and adolescents' first-hand experiences of physical restraint. Future research should address children and adolescents' perceptions and first-hand experiences of physical restraint.

The Use of Restraint and Seclusion in Residential Treatment Care for Youth: A Systematic Review of Related Factors and Interventions

Children placed in residential treatment centers (RTCs) typically present challenging behavior including aggression. In this context, restraint and seclusion (R&S) are seen as "last resort" strategies for educators to manage youth aggression. The use of R&S is controversial, as they can lead to psychological and physical consequences for both the client and the care provider and have yet to be empirically validated as therapeutic. The objectives of this systematic review are to identify the factors related to R&S use in RTCs for youth and to review the interventions aiming to reduce the use of R&S. The identification of these factors is the first step to gaining a better understanding of the decision-making process leading to the use of R&S and ultimately to reducing the use of these strategies to a minimum. Thus, the present systematic review was conducted by searching PubMed, CINAHL, ERIC, and PsycNET for articles published between 2002 and 2017. Key words used were synonyms of R&S, youth, and RTCs. Thirty-one studies met the inclusion criteria: must report on factors affecting the use of R&S in RTCs, must be conducted in RTCs for youth under the age of 21, and must report on original and empirical data. Factors related to the characteristics of the client, the care provider, and the environment, as well as to the implementation of programs for the reduction of R&S, were found to influence the use of R&S in RTCs. A conceptual model is presented. The implementation of programs to reduce R&S use is discussed.

Worker and perceived team climate factors influence the use of restraint and seclusion in youth residential treatment centers: Results from a mixed-method longitudinal study

BACKGROUND

Restraint and seclusion (R&S) are controversial methods of intervention aimed at protecting children from immediate harm in residential treatment centers (RTC). Previous studies have mainly focused on situational factors and youth characteristics to predict its use.

OBJECTIVES

This study sought to evaluate the role other potential predictors could play in the decision to use R&S, namely characteristics of residential workers and their perceived team climate.

METHODS

For two months, a total of 132 residential workers from different RTC in the greater Montreal area completed weekly diaries of standardized questionnaires. Using an explanatory sequential design (i.e., mixed methods), this study aimed at exploring the role of residential workers' characteristics (e.g., exposure to client aggression, stress and fatigue) and aspects of their perceived team climate (e.g., order and organization, communication and openness) as predictors of R&S use. Survey results were later also presented to four focus groups for discussion.

RESULTS

Results indicated that exposure to verbal violence from youths was associated with the increased use of R&S. Meanwhile, perceived communication and openness were associated with lower rates of R&S use. Participants shared that repeated exposure to verbal violence diminished their level of tolerance while teamwork provided them with the emotional space needed to focus on the needs of youths and find alternatives to R&S.

CONCLUSION

This study sheds light on the complex role of human emotions in the decision to use of R&S. Specifically, intense momentary emotions during crisis interventions had a greater influence on the use R&S than chronic states, such as fatigue.

Characteristics of adolescents frequently restrained in acute psychiatric units in Norway: a nationwide study

BACKGROUND

The use of restraints in adolescent psychiatric settings requires particular professional, ethical, and legal considerations. The purpose of this study was to investigate whether the number of restraint episodes per patient was related to any of several characteristics of the adolescents.

METHODS

In this nationwide study, we included all adolescents restrained during the period 2008-2010 (N = 267) in Norwegian adolescent acute psychiatric inpatient units. They constitute 6.5% of the adolescents hospitalized in these units in the same period of time. We collected data on the number of restraint episodes they experienced during the study period; Poisson regression was then used to analyze the impact of gender, social, mental health, and treatment characteristics on the frequency of restraint. We developed a risk index for the likelihood of experiencing multiple restraint episodes.

RESULTS

We found a skewed distribution of restraint episodes in which a small group (18%) of restrained adolescents experienced a majority (77%) of the restraint episodes. A large percentage of the restrained adolescents (36%) experienced only one restraint episode. Risk factors for multiple restraint episodes were female gender, lower psychosocial functioning (Children's Global Assessment Scale below 35), more and longer admissions, and concomitant use of pharmacological restraint. Except for gender, we used these variables to develop a risk index that was moderately associated with multiple restraint episodes.

CONCLUSIONS

As a small group of patients accounted for a large percentage of the restraint episodes, future research should further investigate the reasons for and consequences of multiple restraint episodes in patients at acute adolescent psychiatric units, and evaluate preventive approaches targeted to reduce their risk for experiencing restraint.

A nationwide study of why and how acute adolescent psychiatric units use restraint

The purpose of this study was to examine the type, reason, and duration of restraint episodes in acute adolescent psychiatric units. In a retrospective design we included data from paper-based protocols on all episodes of restraint and data from electronic patient records during 2008-2010 in all acute adolescent psychiatric in-patient units in Norway (N=16). The episodes of restraint included mechanical and pharmacological restraint, seclusion and physical holding that was not part of the implementation of forced feeding. Six-and-a-half per cent of all 4099 adolescents admitted to the acute units experienced restraint. Of the 2277 episodes, 13.4% were mechanical restraint, 1.6% were pharmacological restraint, 5.9% were seclusion and 78.7% were physical holding. The median number of restraint episodes per patient was two, the range was 1-171 and 47 patients (18%) experienced ≥10 episodes. The most common reason for using restraint was harming others. The median duration of the mechanical restraint episodes was 3.5h. The median duration of seclusion was 30min and the median duration of physical holding was 10min.

Frequency, characteristics and management of adolescent inpatient aggression

BACKGROUND

Inpatient aggression is a serious challenge in pediatric psychiatry.

METHODS

A chart review study in adolescent psychiatric inpatients consecutively admitted over 24 months was conducted, to describe aggressive events requiring an intervention (AERI) and to characterize their management. AERIs were identified based on specific institutional event forms and/or documentation of as-needed (STAT/PRN) medication administration for aggression, both recorded by nursing staff.

RESULTS

Among 408 adolescent inpatients (age: 15.2±1.6 years, 43.9% male), 1349 AERIs were recorded, with ≥1 AERI occurring in 28.4% (n=116; AERI+). However, the frequency of AERIs was highly skewed (median 4, range: 1-258). In a logistical regression model, the primary diagnosis at discharge of disruptive behavior disorders and bipolar disorders, history of previous inpatient treatment, length of hospitalization, and absence of a specific precipitant prior to admission were significantly associated with AERIs (R(2)=0.32; p<0.0001). The first line treatment of patients with AERIs (AERI+) was pharmacological in nature (95.6%). Seclusion or restraint (SRU) was used at least once in 59.4% of the AERI+ subgroup (i.e., in 16.9% of all patients; median within-group SRU frequency: 3). Treatment and discharge characteristics indicated a poorer prognosis in the AERI+ (discharge to residential care AERI+: 22.8%, AERI-: 5.6%, p<0.001) and a greater need for psychotropic polypharmacy (median number of psychotropic medications AERI+: 2; AERI-: 1, p<0.001).

CONCLUSIONS

Despite high rates of pharmacological interventions, SRU continue to be used in adolescent inpatient care. As both of these approaches lack a clear evidence base, and as adolescents with clinically significant inpatient aggression have increased illness acuity/severity and service needs, structured research into the most appropriate inpatient aggression management is sorely needed.

Factors associated with the use of intrusive measures at a tertiary care facility for children and youth with mental health and developmental disabilities

This study seeks to identify some of the explanatory factors associated with the use of intrusive measures among children with mental health and developmental disabilities in psychiatric facilities. Intrusive intervention data were collected using an organizational database that was developed internally at a tertiary care facility. The sample was composed of 338 children/youth aged between 6 and 18 years (mean = 12.33, standard deviation = 2.70) admitted within a 2-year period. Logistic regression was used to examine the relationship between chemical restraint, physical restraint and secure isolation, and programme type after controlling for demographic and other relevant client characteristics. The study found that the number of chemical restraints and secure isolations was higher for clients with developmental disabilities than for clients with mental health, whereas the number of physical restraints was lower for clients with developmental disabilities than clients with mental health issues. Demographic variables also predicted specific types of intrusive measures. The results of this study outline the differential factors associated with specific types of intrusive measures to control aggressive and self-harm behaviours. The paper also outlines cultural change initiatives, organizational interventions, and policy implications for best practice services for children/youth in psychiatric facilities to further reduce intrusive measures.

Antipsychotic treatment patterns and aggressive behavior among adolescents in residential facilities

This study examined the association between acute aggressive behavior patterns of 145 adolescents in residential treatment facilities with use of and changes in antipsychotic medication for the chronic management of aggression. Seclusion/restraint (S/R) frequency over 12 months was used to categorize youth into none, low, moderate, and high S/R groups. Data were analyzed using longitudinal mixed effects logistic regression models that allowed for intra-subject variability over time. The high and moderate S/R groups were significantly more likely to receive antipsychotics, get higher doses, and have changes in medication compared with the none S/R group. Increases in antipsychotic dose were associated with a lower likelihood of changes in antipsychotic medication over time. Despite persistent antipsychotic use at higher doses, youth in the high and moderate S/R groups continued to be secluded/restrained frequently. The findings question the adequacy of these medications in managing aggressive behavior.

Prevalence and correlates of seclusion and restraint use in children and adolescents: a systematic review

Seclusion and restraint are frequent procedures to intervene in aggressive and potentially dangerous patients in psychiatric settings. However, little is known about their utilization and effectiveness in pediatric populations. We aimed to examine the prevalence and determinants of seclusion and restraint utilization in children and adolescents in psychiatric settings. Using PubMed, PsychInfo and Cinahl, we performed a systematic literature review of studies published in the last 10 years reporting on the prevalence of seclusion and restraint use in psychiatrically ill youth (<21 years old) treated in psychiatric settings. Only seven publications addressed the topic. Primary outcomes were prevalence rates, reported either as the proportion of patients restrained/secluded or as the number of restraints/seclusions per number of patient days. All studies found relatively high baseline rates of seclusion (26% of patients; 67/1,000 patient days), and restraints (29% of patients; 42.7/1,000 patient days). In four studies, an intervention, implemented to reduce seclusion and restraints, resulted in a dramatic weighted mean reduction in the more restrictive use of restraints by 93.2%, with a 54.2% shorter duration. There was a small, weighted mean reduction in the use of less restrictive seclusions (-0.6%), but results were heterogeneous (-97.2 to +71.0%), with the only increase in seclusions being reported in one study in which the intervention-based padded seclusion room was utilized more frequently instead of more restrictive measures. Otherwise, seclusion episodes reduced by 74.7%, including a 32.4% shorter duration. Few studies reported on risk-factors and predictors, consisting of past or current aggression and/or violence, suicidal behavior, more severe psychopathology, non-White ethnicity, emergency admissions, out-of-home placement, and poorer family functioning, while findings regarding age were inconsistent Except for duration, data about the effectiveness of seclusion and restraints were missing, although there is some indication that seclusion and restraints can lead to severe psychological and physical consequences. Future research should focus on indications, predictors, preventive and alternative strategies, as well as on clinical outcomes of seclusion and restraints in psychiatrically ill youth. In addition, there is a clear need for transparent policies and guidelines.