Behavior Modification Is Associated With Reduced Psychotropic Medication Use in Children With Aggression in Inpatient Treatment: A Retrospective Cohort Study

Factors Associated With Prolonged Mental Health Admissions at US Children's Hospitals

BACKGROUND AND OBJECTIVES

Mental health (MH) hospitalizations at medical hospitals are associated with longer length of stay (LOS) compared with non-MH hospitalizations, but patient factors and costs associated with prolonged MH hospitalizations are unknown. The objective of this paper is to assess patient clinical and demographic factors associated with prolonged MH hospitalizations and describe variation in MH LOS across US children's hospitals.

METHODS

We studied children aged 5 to 20 years hospitalized with a primary MH diagnosis during 2021 and 2022 across 46 children's hospitals using the Pediatric Health Information System database. Generalized estimating equations, clustered on hospital, tested associations between patient characteristics with prolonged MH hospitalization, defined as those in the 95th percentile or above (>14 days).

RESULTS

Among 42 654 primary MH hospitalizations, most were aged 14 to 18 (62.4%), female (68.5%), and non-Hispanic white (53.8%). The most common primary MH diagnoses were suicide/self-injury (37.4%), depressive disorders (16.6%), and eating disorders (10.9%). The median (interquartile range) LOS was 2 days (1-5), but 2169 (5.1%) experienced a hospitalization >14 days. In adjusted analyses, race and ethnicity, category of MH diagnosis, and increasing medical and MH complexity were associated with prolonged hospitalization.

CONCLUSIONS

Our results emphasize several diagnoses and clinical descriptors for targeted interventions, such as behavioral and inpatient MH resources and discharge planning. Expanded investment in both community and inpatient MH supports have the potential to improve health equity and reduce prolonged MH hospitalizations.

Future Directions: The Phenomenology of Irritable Mood and Outbursts: Hang Together or Hang Separately1

Recognition of the importance of irritable mood and outbursts has been increasing over the past several decades. This "Future Directions" aims to develop a set of recommendations for future research emphasizing that irritable mood and outbursts "hang together," but have important distinctions and thus also need to "hang separately." Outbursts that are the outcome of irritable mood may be quite different from outbursts that are the trigger or driving force that make youth and his/her environment miserable. What, then, is the relation between irritable mood and outbursts? As the field currently stands, we not only cannot answer this question, but we may also lack the tools to effectively do so. Here, we will propose recommendations for understanding the phenomenology of irritable mood and outbursts so that more directed and clinically useful assessment tools can be designed. We discuss the transdiagnostic and treatment implications that relate to improvements in measurement. We describe the need to do more than repurpose our current assessment tools, specifically interviews and rating scales, which were designed for different purposes. The future directions of the study and treatment of irritable mood and outbursts will require, among others, using universally accepted nomenclature, supporting the development of tools to measure the characteristics of each irritable mood and outbursts, understanding the effects of question order, informant, development and longitudinal course, and studying the ways in which outbursts and irritable mood respond to treatment.

Consultation-Liaison Case Conference: Systemic Challenges in Management of Aggression in a Pediatric Patient With Seronegative Autoimmune Encephalitis

We present the case of a 9-year-old girl who presented to a tertiary-care academic children's hospital with acute onset of severe obsessive-compulsive symptoms, perseveration, grimacing, and personality changes with resultant agitation. Extensive multidisciplinary workup led to a diagnosis of seronegative autoimmune encephalitis. The clinical course included multiple general pediatric and inpatient psychiatric unit admissions that were complicated by severe affective dysregulation with physical aggression towards staff and family. Top experts in the consultation-liaison field provide guidance for this commonly encountered clinical case based on their experience and a review of available literature. Key teaching points include assessment and management of seronegative autoimmune encephalitis and catatonia. We discuss the system-level challenges of management of aggression in health care settings and ways to improve care for patients presenting with behavioral manifestations (aggression) of physical illness.

Pharmacologic Restraint Use During Mental Health Admissions to Children's Hospitals

OBJECTIVES

Primary mental health admissions are increasing across US children's hospitals. These patients may experience agitation requiring pharmacologic restraint. This study characterized pharmacologic restraint use in medical inpatient units by primary mental health diagnosis.

METHODS

This retrospective, cross-sectional study used the Pediatric Health Information System database. The study included children aged 5 to 17 years admitted with a primary mental health diagnosis between 2016 and 2021. Rates of pharmacologic restraint use per 1000 patient days were determined for 13 mental health diagnoses and trended over time with Poisson regression.

RESULTS

Of 91 898 hospitalizations across 43 hospitals, 3% of admissions and 1.3% of patient days involved pharmacologic restraint. Trends in the rate of pharmacologic restraint use remained stable (95% confidence interval [CI], 0.7-2.1), whereas the incidence increased by 141%. Diagnoses with the highest rates of pharmacologic restraint days per 1000 patient days included autism (79.4; 95% CI, 56.2-112.3), substance-related disorders (45.0; 95% CI, 35.9-56.4), and disruptive disorders (44.8; 95% CI, 25.1-79.8). The restraint rate significantly increased in disruptive disorders (rate ratio [RR], 1.4; 95% CI, 1.1-1.6), bipolar disorders (RR, 2.0; 95% CI, 1.4-3.0), eating disorders (RR, 2.4; 95% CI, 1.5-3.9), and somatic disorders (RR, 4.2; 95% CI, 1.9-9.1). The rate significantly decreased for autism (RR, 0.8; 95% CI, 0.6-1.0) and anxiety disorders (RR, 0.3; 95% CI, 0.2-0.6).

CONCLUSIONS

Pharmacologic restraint use among children hospitalized with a primary mental health diagnosis increased in incidence and varied by diagnosis. Characterizing restraint rates and trends by diagnosis may help identify at-risk patients and guide targeted interventions to improve pharmacologic restraint utilization.

Narrative Review: Impairing Emotional Outbursts: What They Are and What We Should Do About Them

OBJECTIVE

Impairing emotional outbursts, defined by extreme anger or distress in response to relatively ordinary frustrations and disappointments, impact all mental health care systems, emergency departments, schools, and juvenile justice programs. However, the prevalence, outcome, and impact of outbursts are difficult to quantify because they are transdiagnostic and not explicitly defined by current diagnostic nosology. Research variably addresses outbursts under the rubrics of tantrums, anger, irritability, aggression, rage attacks, or emotional and behavioral dysregulation. Consistent methods for identifying and assessing impairing emotional outbursts across development or systems of care are lacking.

METHOD

The American Academy of Child and Adolescent Psychiatry Presidential Task Force (2019-2021) conducted a narrative review addressing impairing emotional outbursts within the limitations of the existing literature and independent of diagnosis.

RESULTS

Extrapolating from the existing literature, best estimates suggest that outbursts occur in 4%-10% of community children (preschoolers through adolescents). Impairing emotional outbursts may respond to successful treatment of the primary disorder, especially for some children with attention-deficit/hyperactivity disorder whose medications have been optimized. However, outbursts are generally multi-determined and often represent maladaptive or deficient coping strategies and responses.

CONCLUSION

Evidence-based strategies are necessary to address factors that trigger, reinforce, or excuse the behaviors and to enhance problem-solving skills. Currently available interventions yield only modest effect sizes for treatment effect. More specific definitions and measures are needed to track and quantify outbursts and to design and assess the effectiveness of interventions. Better treatments are clearly needed.

Pharmacologic restraint use for children experiencing mental health crises in pediatric hospitals

BACKGROUND

Children in mental health crises are increasingly admitted to children's hospitals awaiting inpatient psychiatric placement. During hospitalization, patients may exhibit acute agitation prompting pharmacologic restraint use.

OBJECTIVE

To determine hospital-level incidence and variation of pharmacologic restraint use among children admitted for mental health conditions in children's hospitals.

DESIGN, SETTING, AND PARTICIPANTS

We examined data for children (5 to ≤18 years) admitted to children's hospitals with a primary mental health condition from 2018 to 2020 using the Pediatric Health Information System database. Hospital rates of parenteral pharmacologic restraint use per 1000 mental health bed days were determined and compared after adjusting for patient-level and demographic factors. Cluster analysis (k-means) was used to group hospitals based on overall restraint use (rate quartiles) and drug class. Hospital-level factors for pharmacologic restraint use were compared.

RESULTS

Of 29,834 included encounters, 3747 (12.6%) had pharmacologic restraint use. Adjusted hospital rates ranged from 35 to 389 pharmacologic restraint use days per 1000 mental health bed days with a mean of 175 (standard deviation: 72). Cluster analysis revealed three hospitals were high utilizers of all drug classes. No significant differences in pharmacologic restraint use were found in the hospital-level analysis.

CONCLUSIONS

Children's hospitals demonstrate wide variation in pharmacologic restraint rates for mental health hospitalizations, with a 10-fold difference in adjusted rates between highest and lowest utilizers, and high overall utilizers order medications across all drug classes.

Reducing seclusion use in an Australian child and adolescent psychiatric inpatient unit

BACKGROUND

In inpatient psychiatric units, seclusion (isolation in a locked room) is recommended only as a last resort for serious aggression or agitation. In response to an increase in seclusion during 2015, an 8-bed child and adolescent inpatient unit implemented a suite of multidisciplinary interventions. This study examines changes in seclusion rates following intervention implementation and assesses whether specific patient factors were associated with seclusion rates before and after interventions.

METHOD

Multi-modal interventions, comprised of patient treatment plans, intake and handover meetings, staff supervision and debriefing sessions, were implemented from January 2016. We compared quarterly seclusion rates (episodes per 1000 patient days) across a thirteen-year period, from July 2008 to June 2021. Change in seclusion rates following intervention was evaluated using a segmented regression analysis. We examined whether patient factors were associated with seclusion rates, and whether the duration of seclusion episodes differed before and after interventions.

RESULTS

There was a 100% reduction in seclusion rates in the 6 months following intervention implementation, from 28.4 episodes per 1000 patient days in July-September 2015, to 4.7 episodes in January-March 2016, reaching 0.0 episodes by April-June 2016. This reduction was maintained until April-June 2021. Most patients with seclusion events before and after intervention implementation had a neurodevelopmental disorder diagnosis and a minority of patients accounted for most seclusion events. There was a 65% reduction in the average duration of seclusion episodes following interventions, however this was not statistically significant.

LIMITATIONS

Due to a crisis in staff morale, interventions were implemented simultaneously, preventing an understanding of whether a single intervention accounted for change. While not addressed in the current study, assessing perceptions of staff, children and parents following intervention implementation may have elucidated barriers and facilitators to change.

CONCLUSIONS

Multidisciplinary, patient-centered interventions may be effective for long-term reduction of seclusion rates in inpatient psychiatric units. These findings highlight patient factors associated with seclusion reduction which should be considered when implementing interventions.

Methods and Strategies for Reducing Seclusion and Restraint in Child and Adolescent Psychiatric Inpatient Care

Restraints and seclusions are restrictive interventions used in psychiatric inpatient units when there is an imminent risk of harm to the patient or others. Coercive measures are controversial and can lead to negative consequences, including negative emotions, re-traumatization, injuries, or death. The article summarizes the last 10 years of literature regarding methods and strategies used for reducing seclusions and restraints in child and adolescent psychiatric inpatient units, and reports on their outcomes. The literature was reviewed by searching PubMed and PsycInfo for English-language articles published between May 2010 and May 2020. Eighteen articles were found that described methods or strategies aimed at reducing restraint or seclusion utilization in child and adolescent psychiatric inpatient units. The following interventions were evaluated: Trauma-Informed Care (TIC), Six Core Strategies, Child and Family Centered Care (CFCC), Collaborative & Proactive Solutions (CPS), Strength-Based Care, Modified Positive Behavioral Interventions and Supports (M-PBIS), Behavioral Modification Program (BMP), Autism Spectrum Disorder Care Pathway (ASD-CP), Dialectical Behavior Therapy (DBT), sensory rooms, Mindfulness-Based Stress Reduction Training (MBSR) of staff, and Milieu Nurse-Client Shift Assignments. Most of the interventions reduced the use of seclusions and/or restraints. Two child-centered and trauma-informed initiatives eliminated the use of mechanical restraints. This review shows that the use of coercive measures can be reduced and should be prioritized. Successful implementation requires ongoing commitment on all levels of an organization and a willingness to learn. To facilitate comparisons, future models should evaluate different standardized parameters.

Management of Emotion Dysregulation and Outbursts in Children and Adolescents

PURPOSE OF REVIEW

Emotion dysregulation and outbursts are very common reasons for referral to child and adolescent mental health services and a frequent cause of admission to hospitals and residential programs. Symptoms of emotion dysregulation and outburst are transdiagnostic, associated with many disorders, have the potential to cause severe impairment and their management presents a major challenge in clinical practice.

RECENT FINDINGS

There are an increasing number of psychosocial interventions that demonstrate promise in improving emotion dysregulation and outbursts. Acute care systems to manage the most severely ill patients have limited best practice guidelines but program advancements indicate opportunities to improve care models. Pharmacotherapy may be of assistance to psychosocial interventions but must be used with caution due to potential adverse effects. Much remains to be discovered however evidence informed, targeted treatments for specific populations show potential for future improvements in outcomes.

Acknowledging caregivers' vulnerability in the managment of challenging behaviours to reduce control measures in psychiatry

BACKGROUND

The management of challenging behaviours in inpatient with intellectual disability and/or autism spectrum disorders can lead to an escalation of control measures. In these complex situations where patients have an intellectual disability/autism spectrum disorder accompanied by a psychiatric comorbidity, the experiences of caregivers related to the crisis management have rarely been studied.

PURPOSE

This study examined the moral experiences of caregivers related to challenging behaviours' management and alternatives to control measures.

RESEARCH DESIGN

Using Charles Taylor's hermeneutic framework, a 2-month focused ethnography with a participatory approach was used.

PARTICIPANTS AND RESEARCH CONTEXT

Sixteen caregivers were interviewed in a Canadian mental health setting for adults with intellectual disability/autism spectrum disorder and psychiatric comorbidity.

ETHICAL CONSIDERATIONS

The research was conducted in compliance with the Declaration of Helsinki and local Research Ethics Board approval. Written informed consent was collected systematically from participants.

FINDINGS

By accounting for caregivers' moral experiences, this study sheds light on a neglected dimension of the care relationship: the vulnerability of the caregiver. We highlight the main barriers and facilitators to alternatives to control measures. First, a caregiver's vulnerability was characterised by the overall impact of challenging behaviours and the moral distress associated with the use of control measures and exclusion mechanisms of intellectual disability/autism spectrum disorder patients. Second, a strong ambiguity between care and control measures and a lack of inclusive approaches were identified as the two main barriers to challenging behaviour management. Third, the involvement, both professional and personal, of caregivers was deemed necessary to implement alternatives to control measures.

DISCUSSION

A conflict of values opposes two conceptions of autonomy: a rational autonomy, which is counterproductive to the reduction of control measures, versus a relational autonomy based on shared vulnerability.

CONCLUSION

The recognition of caregiver's vulnerability is a benchmark to create alternative approaches, which defuse the logic of control and promote an ethics of care within which caregivers' self-concern can be understood as fostering mutual respect.

Does Pro Re Nata Oral Medication Shorten Outburst Duration in Children?

We report a prospective, naturalistic, institutional review board-approved study of 104 children ages 5-12 in a psychiatric hospital, of whom 59 were treated with oral PRN medications per parent/guardian-consent, given at nursing discretion, with physicians informed subsequently, and intramuscular STAT medication and/or seclusion/restraint/holds (S/R/H) in dangerous situations when oral medication failed. Intramuscular STAT medication and/or S/R/H were ordered by physicians with parents informed subsequently. The outcome of interest was the duration of the outburst and whether this differed by PRN medication.

Treatment of Childhood Emotion Dysregulation in Inpatient and Residential Settings

Children hospitalized in inpatient and residential treatment facilities often present with severe emotion dysregulation, which is the result of a wide range of psychiatric diagnoses. Emotion dysregulation is not a diagnosis but is a common but inconsistently described set of symptoms and behaviors. With no agreed upon way of measuring emotion dysregulation, the authors summarize the existing contemporary treatment focusing on proxy measures of emotion dysregulation in inpatient and residential settings. Interventions are summarized and categorized into individual- and systems-level interventions in addressing aggressive behaviors. Going forward, dysregulation will need to be operationalized in a standard way.

Preventing Irritability and Temper Outbursts in Youth by Building Resilience

Severe irritability and temper outbursts are risk factors for the onset of serious and lifelong mood disorders. In treating children and adolescents with severe irritability, clinicians should evaluate and address safety issues before acute stabilization of symptoms. Then, clinicians can initiate interventions to prevent the onset or relapses of the undesired behavior and its functional consequences. This review summarizes primary, secondary, and tertiary relapse prevention strategies, with an emphasis on strategies that build resilience in youth that mitigate the onset, recurrence, and progression of emotion dysregulation.

Cognitive-behavioral therapy training for multidisciplinary inpatient psychiatric teams: A novel curriculum using animated simulations

PROBLEM

Nurses assume primary responsibility teaching children self-management skills, yet few of them have formal training in evidence-based treatments such as cognitive-behavioral therapy (CBT).

METHODS

We developed a novel CBT training curriculum specifically tailored for nurses and other child psychiatric inpatient team members. The curriculum was anchored in three components: (1) a structured manual; (2) instructional videos of common clinical scenarios using animated simulations; and (3) interactive role-play exercises. The CBT curriculum was implemented through small group training sessions. We then conducted focus group sessions with the 20 participants to assess change in self-reported knowledge of, and utilization of CBT skills in clinical practice.

FINDINGS

The curriculum was well received by staff members, who found its content relevant and applicable to their daily inpatient work. Staff reported four main themes: (1) routine clinical care (feelings, challenges, and approaches); (2) CBT utility in practice; (3) CBT training components that facilitated learning of the discrete skills; and (4) professional development needs.

CONCLUSIONS

We were able to implement the curriculum within the time and staffing constraints of a clinically active inpatient setting. Future refinements of the model will include videotaped interactions between expert clinicians and simulated patients in high acuity situations.

Emotional Dysregulation: A Trauma-Informed Approach

Traumatic experiences, subsequent traumatic stress, and other trauma reactions are common among youth who experience emotional dysregulation. This article highlights key considerations for the delivery of care to emotionally dysregulated youth with histories of trauma. An initial, trauma informed assessment is critical to identify those youth with emotional dysregulation best served by evidence-based, trauma-focused treatments trauma-informed approaches to severely emotionally dysregulated youth, including youth in in-patient and residential settings, can improve emotional and behavioral outbursts while maintaining the safety the milieu. Finally, incorporating awareness of trauma is considered when prescribing psychopharmacologic interventions in severely emotionally dysregulated youth.

Nowhere to Go: Providing Quality Services for Children With Extended Hospitalizations on Acute Inpatient Psychiatric Units

The US mental health system is in crisis because of inadequate treatment resources. The number of youths hospitalized for suicidality more than doubled during the last decade,¹ and the suicide rate for 10- to 14-year-olds nearly tripled from 2007 to 2017.² Although hospitalization is intended as a short-term stabilization setting reserved for the most acute and serious mental health problems, discharge is often delayed because of a lack of suitable step-down care such as outpatient, intensive outpatient (IOP), partial hospitalization programs (PHP), or residential psychiatric care. The availability of step-down care options differs vastly depending on region, insurance, and other factors, and the result is a subset of patients who remain hospitalized in acute inpatient units simply because of the absence of safe alternatives.

Dr. Carlson et al. Reply

We appreciate the thoughtful and supportive comments from Dr. Masters¹ and agree that coercive parent-child relationships were often what was addressed and modified during hospitalization. Lowering seclusion and restraint rates by prohibiting them, without lowering rates of aggression, is not the desired outcome. As we noted in our paper, evidence-based treatments are sorely needed for young children whose severe and destructive outbursts get them psychiatrically hospitalized.

Regulatory Barriers to the Use of Time Out in Child Inpatient Units: Interference With Effective Treatment?

I read with interest the article "Behavior Modification Is Associated With Reduced Psychotropic Medication Use in Children With Aggression in Inpatient Treatment: A Retrospective Cohort Study" by Carlson et al.,¹ and I believe it raises important developmental questions regarding the application of adult criteria for seclusion and restraint (S/R) management to time out (T/O) procedures on child psychiatric inpatient units and the reliance on verbal de-escalation options to address behavioral crises with this patient population.

Editorial: Reducing Aggressive Episodes in Psychiatrically Hospitalized Children: Does Behavior Modification Work?

Aggressive behaviors not manageable at home, school, or in other community settings constitute one of the major reasons for psychiatric hospitalization of children, but reduction and prevention of such behaviors in inpatient settings remain elusive goals. Strategies with varying degrees of success have ranged from reliance on therapeutic milieu as a positive treatment agent in and of itself to psychotherapeutic, behavioral, and psychopharmacological approaches targeted to specific disorders.¹ Challenges include the diverse biologic, psychological, familial, environmental, and diagnostic factors that may be associated with aggressive episodes²; limitations in adapting evidence-based, disorder-specific treatments developed in non-inpatient or specialized settings (for example, for individuals with autism spectrum disorder and other developmental disabilities) to the contingencies of 24-hour care in general inpatient units; and implementation of interventions such as time-outs, manual holds, and PRN and STAT medications for agitation in the context of current Joint Commission standards for seclusion, restraint (physical and chemical), and behavior management.³ Point and level systems that are integral components of behavior modification programs (BMPs) on child inpatient units have been the subject of criticism based on limited empirical support and concerns as to whether such systems take adequate account of the needs of individual patients.⁴ Opportunities for demonstration of relative effectiveness of BMPs in comparison to other milieu-based programs in acute care settings are limited owing to practical issues in implementation of differing interventions requiring round-the-clock staff participation and methodological issues in comparison of findings between studies.

Pro Re Nata Medication Use in Acute Care Adolescent Psychiatric Unit

Objective: Evidence to support the use of pro re nata (PRN) medication is limited, and the details of PRN use (indication, frequency of administration, patient characteristics) are rarely reported, particularly in youth populations. The goal of this study was to report on the pattern of PRN use over 6 years in an acute care psychiatric unit for adolescents. Methods: A retrospective chart review of patients' records from November 2012 to October 2018 was conducted. Variables extracted from electronic medical records included age, gender, race/ethnicity, clinical rating scores at admission (on a subset of patients), length of stay, psychotropic and nonpsychotropic PRN medication administration, timing of administration, discharge diagnosis, and discharge medication. Results: Records from 2961 individuals with a total 3937 admissions were analyzed. A total of 62% of admissions had at least one PRN medication administration. Severity of symptoms, as indicated by higher scores on clinical rating scales at admission, longer length of stay, and readmission were related to high PRN use. Patients with bipolar spectrum disorders received more psychotropic and nonpsychotropic PRN medications than other patients. Patients who were high psychotropic PRN users were also high nonpsychotropic PRN users. Conclusion: Despite the lack of clear evidence in support of the efficacy of PRN medications, they commonly used to control symptoms in acute care inpatient settings. Youth with severe symptoms utilized not only psychotropic PRN medication but also nonpsychotropic PRN more frequently, suggesting a possible role of systemic disorder among youth with serious mental illness. More research is necessary to examine the efficacy of PRN medications for managing targeted symptoms.