Frequency, characteristics and management of adolescent inpatient aggression

Impact of a debrief tool in acute child and adolescent mental health inpatient units: a centre's experience

This manuscript presents the pioneering use of a post-event staff debriefing tool, TALK, in Acute Child and Adolescent Mental Health Units (CAMHU). While unsuccessful in reducing the rate and severity of patient behavioural events, our centre observed promising psychological benefits for CAMHU staff as a result of debriefing, with the tool promoting emotional resiliency and providing a platform for open conversations. Debriefing also served as a venue for patient concerns with care to be raised by staff, addressed and reflected in updated care plans. This initiative demonstrates the utility of debriefing to foster a culture of learning, improve staff wellness and enhance patient safety in CAMHU settings.

Interrater reliability of the violence risk assessment checklist for youth: a case vignette study

BACKGROUND

Facilities providing health- and social services for youth are commonly faced with the need for assessment and management of violent behavior. These providers often experience shortage of resources, compromising the feasibility of conducting comprehensive violence risk assessments. The Violence Risk Assessment Checklist for Youth aged 12-18 (V-RISK-Y) is a 12-item violence risk screening instrument developed to rapidly identify youth at high risk for violent behavior in situations requiring expedient evaluation of violence risk. The V-RISK-Y instrument was piloted in acute psychiatric units for youth, yielding positive results of predictive validity. The aim of the present study was to assess the interrater reliability of V-RISK-Y in child and adolescent psychiatric units and acute child protective services institutions.

METHODS

A case vignette study design was utilized to assess interrater reliability of V-RISK-Y. Staff at youth facilities (N = 163) in Norway and Sweden scored V-RISK-Y for three vignettes, and interrater reliability was assessed with the intraclass correlation coefficient (ICC).

RESULTS

Results indicate good interrater reliability for the sum score and Low-Moderate-High risk level appraisal across staff from the different facilities and professions. For single items, interrater reliability ranged from poor to excellent.

CONCLUSIONS

This study is an important step in establishing the psychometric properties of V-RISK-Y. Findings support the structured professional judgment tradition the instrument is based on, with high agreement on the overall risk assessment. This study had a case vignette design, and the next step is to assess the reliability and validity of V-RISK-Y in naturalistic settings.

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.

Appraising risk factors of aggression in children and adolescents at psychiatric inpatient units

This study examined predictors of aggression and assessed whether different subgroups of children and young people (CYP) display varying risks of aggressive incidents during hospitalization. Data from 10,090 children admitted to the psychiatric inpatient units of Cincinnati Children's Hospital between April 2010 and June 2021 were analysed. Multivariable logistic regression models were used to determine significant predictors associated with aggression, followed by average marginal effects and cluster analyses to rank and establish clusters by the order of predictor importance. About 32.5% reported positive history of an aggressive incident. The mean BRACHA score was doubled compared to those without a prior history. The primary analysis showed that both younger and male CYPs had higher odds of aggressive incidents. We also found that CYP with an African descent, not being able to live with both biological parents, those who reported positive history of psychiatric hospitalisation, and prior externalising behaviours had higher odds of aggressive incidents. These findings have important clinical and public health implications, as they provide valuable knowledge for healthcare professionals to improve prevention strategies for aggression amongst this vulnerable population.

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.

Algorithmic Prediction of Restraint and Seclusion in an Inpatient Child and Adolescent Psychiatric Population

BACKGROUND

Restraint and seclusion in an inpatient child and adolescent psychiatric population adversely affects the overall value and safety of care. Due to adverse events, negative outcomes, and associated costs, inpatient psychiatric hospitals must strive to reduce and ultimately eliminate restraint and seclusion with innovative, data-driven approaches.

AIM

To identify patterns of client characteristics that are associated with restraint and seclusion in an inpatient child and adolescent psychiatric population.

METHOD

A machine learning application of fast-and-frugal tree modeling was used to analyze the sample.

RESULTS

The need for restraint and seclusion were correctly predicted for 73% of clients at risk (sensitivity), and 76% of clients were correctly predicted as negative or low risk (specificity), for needing restraint and seclusion based on the following characteristics: having a disruptive mood dysregulation disorder and/or attention-deficit hyperactivity disorder diagnosis, being 12 years old or younger, and not having a depressive and/or bipolar disorder diagnosis.

CONCLUSIONS

The client characteristics identified in the predictive algorithm should be reviewed on admission to recognize clients at risk for restraint and seclusion. For those at risk, interventions should be developed into an individualized client treatment plan to facilitate a proactive approach in preventing behavioral emergencies requiring restraint and seclusion.

A Large Naturalistic Study on the BRACHA: Confirmation of the Predictive Validity

Aggression is a major challenge on child/adolescent inpatient psychiatric units. A screening instrument to accurately identify risk is urgently needed. To determine the predictive validity of the Brief Rating of Aggression by Children and Adolescents (BRACHA). Prospective cohort study. BRACHA is administered by clinical staff in the emergency department (ED) prior to inpatient psychiatric admission. A consecutive sample of 10,054 admitted patients from 2010-2021. No patients refused screening nor were excluded. BRACHA administered to patients in the ED prior to admission at Cincinnati Children's Hospital Medical Center (CCHMC). Patient behavioral outcomes measured by Overt Aggression Scale (OAS), categorizing aggression as verbal or physical, then as towards self, others, or objects. Female patients comprised 53.6% (n = 5,386) of the sample. Most patients were white (n = 6,556, 65.2%). Patients ranged in age from 4 to 18 years, with a mean age of 13.6 ± 3.1 years. A single biological parent (n = 5,317, 52.9%) was the predominant living arrangement among patients. The Area Under the Curve (AUC), as an assessment of predictive validity across all possible cut-offs of BRACHA scores ranged from 0.640 (aggression to self) to 0.758 (physical aggression towards others). Our findings support the BRACHA as a useful predictive instrument for aggression in inpatient psychiatric admissions from ED regardless of length of stay. Treating staff are then able to immediately classify risk level and inform care plans for all lengths of hospitalization. Applies to potential risk for aggression, except for self-aggression. Future data analyses will evaluate demographic factors to determine which improve predictive power of the BRACHA and can be used to create a BRACHA calculator. To our knowledge, this naturalistic outcomes study is one of the largest in psychiatry. The BRACHA will continue to be studied to evaluate risk for aggression on inpatient units and aim to assist in keeping unit staff and patients safe.

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.

Agitation and Restraint in a Pediatric Psychiatric Emergency Program: Clinical Characteristics and Diagnostic Correlates

OBJECTIVES

Agitation and restraint among pediatric psychiatric patients are a frequent, yet little studied, source of morbidity and, rarely, mortality in the emergency department (ED). This study examined agitation and restraint among youth patients in a specialized pediatric psychiatric ED, considering clinical and sociodemographic characteristics of those who required restraint to determine the clinical correlates of agitation and restraint in this population.

METHODS

This descriptive study was a 6-year retrospective chart review of all patients restrained for acute agitation. Demographics, clinical characteristics, diagnoses, and reasons for restraint were collected. Relationships between sociodemographic and clinical variables to types of restraints used were examined, along with change over the study period in rate of and mean time in restraint.

RESULTS

The average restraint rate was 1.94%, which remained fairly consistent throughout study period, although average time in restraint decreased significantly. Restraints were more common in males. Adolescents were overrepresented in the ED population, and after controlling for this, restraint rates were similar in adolescents and younger children. Physical aggression was the most frequent precipitant, although among adolescents verbal aggression was also a precipitant (more so than in younger children). Disruptive behavior disorder diagnoses were most frequently associated with restraint.

CONCLUSIONS

A lower rate of restraint is reported here than has been seen in programs where youths are treated in medical or adult psychiatric EDs. Hospitals without specialized pediatric psychiatric emergency programs should invest in staff training in deescalation techniques and in access to pediatric psychiatric treatment. The finding that, of youth restrained, a significant proportion were under 12 years old and/or carried diagnoses not typically associated with aggressive behavior, indicates that crisis prevention, management, and treatment should include younger populations and diverse diagnostic groups, rather than focusing narrowly on older patients with psychotic or substance use disorders.

Elevated Rates of Restraint and Seclusion in Child and Adolescent Psychiatric Inpatients in China and Their Associated Factors

To investigate the rate of restraint and seclusion (R&S) use in child and adolescent psychiatric inpatients in China and to examine factors associated with use of these interventions. As part of an official national survey, 41 provincial tertiary psychiatric hospitals in China were selected. Data from 196 youth inpatients discharged from these hospitals from March 19 to 31, 2019 were retrieved and analyzed. (1) The overall rate of R&S was 29.1% (N = 57) and the rate of restraint was 28.6% (N = 56), and seclusion was 11.7% (N = 23) respectively. (2) Compared to patients who did not require R&S, those who required R&S were more likely to have been hospitalized on an involuntary basis, more likely to present with either manic symptoms or aggressive behavior as primary reason for admission, had more frequent aggressive behaviors during hospitalization, and had a significantly longer length of stay. (3) A logistic regression showed that aggressive behaviors during hospitalization was significantly associated with the use of R&S (OR = 21.277, p < 0.001), along with three other factors: manic symptoms as a reason for admission, involuntary admission and a lower GAF score at admission (all p < 0.01). The rate of R&S is dramatically higher in child and adolescent psychiatric hospitalizations in China compared to other regions. Targeted training of staff, development of precise operational guidelines for appropriate use of R&S, and strict oversight are urgently needed to minimize the inappropriate use of R&S in child and adolescent patients.

Patient Risk Factors for Violent Restraint Use in a Children's Hospital Medical Unit

BACKGROUND AND OBJECTIVES

To inform efforts to reduce violent restraint use, we examined risk factors for restraint use among hospitalized children with known behavior concerns.

METHODS

We conducted a retrospective cross-sectional study of restraint events in all hospitalizations from 2017 to 2019 on a 10-bed medical-surgical unit with dedicated mental health clinician support. We examined characteristics of restraint events, used adjusted logistic regression models to identify independent risk factors for restraint use, and used an adjusted Poisson regression model to determine the adjusted rate of restraint events per hospital day.

RESULTS

The sample included 1507 hospitalizations representing 1235 patients. Among included hospitalizations, 48% were for a psychiatric indication awaiting transfer to an inpatient psychiatric unit, and 52% were for a primary medical or surgical problem. Sixteen percent had a restraint event. Patient demographic characteristics were not associated with risk of a restraint event. Having a psychiatric indication for hospitalization was an independent risk factor for restraint use (odds ratio: 2.85; 95% confidence interval: 2.06-3.94). Rate of restraint use per day decreased as length of stay increased; hospitalizations lasting 9 days or longer had a 58% lower rate of restraint use per day than 1- to 2-day hospitalizations (P < .001).

CONCLUSIONS

Interventions to reduce restraint use may benefit from incorporating information about a patient's psychiatric risk factors, including type and number of diagnoses and reason for hospitalization. Future efforts could investigate whether providing enhanced behavior supports during the first several days of a patient's hospitalization reduces violent restraint use.

Predicting the time trend of first episodes of aggressive behaviors in pediatric psychiatric inpatient units

The goal of the current study is to assess whether the scores of Brief Rating of Aggression by Children and Adolescents (BRACHA) at the emergency room (ER) can predict the aggressive incidents at pediatric psychiatric inpatient units. The study aims to identify predictors for two outcome measurements: 1) hazard rates for the first aggressive incident and 2) numbers of days between admission and the first aggressive incident, using the Cox regression model and Poisson regression model, respectively. The clinical records of a total of 5,610 adolescents admitted into the pediatric psychiatric inpatient units of Cincinnati Children's Hospital Medical Center were extracted for the analysis. The aggressive incident was defined as a score >0 from any category of the Overt Aggression Scale (OAS) and the high-aggressive incident was defined as a score ≥ 2 from any category of the OAS. The results indicate that the BRACHA score was not associated with high-aggressive incidents (hazard ratio: 0.98, p = 0.7543). Similarly, the BRACHA scores was only associated with the number of days from admission to the first aggressive incident (Poisson regression coefficient: 0.24, p < 0.0001) but not the number of days from admission to the first high-aggressive incident (Poisson regression coefficient: 0.03, p = 0.3994). Furthermore, the second peak of first aggressive incidents during the hospitalization highlights the importance of interventions at the end of the inpatient treatment course. To summarize, BRACHA scores based on initial assessments at the ER could correlate with first aggressive incidents, but not the first high-aggressive incidents.

Psychopharmacology of Treating Explosive Behavior

Explosive and aggressive behavior in children can pose safety risks, disturb family functioning, and lead to significant impairments. Pharmacologic management should be based on the first-line treatment of the primary psychiatric diagnoses of the patient and initiated in combination with appropriate psychosocial interventions. Review of the literature suggests that risperidone has the most supporting evidence in the treatment of explosive behavior. Stimulants have been shown to be helpful in the treatment of explosive behavior in attention-deficit/hyperactivity disorder. Medication treatment can be associated with significant side effects and therefore the risks and benefits of medication management must be weighed carefully.

Management of Acute Agitation and Aggression in Children and Adolescents with Pro Re Nata Oral Immediate Release Antipsychotics in the Pediatric Emergency Department

Background: Acute agitation in the pediatric emergency department (ED) has the potential to escalate into aggression and result in harm. Rapid and effective management may be warranted. Use of pro re nata (prn) oral immediate-release (IR) quetiapine, haloperidol, loxapine, and chlorpromazine has been observed in the pediatric ED at Surrey Memorial Hospital to manage this condition; however, evidence for oral prn antipsychotic use is limited in the pediatric population. Objectives: The primary objective is to characterize the dose of prn oral IR quetiapine used to manage acute agitation or aggression in a pediatric ED. Secondary objectives include characterizing the dose of prn oral IR haloperidol, loxapine, and chlorpromazine; and describing the 1-hour response rate, admission rate, length of stay (LOS), and adverse drug effects. Method: The medical records of pediatric patients who received at least one prn oral dose of IR quetiapine, haloperidol, loxapine, or chlorpromazine for acute agitation and aggression, without regard to the etiology of symptom presentation, between January 1, 2012 and December 31, 2016, were analyzed retrospectively. Results: Sixty-nine patients met the inclusion criteria. The mean dose of quetiapine was 32 mg/dose (0.54 mg/kg per dose); and the response rate was 53%. The mean haloperidol, loxapine, and chlorpromazine doses were 4 mg (0.07 mg/kg per dose), 13 mg (0.19 mg/kg per dose), and 29 mg/dose (0.53 mg/kg per dose) respectively; and the response rates were 36%, 30%, and 50%, respectively. Between 19% and 60% of patients were admitted, majority to the psychiatry ward. The median LOS in the ED was between 5 and 18 hours for nonadmitted patients. Extrapyramidal side effects (EPS) were reported with first-generation antipsychotics (FGA), but not with quetiapine. Conclusion: Quetiapine appears to be a viable agent for managing acute agitation and aggression in the pediatric ED with low rates of EPS. Further studies are encouraged to compare the effectiveness of quetiapine with FGA. A Clinical Trial Registration number is not applicable for this study.

Frequency, Characteristics and Risk Factors of Aggressive Incidents in a Paediatric Rehabilitation Setting: A Prospective Survey

Aim: Aggressive incidents (AI) are a serious concern in health care and can have negative effects on the physical and emotional well-being staff. This study aimed to determine frequency, characteristics and risk factors for aggressive behavior.Methods: AI were recorded during six months by the staff in a pediatric rehabilitation clinic using the evaluation form for AI (EVA). Patients were divided into the study group (patients who were involved in AI) and controls.Results: 14/105 (13%) of patients were involved in 79 AI. 0.44 AI per day occurred. Most often AI occurred on Mondays and 98% included physical, 22% verbal aggression. Most frequent target (43%) were nurses, followed by therapists (31.6%).Significant risk factors for AI were: previous aggressive behavior (p = .038), lower cognitive and higher mobility sub-scores in the WeeFIM. Conclusion: Findings emphasize the magnitude of AI in pediatric rehabilitation and thus the importance of implement preventive strategies.Abbreviations: ADL: Activity of daily living; AI: Aggressive Incidents; CFCS: Communication Function Classification System; EVA: Recording aggressive incidents (Erfassung von Aggressionsereignissen); GMFCS: Gross Motor Function Classification System; MACS: Manual Ability Classification System; SOAS-R: Staff Observation of Aggression Scale-Revised; WeeFIM: Functional Independence Measure for Children; WPV: Workplace violence.

Physical restraint during inpatient treatment of adolescent anorexia nervosa: frequency, clinical correlates, and associations with outcome at five-year follow-up

BACKGROUND

Studies of the use and effects of physical restraint in anorexia nervosa (AN) treatment are lacking. The purpose of this study was to describe the frequency of physical restraint in a specialized program for adolescents with AN, and to examine if meal-related physical restraint (forced nasogastric tube-feeding) was related to 5-year outcome.

METHOD

Thirty-eight (66% of 58) patients with AN (mean age 15.9, SD = 1.9) admitted to a regional, specialized adolescent eating disorders (ED) inpatient unit. Patient data, including restraint episodes, were obtained from hospital records, and outcome was assessed at a 5-year follow-up.

RESULTS

A total of 201 restraint episodes occurred over 5513 days of inpatient treatment, including 109 meal-related episodes and 56 episodes to avoid self-harm. Twelve (32%) patients experienced at least one restraint episode during the admission, of which eight (21%) experienced meal-related restraint. Four patients represented 91% of all restraint episodes, experiencing 10 or more episodes during admission. Meal-related restraint was significantly associated with a higher rate of persisting ED diagnosis, but not with weight gain during admission, EDE-Q global score or BMI at follow-up.

CONCLUSIONS

Restraint episodes occurred rather infrequently. A small number of patients (n = 4) accounted for a high proportion of episodes (91%). More knowledge is important to reduce the need for restraint in treatment for AN.

Factors Associated With Involuntary Psychiatric Hospitalization of Youths in China Based on a Nationally Representative Sample

Objective: This nationally representative sample investigates demographic, diagnostic and clinical features associated with both voluntary and involuntary psychiatric hospitalization among children and adolescents psychiatrically hospitalized in China. Method: As part of an official national survey, 41 provincial tertiary psychiatric hospitals in China were selected. Data from 196 children and adolescents who were discharged from these psychiatric hospitals from March 19 to 31, 2019 were retrieved and analyzed. Results: 1. Psychotic symptoms, depressive symptoms and self-injury/suicide were the most common reasons of admission. Girls were significantly likely to be admitted due to depressive symptoms, whereas boys were more likely to be admitted due to aggressive behaviors. 2. The overall rate of involuntary admission was 32.1% (N = 63). Compared to patients who were admitted voluntarily, those who were admitted involuntarily had lower GAF scores on admission, were older, were more likely to present with psychotic symptoms, manic symptoms or aggressive behavior as primary reason for admission, were less likely to present with depressive symptoms, had a significantly longer length of stay, were more likely to be diagnosed with schizophrenia and were less likely to be diagnosed as depressive disorder. 3. A logistic regression showed that depressive symptom as primary reason for admission was significantly associated with voluntary admission (OR = 0.159, p < 0.001), along with two other factors: age (p < 0.01) and a lower GAF score at admission (p < 0.001) were significantly associated with involuntary admission. Conclusion: The rate of involuntary psychiatric hospitalization among children and adolescents is higher in China than in other regions. Developing more specific and more operational criteria to guide involuntary psychiatric admission for child and adolescent patients is of urgency and great importance to ensure appropriate treatment of these patients and protect their rights.

Modifiable factors affecting inpatient violence in an acute child and adolescent psychiatric unit: A 16-year retrospective study

Violent incidents in acute inpatient units for children and adolescents are a major and persistent problem. The demographic, clinical, and modifiable (environmental-organizational) risk factors that affect inpatient violence in an Acute Child and Adolescent Psychiatric Unit were investigated via a retrospective study. Data were collected from nursing and medical reports and the unit's census and included 100 days per year for 16 years. Incidents of violence and assault types were recorded, and variables such as the diagnostic category of assailants, total number of patients, and staffing factors during the incident were examined. Of the 2390 violent incidents recorded, 50% were attributed to cases of physical violence towards another patient, 17% to physical violence towards nursing staff, 19% to physical violence towards self and 14% to destruction of property. According to the final multivariable model, for each additional patient in the unit, the risk of a violent event increased by 9.51%; for each additional offender patient, the risk increased by 14.06%; the number of assistant nurses was associated with a 25.03% increased risk; and, after 2006, the risk increased by 68.99%. The most significant factor associated with a 59.98% decreased risk was the total number of nursing staff. All variables significantly and independently contributed to the model. Acute inpatient psychiatric units with a small number of hospitalized patients, adequate, well-trained and specialized nursing staff, and the hospitalization of different types of patients in separate wards or units are expected to facilitate a reduction in the frequency of violent incidents.

Prevalence and predictors of restrictive interventions in a youth-specific mental health inpatient unit

INTRODUCTION

The use of restrictive interventions is one of the most controversial practices in medicine. They are utilized in an inpatient setting to manage agitated or aggressive behaviour or to ensure that an individual receives the necessary treatments. However, restrictive interventions remove autonomy and adverse events can be associated with their practice. Youth-specific inpatient units (IPUs) are now being established and it is imperative that the use of restrictive interventions is reduced. In order to inform and facilitate prevention and reduction strategies, this study aimed to determine the prevalence and determinants of restrictive interventions (restraint, seclusion and medication without consent) in a youth specialist mental health IPU.

METHODS

This study was set at a 16-bed youth specialist acute IPU of Orygen Youth Health, a specialist youth mental health service that provides inpatient care for those aged 18 to 25 years within a catchment area of west and north-western regions of Melbourne, Australia. A retrospective file audit was conducted of all the admissions to the unit from 01 January 2015 to 30 June 2015.

RESULTS

Over the 6-month study period, 159 young people were admitted and this accounted for 188 admissions. Over half (54.3%) of admissions were involuntary and restrictive intervention were used in 17.6% of admissions. Specifically, 15.7% (N = 25) of young people experienced restraint, 10.1% (N = 16) were secluded, and 8.1% (N = 12) experienced medication without consent. Absent insight and involuntary status on admission were associated with restrictive interventions.

CONCLUSION

As youth mental health services develop, interventions aimed at reducing restrictive interventions are needed.

Agression en milieu psychiatrique fermé : identification des déclencheurs qui précèdent les agressions contre les intervenants

Cette étude vise l’identification des déclencheurs qui précèdent les agressions survenues dans un hôpital psychiatrique fermé. Une analyse de contenu de 140 rapports d’incident visant l’identification du déclencheur qui précédait immédiatement les événements d’agression survenus entre 2012 et 2017 a été effectuée. Avec un accord interjuge de 0,87, les résultats concordent avec ceux retrouvés dans des études précédentes. Plus de 37 % des agressions surviennent à la suite d’une intervention verbale d’un intervenant, alors qu’un peu plus de 54 % ont lieu à la suite d’un contact physique entre un intervenant et un patient. Moins de 9 % des agressions subies par le personnel sont liées à des événements où il a été impossible d’observer un déclencheur. Ces résultats sont discutés dans le cadre d’une approche interactionnelle sur l’agression en psychiatrie légale et ils permettent de proposer des pistes pour réduire le risque d’agression.

Mental health of the male adolescent and young man: the Copenhagen statement

BACKGROUND

Male adolescents and young men benefit when their mental health care is specialized to match their unique gendered and developmental needs. Sensitivity to the social circumstances of this population is important; additionally, the emerging ability to tailor care through knowledge gleaned from the intersection of psychiatry, neurology, and endocrinology informs care.

DATA SOURCES

This article summarized the views of six experts in the area of the adolescent and young adult male mental health. These experts were select members of the World Federation of Societies of Biological Psychiatry's Task Force on Men's Mental Health. They convened to present two symposia on the topic of men's mental health at the 13th World Congress of Biological Psychiatry (WCBP) in Copenhagen, Denmark in 2017.

RESULTS

In these works, a special focus is paid to addictive disorders, disruptive behavior disorders, aggression, and brain development. Collectively, the authors present an argument for the merits of a male-specific model of mental health care to advance the overall well-being of this population.

CONCLUSIONS

Men's mental health should be recognized as a social issue as much as a medical issue, with special attention paid to problems such as unemployment, familial disruption, and substance abuse. These problems, and especially those of major societal impact including violence and suicide which are much more frequently the product of male youth and men, should have more male-tailored options for service provision that respond to men's mental health needs.

Selection of employee personal protective equipment based on aggressive behavior in pediatric neuropsychiatry

PURPOSE

Hospitalized patients with a developmental or intellectual disability and a psychiatric disorder (dual-diagnosis) often pose a risk to themselves or others leading to high injury rates for their providers. Therefore, evidence-based strategies to reduce employee injuries resulting from interactions are necessary.

METHODS

To reduce injuries resulting from interactions with dual-diagnosis patients, the Initial Behavioural Assessment (IBA) and Protective Equipment Decision Key (PEDK) were used in inpatient neuropsychiatry. The IBA-PEDK identify patients' aggressive behaviors to provide employees with personal protective equipment (PPE). Inter-rater reliability, validity, and adherence were examined.

RESULTS

Injuries significantly decreased after implementing the IBA-PEDK. The average kappa coefficient was 0.64 with a 90.6% agreement. Ninety-three percent of respondents reported wearing PPE at the time of injury.

CONCLUSIONS

A quick, user-friendly tool that provides a standardized method for determining PPE based on patient-specific behavior can significantly reduce aggression-related injuries.

Improved Metabolic and Psychiatric Outcomes with Discontinuation of Atypical Antipsychotics in Youth Hospitalized in a State Psychiatric Facility

OBJECTIVES

To assess the impact of antipsychotic tapering and discontinuation on measures of metabolic functioning and psychiatric symptom severity in severely impaired youth hospitalized in a psychiatric state hospital.

METHODS

The study examined psychiatric and metabolic measures in 67 hospitalized children and adolescents (mean age 11.9; 56 with discontinued use of antipsychotics, 10 with continued use of antipsychotics, and 1 started on an antipsychotic) from admission to discharge.

RESULTS

Upon admission, 56 youth were tapered off of antipsychotic medications, started on other forms of pharmacotherapy (92.9% were started on medications used to treat attention-deficit/hyperactivity disorder), and received evidence-based behavioral programming and were ultimately discharged from the hospital. The mean duration of treatment was 228 days for the discontinuation group and 204 days for the continuation group. Significant decreases in body mass index [BMI; t(53) = 7.12, p = 0.0001] and BMI percentile [t(53) = 6.73, p = 0.0001] were found from admission to discharge in the antipsychotic discontinuation group. Changes in BMI, BMI percentile, or systolic blood pressure were not found in the group (n = 10) who were maintained on antipsychotics. Both groups experienced a significant increase in their Global Assessment of Functioning score [t(52) = 19.98, p = 0.0001 for discontinued; t(8) = 5.092, p = 0.001 for maintained]. Psychiatric symptom severity scores significantly improved in many subscales relevant to disruptive behaviors and mood disorders for those who were removed from the medications. For those maintained on the antipsychotics, there were fewer changes in psychiatric symptom scores.

CONCLUSION

Discontinuation of atypical antipsychotic medications in conjunction with tailoring treatment to presenting diagnoses resulted in metabolic and psychiatric symptom improvement among severely impaired state hospital inpatient youth. These results serve as a feasibility demonstration that discontinuation of antipsychotics does not provoke psychiatric destabilization, particularly among disruptive behavior disordered youth.

Stability and Change of Adolescents' Aggressive Behavior in Residential Youth Care

BACKGROUND

Aggression in residential youth care institutions is a frequent problem.

OBJECTIVE

The present short-term longitudinal study examined individual and institutional predictors of aggression in a group of 198 adolescents placed in open, semi-secure and secure residential institutions from the perspective of the importation and deprivation model.

METHODS

A total of 198 adolescents in residential youth care filled in questionnaires regarding group climate and aggression with a 3 month interval. Hierarchical multiple regression analyses were performed to test the degree to which individual and contextual factors predict aggression.

RESULTS

Very limited support was found for the effect of contextual factors; only repression showed a trend, predicting direct aggression, while gender composition of the living groups yielded a small effect. Girls placed in same-gender groups showed lower levels of indirect (relational) aggression compared to adolescents placed in mixed-gender or boys-only groups, even when controlled for gender and initial levels of aggression. Type of institution (i.e., level of security) did not predict differences in aggression. In particular individual characteristics of the adolescents were associated with later aggression, including initial levels of aggression, showing substantial 3 months stability, age and gender of the adolescents.

CONCLUSIONS

These findings are in line with research showing that aggression is relatively stable. Very limited support for environmental effects was found.

The use and effectiveness of pro re nata psychotropic medications in children and adolescents: A systematic review

BACKGROUND

Published studies have not demonstrated the benefits of the practice of psychotropic PRN administration.

AIM

The goal of this study is to perform a systematic review on pro re nata (PRN) psychotropic medications administration in children and adolescents and examine the safety and effectiveness of this practice in child and adolescent psychiatric care units.

SETTINGS AND DESIGN

This is a systematic review.

MATERIALS AND METHODS

Several databases were searched till date. One hundred and sixty-five titles and abstracts were found and a total of 14 studies, for which most were retrospective, met the absolute criteria. The patients studied were children, adolescents and patients that presented to the emergency room or admitted as inpatient.

RESULTS

Indications for admission included aggression and agitation for all the studies. Most the medications used include haloperidol, olanzapine, diazepam, and risperidone. Commonly reported adverse effects following the administration of the PRN medications were sleepiness, acute dystonia, and drowsiness. The effectiveness of PRN medications, which was reported in four of reviewed studies, ranged from 30% to 50%.

CONCLUSION

Different effectiveness/outcome measures were used for all the studies; therefore, we could not generalize effectiveness across all the studies. Findings of the reviewed articles show the imperativeness of more research to evaluate the safety and effectiveness of PRN medications among child and adolescent populations.

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.

Child Psychiatric Emergencies: Updates on Trends, Clinical Care, and Practice Challenges

Over the past 15 years, the number of pediatric patients presenting to the emergency room in psychiatric crisis has nearly doubled. Suicidality and aggression are among the most common presenting problems, making it important for providers to have up-to-date knowledge about the assessment and management of these frequently encountered clinical issues. Psychometrically sound suicide risk assessment tools are available for use in the emergency room setting, which can be administered efficiently with minimal provider training. Rates of off-label medication use in the pediatric population continue to increase and are often used in the management of acute agitation in the pediatric population. The current literature will be reviewed and summarized for application in emergent treatment settings. Overall, evidence to inform best practice is limited, leading to opportunities for innovation in health care delivery, the development of new research aims, and discussion of challenging clinical dilemmas.

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.

Registration of aggressive incidents in an adolescent forensic psychiatric unit and implications for further practice

Although aggression is part of daily life in psychiatric units for adolescents, empirical data on its prevalence are sparse. Only few studies have described prevalence of aggressive incidents in adolescent psychiatric wards, and data in forensic psychiatric care are even more limited. Available studies reported high prevalence rates of aggression, ranging from 0.4 to 2.4 incidents of aggression per day across (forensic) child and adolescent psychiatric units. Between 27 and 78 % of all admitted youth committed an aggressive act. In this study, we collected systematically registered data of all aggressive incidents from the first 2 years (2010-2012) on a newly established forensic adolescent psychiatric unit, which used a formal aggression management program embedded in the social competence model, which is based on early intervention in the 'chain of behavior' to prevent any further escalation. The inclusion of also minor aggressive incidents is unique in the literature and the clinical relevance is highlighted. A mean of one incident a day took place, with each adolescent involved in at least one incident. Notably, 1.7 aggressive incidents per month made seclusion of restraint use necessary. Based on the social competence theory, the aggression management model suggests intervening early in the cascade of aggression, in order to prevent further escalation and reduce the need for intrusive interventions. Evidence supported that aggression is a contextual event, as external factors clearly influence the incidence of aggression. Aggression management should be built on both relational and structural security.

Use of restrictive interventions in a child and adolescent inpatient unit - predictors of use and effect on patient outcomes

OBJECTIVES

Restrictive interventions (seclusion, physical restraint, and use of acute/p.r.n. sedation) may have negative effects on patients. Identifying factors associated with use of restrictive interventions and examining their effect on admission outcomes is important for optimising inpatient psychiatric care.

METHODS

This study documented use of restrictive interventions within a child and adolescent psychiatric inpatient unit for 15 months. Two models examined predictors of use of restrictive interventions: (i) incident characteristics; and (ii) patient characteristics. The relationship between use of restrictive interventions and global clinical outcomes was also examined.

RESULTS

Of 134 patients admitted during the study period (61.9% female, mean age=13.8±2.9 years), 26.9% received at least one restrictive intervention. Incident factors associated with restrictive interventions were: physical aggression, early admission stage, and occurrence in private space. Patient factors that predicted use of restrictive interventions were developmental disorder and younger age. Use of restrictive interventions was not associated with increased length of stay or diminished improvement in global symptom ratings.

CONCLUSIONS

Further research is needed to identify best practice in children at high risk for receiving restrictive interventions.