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Czernin K, Bründlmayer A, Oster A, Baumgartner JS, Plener PL. Children and adolescents at risk for seclusion and restraint in inpatient psychiatric treatment: a case control study. Child Adolesc Psychiatry Ment Health 2024; 18:102. [PMID: 39138471 PMCID: PMC11323577 DOI: 10.1186/s13034-024-00791-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 07/26/2024] [Indexed: 08/15/2024] Open
Abstract
To reduce coercion in acute inpatient child and adolescent psychiatric units, a better understanding of individuals at risk for seclusion and/or restraint (S/R) is needed. We report data on the proportion of patients secluded/restrained and factors associated with higher risk of S/R. Identifying preventative mechanisms through risk stratification upon inpatient admission can aid the training of mental health professionals, and support shaping specific workflows for at-risk populations for example by joint crisis plans or post-coercion review sessions. METHODS A case-control study included all admissions (n = 782) to a department of child and adolescent psychiatry within 36 months between 2019 and 2022. Data on age, sex, out of home care, primary and comorbid ICD-10 diagnoses, length of stay, prior/multiple admissions were compared between admissions with and without S/R using chi square tests for categorical and t-tests for continuous variables. Uni- and multivariate binary logistic regression models were computed. RESULTS The overall proportion of S/R was 12.8% (n = 100). Females (p = 0.001), patients in out of home care (p < 0.001), with prior admission (p < 0.001), Post-traumatic stress disorder (PTSD; p < 0.001) and Borderline personality disorder (BPD; p < 0.001) were at a significantly higher risk of S/R. Length of stay in days (OR 1.01), out of home care (OR 3.85), PTSD (OR 6.20), BPD (OR 15.17), Attention deficit hyperactivity disorder (ADHD)/conduct disorder (OR 4.29), and manic episode/bipolar disorder (OR 36.41) were significantly associated with S/R in multivariate regression. CONCLUSIONS Child and adolescent psychiatric staff should consider risk factors when using coercive measures. Patients with PTSD and/or BPD are the most vulnerable subgroups. Training of professionals and clinical practice need to be adapted in order to prevent the use of S/R and its potential hazards.
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Affiliation(s)
- Klara Czernin
- Department of Child and Adolescent Psychiatry, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Anselm Bründlmayer
- Department of Child and Adolescent Psychiatry, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Anna Oster
- Department of Psychiatry and Psychotherapy, Clinics in the Theodor-Wenzel-Werk, Berlin, Germany
| | - Josef S Baumgartner
- Clinical Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Paul L Plener
- Department of Child and Adolescent Psychiatry, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
- Department of Child and Adolescent Psychiatry and Psychotherapy, University of Ulm, Ulm, Germany.
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Moell A, Lyle MS, Rozental A, Långström N. Rates and risk factors of coercive measure use in inpatient child and adolescent mental health services: a systematic review and narrative synthesis. Lancet Psychiatry 2024:S2215-0366(24)00204-9. [PMID: 39121879 DOI: 10.1016/s2215-0366(24)00204-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 05/30/2024] [Accepted: 06/07/2024] [Indexed: 08/12/2024]
Abstract
Reducing the use of coercive measures in inpatient child and adolescent mental health services (CAMHS) requires an understanding of current rates and associated factors. We conducted a systematic review of research published between Jan 1, 2010, and Jan 10, 2024, addressing rates and risk factors for mechanical, physical, or pharmacological restraint, seclusion, or forced tube feeding in inpatient CAMHS. We identified 30 studies (including 39 027 patients or admissions) with low risk of bias. Median prevalence was 17·5% for any coercive measure, 27·7% for any restraint, and 6·0% for seclusion. Younger age, male sex, ethnicity or race other than White, longer stay, and repeated admissions were frequently linked to coercive measure use. Variable rates and conflicting risk factors suggest that patient traits alone are unlikely to determine coercive measure use. More research, especially in the form of nationwide studies, is needed to elucidate the impact of care and staff factors. Finally, we propose reporting guidelines to improve comparisons over time and settings.
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Affiliation(s)
- Astrid Moell
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
| | - Maria Smitmanis Lyle
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Alexander Rozental
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden; Department of Psychology, Uppsala University, Uppsala, Sweden; Department of Health, Education and Technology, Luleå University of Technology, Luleå, Sweden
| | - Niklas Långström
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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Shepherd WB, Patterson K, Blake J, Ward D, Clarke A, Diaz-Navarro C, Abdulsatar F. Impact of a debrief tool in acute child and adolescent mental health inpatient units: a centre's experience. BMJ Open Qual 2024; 13:e002704. [PMID: 38782486 PMCID: PMC11116849 DOI: 10.1136/bmjoq-2023-002704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 05/15/2024] [Indexed: 05/25/2024] Open
Abstract
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.
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Affiliation(s)
- William Billal Shepherd
- Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
| | | | - Jessica Blake
- Department of Child and Adolescent Psychiatry, London Health Sciences Centre, London, Ontario, Canada
| | - Danielle Ward
- London Health Sciences Centre, London, Ontario, Canada
| | - Ashlee Clarke
- Department of Child and Adolescent Psychiatry, London Health Sciences Centre, London, Ontario, Canada
| | | | - Farah Abdulsatar
- Department of Paediatrics, Western University, London, Ontario, Canada
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Laake ALW, Roaldset JO, Husum TL, Bjørkly SK, Gustavsen CC, Lockertsen Ø. Interrater reliability of the violence risk assessment checklist for youth: a case vignette study. BMC Psychiatry 2024; 24:303. [PMID: 38654194 DOI: 10.1186/s12888-024-05746-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 04/08/2024] [Indexed: 04/25/2024] Open
Abstract
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.
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Affiliation(s)
- Anniken L W Laake
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway.
- Oslo University Hospital, Centre for Research and Education in Forensic Psychiatry, Oslo, Norway.
| | - John Olav Roaldset
- Oslo University Hospital, Centre for Research and Education in Forensic Psychiatry, Oslo, Norway
| | - Tonje Lossius Husum
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway
| | - Stål Kapstø Bjørkly
- Faculty of Health Sciences and Social Care, Molde University College, Molde, Norway
| | | | - Øyvind Lockertsen
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway
- Oslo University Hospital, Centre for Research and Education in Forensic Psychiatry, Oslo, Norway
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Haran M, Killeen D, Healy M, Brophy P, Donohue A, Whyte I, Doody B. Prevalence and correlates of restrictive interventions in an Irish child and adolescent psychiatric unit: a 4-year retrospective study. Ir J Med Sci 2023; 192:2929-2936. [PMID: 36813877 PMCID: PMC10692034 DOI: 10.1007/s11845-023-03316-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/09/2023] [Indexed: 02/24/2023]
Abstract
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.
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Affiliation(s)
- Maeve Haran
- Department of Psychiatry, School of Medicine, University College Dublin, Dublin, Ireland.
- Children's Health Ireland at Crumlin, Dublin, D12N512, Ireland.
| | - David Killeen
- Dublin North City and County CAMHS - Ballymun CAMHS, Ballymun Civic Centre, Dublin, Ireland
| | - Mike Healy
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
| | - Peadar Brophy
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
| | - Aoife Donohue
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
| | - Imelda Whyte
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
| | - Brendan Doody
- Linn Dara Inpatient Unit, Cherry Orchard Hospital, Ballyfermot Rd, Cherry Orchard, Dublin, Ireland
- Department of Psychiatry, Trinity College Dublin, Dublin, Ireland
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John JR, Thavalingam V, Tye M, Dean K, Barzman D, Sorter M, Lin PI. Appraising risk factors of aggression in children and adolescents at psychiatric inpatient units. Psychiatry Res 2023; 327:115368. [PMID: 37506586 DOI: 10.1016/j.psychres.2023.115368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/26/2023] [Accepted: 07/23/2023] [Indexed: 07/30/2023]
Abstract
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.
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Affiliation(s)
- James Rufus John
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia; Ingham Institute of Applied Medical Research, Liverpool, NSW, Australia
| | - Vignesh Thavalingam
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Michelle Tye
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia; Black Dog Institute, University of New South Wales, Hospital Road, Randwick, NSW, Australia
| | - Kimberlie Dean
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia; Justice Health and Forensic Mental Health Network, Sydney, NSW, Australia
| | - Drew Barzman
- Department of Psychiatry and Behavioural Neuroscience, University of Cincinnati, Ohio, United States; Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Ohio, United States
| | - Michael Sorter
- Department of Psychiatry and Behavioural Neuroscience, University of Cincinnati, Ohio, United States; Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Ohio, United States
| | - Ping-I Lin
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia; Ingham Institute of Applied Medical Research, Liverpool, NSW, Australia; Department of Mental Health, School of Medicine, Western Sydney University, Penrith, NSW, Australia.
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7
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Carlson GA, Singh MK, Amaya-Jackson L, Benton TD, Althoff RR, Bellonci C, Bostic JQ, Chua JD, Findling RL, Galanter CA, Gerson RS, Sorter MT, Stringaris A, Waxmonsky JG, McClellan JM. Narrative Review: Impairing Emotional Outbursts: What They Are and What We Should Do About Them. J Am Acad Child Adolesc Psychiatry 2023; 62:135-150. [PMID: 35358662 DOI: 10.1016/j.jaac.2022.03.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/31/2022] [Accepted: 03/21/2022] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Gabrielle A Carlson
- Renaissance School of Medicine at Stony Brook University, Putnam Hall, South Campus, Stony Brook, New York.
| | | | | | - Tami D Benton
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | | | - Jeff Q Bostic
- MedStar Georgetown University Hospital, Washington, DC
| | - Jaclyn Datar Chua
- Perelman School of Medicine, University of Pennsylvania, Philadelphia; University of Pennsylvania, Philadelphia
| | | | - Cathryn A Galanter
- SUNY Downstate, Brooklyn, New York; Kings County Hospital Center, Brooklyn, New York
| | | | - Michael T Sorter
- Cincinnati Children's Hospital and the University of Cincinnati, Ohio
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8
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Magnowski SR, Kick D, Cook J, Kay B. Algorithmic Prediction of Restraint and Seclusion in an Inpatient Child and Adolescent Psychiatric Population. J Am Psychiatr Nurses Assoc 2022; 28:464-473. [PMID: 33251913 DOI: 10.1177/1078390320971014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Stefani R Magnowski
- Stefani R. Magnowski, DNP, RN, NE-BC, CPHQ, Rogers Behavioral Health, Oconomowoc, WI, USA
| | - Dalton Kick
- Dalton Kick, MS, Rogers Behavioral Health, Oconomowoc, WI, USA
| | - Jessica Cook
- Jessica Cook, MS, Rogers Behavioral Health, Oconomowoc, WI, USA
| | - Brian Kay
- Brian Kay, MS, Rogers Behavioral Health, Oconomowoc, WI, USA
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Barzman D, Hemphill R, Appel K, Kerekes O, Sorter M, Berry AM, Combs J, Osborn A, Lin PD. A Large Naturalistic Study on the BRACHA: Confirmation of the Predictive Validity. Psychiatr Q 2022; 93:803-811. [PMID: 35732915 DOI: 10.1007/s11126-022-09993-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2022] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Drew Barzman
- Director of the Child & Adolescent Forensic Research Program Director of Research for the UC Division of Forensic Psychiatry Professor of Psychiatry, University of Cincinnati & Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Rosalie Hemphill
- Director of the Child & Adolescent Forensic Research Program Director of Research for the UC Division of Forensic Psychiatry Professor of Psychiatry, University of Cincinnati & Cincinnati Children's Hospital Medical Center, Cincinnati, USA.
| | - Kacey Appel
- Director of the Child & Adolescent Forensic Research Program Director of Research for the UC Division of Forensic Psychiatry Professor of Psychiatry, University of Cincinnati & Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Olivia Kerekes
- Director of the Child & Adolescent Forensic Research Program Director of Research for the UC Division of Forensic Psychiatry Professor of Psychiatry, University of Cincinnati & Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Michael Sorter
- Director of the Child & Adolescent Forensic Research Program Director of Research for the UC Division of Forensic Psychiatry Professor of Psychiatry, University of Cincinnati & Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Ashley-Marie Berry
- Director of the Child & Adolescent Forensic Research Program Director of Research for the UC Division of Forensic Psychiatry Professor of Psychiatry, University of Cincinnati & Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Jennifer Combs
- Director of the Child & Adolescent Forensic Research Program Director of Research for the UC Division of Forensic Psychiatry Professor of Psychiatry, University of Cincinnati & Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Alexander Osborn
- Director of the Child & Adolescent Forensic Research Program Director of Research for the UC Division of Forensic Psychiatry Professor of Psychiatry, University of Cincinnati & Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - P Daniel Lin
- University of New South Wales School of Psychiatry, Taipei Medical University, Taipei, Taiwan
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10
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Boulton KA, Raghupathy V, Guastella AJ, Bowden MR. Reducing seclusion use in an Australian child and adolescent psychiatric inpatient unit. J Affect Disord 2022; 305:1-7. [PMID: 35227762 DOI: 10.1016/j.jad.2022.02.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/19/2022] [Accepted: 02/22/2022] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Kelsie A Boulton
- Autism Clinic for Translational Research, Brain and Mind Centre, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Child Neurodevelopment and Mental Health Team, Brain and Mind Centre, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Veena Raghupathy
- Psychological Medicine, Children's Hospital at Westmead, Sydney Children's Hospital Network, Sydney, Australia
| | - Adam J Guastella
- Autism Clinic for Translational Research, Brain and Mind Centre, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Child Neurodevelopment and Mental Health Team, Brain and Mind Centre, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
| | - Michael R Bowden
- Psychological Medicine, Children's Hospital at Westmead, Sydney Children's Hospital Network, Sydney, Australia; Mental Health - Children and Young People, Mental Health Branch, NSW Health, Sydney, Australia; Faculty of Medicine and Health, Sydney Medical School, University of Sydney, Sydney, Australia
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11
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Perers C, Bäckström B, Johansson BA, Rask O. Methods and Strategies for Reducing Seclusion and Restraint in Child and Adolescent Psychiatric Inpatient Care. Psychiatr Q 2022; 93:107-136. [PMID: 33629229 PMCID: PMC8993718 DOI: 10.1007/s11126-021-09887-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2020] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
| | - Beata Bäckström
- Skåne Child & Adolescent Psychiatry, Unit for Pediatric Bipolar & Psychotic Disorders, Lund, Sweden
| | - Björn Axel Johansson
- Department of Clinical Sciences Lund, Division of Child & Adolescent Psychiatry, Lund University, Lund, Sweden
- Skåne Child & Adolescent Psychiatry, Regional Inpatient Care, Emergency Unit, Malmö, Sweden
| | - Olof Rask
- Skåne Child & Adolescent Psychiatry, Unit for Pediatric Bipolar & Psychotic Disorders, Lund, Sweden
- Department of Clinical Sciences Lund, Division of Child & Adolescent Psychiatry, Lund University, Lund, Sweden
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12
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Agraharkar S, Horwitz S, Lewis K, Goldstein G, Havens J, Gerson R. Agitation and Restraint in a Pediatric Psychiatric Emergency Program: Clinical Characteristics and Diagnostic Correlates. Pediatr Emerg Care 2021; 37:e836-e840. [PMID: 34908377 DOI: 10.1097/pec.0000000000002385] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Shilpa Agraharkar
- From the New York University Langone Health Child Study Center, Bellevue Hospital, New York, NY
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13
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Geng F, Jiang F, Conrad R, Liu T, Liu Y, Liu H, Tang YL. Elevated Rates of Restraint and Seclusion in Child and Adolescent Psychiatric Inpatients in China and Their Associated Factors. Child Psychiatry Hum Dev 2021; 52:939-944. [PMID: 33037522 DOI: 10.1007/s10578-020-01074-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Feng Geng
- Affiliated Psychological Hospital of Anhui Medical University, No. 316 Huangshan Road, Hefei, 230022, China.,Hefei Fourth People's Hospital, No. 316 Huangshan Road, Hefei, 230022, China.,Anhui Mental Health Center, No. 316 Huangshan Road, Hefei, 230022, China.,Department of Psychiatry, Chaohu Hospital of Anhui Medical University, No. 64 Chaohu North Road, Chaohu District, Hefei, 238000, China
| | - Feng Jiang
- Institute of Health Yangtze River Delta, Shanghai Jiaotong University, No. 1954 Huashan Road, Xuhui District, Shanghai, 200030, China
| | - Rachel Conrad
- Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA.,Harvard Medical School Center for Bioethics, 641 Huntington Ave, Boston, MA, 02115, USA
| | - Tingfang Liu
- Institute for Hospital Management of Tsinghua University, Haidian District, Beijing, 100730, China
| | - Yuanli Liu
- School of Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 3 Dong Dan San Tiao, Dongcheng District, Beijing, 100730, China
| | - Huanzhong Liu
- Department of Psychiatry, Chaohu Hospital of Anhui Medical University, No. 64 Chaohu North Road, Chaohu District, Hefei, 238000, China.
| | - Yi-Lang Tang
- Department of Psychiatry and Behavioral Sciences, Emory University, 12 Executive Park Drive NE, Atlanta, GA, 30329, USA. .,Mental Health Service Line, Atlanta VA Medical Center, Decatur, GA, 30033, USA.
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Noah A, Andrade G, DeBrocco D, Dunn M, Herz K, Worsley D, Camacho P, Doupnik SK. Patient Risk Factors for Violent Restraint Use in a Children's Hospital Medical Unit. Hosp Pediatr 2021; 11:833-840. [PMID: 34230060 PMCID: PMC8336459 DOI: 10.1542/hpeds.2020-000273] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Akaninyene Noah
- Center for Pediatric Clinical Effectiveness and PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gabriela Andrade
- Departments of Child and Adolescent Psychiatry and Behavioral Sciences
| | - Dawn DeBrocco
- Departments of Child and Adolescent Psychiatry and Behavioral Sciences
| | - Michelle Dunn
- Division of General Pediatrics, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Katherine Herz
- Division of General Pediatrics, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Diana Worsley
- Center for Pediatric Clinical Effectiveness and PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Stephanie K Doupnik
- Center for Pediatric Clinical Effectiveness and PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of General Pediatrics, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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15
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Predicting the time trend of first episodes of aggressive behaviors in pediatric psychiatric inpatient units. J Psychiatr Res 2021; 140:117-123. [PMID: 34111701 DOI: 10.1016/j.jpsychires.2021.05.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 03/30/2021] [Accepted: 05/21/2021] [Indexed: 02/03/2023]
Abstract
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.
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16
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Abstract
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.
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17
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Yip L, Aeng E, Elbe D. Management of Acute Agitation and Aggression in Children and Adolescents with Pro Re Nata Oral Immediate Release Antipsychotics in the Pediatric Emergency Department. J Child Adolesc Psychopharmacol 2020; 30:534-541. [PMID: 33035069 DOI: 10.1089/cap.2019.0171] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Lisa Yip
- Department of Pharmacy, Children's and Women's Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Elissa Aeng
- Department of Pharmacy, Surrey Memorial Hospital, Surrey, British Columbia, Canada
| | - Dean Elbe
- Department of Pharmacy, Children's and Women's Health Centre of British Columbia, Vancouver, British Columbia, Canada
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18
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Meier SBB, Uenver Y, Stooss A, Meyer-Heim A. Frequency, Characteristics and Risk Factors of Aggressive Incidents in a Paediatric Rehabilitation Setting: A Prospective Survey. Dev Neurorehabil 2020; 23:9-17. [PMID: 31055992 DOI: 10.1080/17518423.2019.1604579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- S B B Meier
- Rehabilitation centre Affoltern am Albis, University Children's Hospital Zurich, Switzerland
| | - Y Uenver
- Rehabilitation centre Affoltern am Albis, University Children's Hospital Zurich, Switzerland
| | - A Stooss
- Rehabilitation centre Affoltern am Albis, University Children's Hospital Zurich, Switzerland
| | - A Meyer-Heim
- Rehabilitation centre Affoltern am Albis, University Children's Hospital Zurich, Switzerland
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19
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Blikshavn T, Halvorsen I, Rø Ø. Physical restraint during inpatient treatment of adolescent anorexia nervosa: frequency, clinical correlates, and associations with outcome at five-year follow-up. J Eat Disord 2020; 8:20. [PMID: 32514349 PMCID: PMC7262758 DOI: 10.1186/s40337-020-00297-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/23/2020] [Indexed: 01/18/2023] Open
Abstract
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.
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Affiliation(s)
- Thomas Blikshavn
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, P.O. Box 4956 Nydalen, N-0424 Oslo, Norway.,Department of Child and Adolescent Mental Health, Akershus University Hospital, Lørenskog, Norway
| | - Inger Halvorsen
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, P.O. Box 4956 Nydalen, N-0424 Oslo, Norway
| | - Øyvind Rø
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, P.O. Box 4956 Nydalen, N-0424 Oslo, Norway.,Division of Mental Health and Addiction, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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20
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Geng F, Jiang F, Conrad R, Liu T, Liu Y, Liu H, Tang YL. Factors Associated With Involuntary Psychiatric Hospitalization of Youths in China Based on a Nationally Representative Sample. Front Psychiatry 2020; 11:607464. [PMID: 33343433 PMCID: PMC7744285 DOI: 10.3389/fpsyt.2020.607464] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 11/09/2020] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Feng Geng
- Affiliated Psychological Hospital of Anhui Medical University, Hefei, China.,Hefei Fourth People's Hospital, Hefei, China.,Anhui Mental Health Center, Hefei, China.,Department of Psychiatry, Chaohu Hospital of Anhui Medical University, Hefei, China
| | - Feng Jiang
- Institute of Health Yangtze River Delta, Shanghai Jiao Tong University, Shanghai, China
| | - Rachel Conrad
- Brigham and Women's Hospital, Boston, MA, United States.,Harvard Medical School Center for Bioethics, Boston, MA, United States
| | - Tingfang Liu
- Institute for Hospital Management of Tsinghua University, Beijing, China
| | - Yuanli Liu
- School of Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huanzhong Liu
- Department of Psychiatry, Chaohu Hospital of Anhui Medical University, Hefei, China
| | - Yi-Lang Tang
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, United States.,Mental Health Service Line, Atlanta VA Medical Center, Decatur, GA, United States
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21
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Panagiotou A, Mafreda C, Moustikiadis A, Prezerakos P. Modifiable factors affecting inpatient violence in an acute child and adolescent psychiatric unit: A 16-year retrospective study. Int J Ment Health Nurs 2019; 28:1078-1089. [PMID: 31169358 DOI: 10.1111/inm.12619] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2019] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Aspasia Panagiotou
- Laboratory of Integrated Health Care, Department of Nursing, University of Peloponnese, Sparta, Greece
| | | | | | - Panagiotis Prezerakos
- Laboratory of Integrated Health Care, Department of Nursing, University of Peloponnese, Sparta, Greece
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22
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Goz K, Rudhran V, Blackburn J, Schäfer MR, O'Donoghue B. Prevalence and predictors of restrictive interventions in a youth-specific mental health inpatient unit. Early Interv Psychiatry 2019; 13:1105-1110. [PMID: 30328276 DOI: 10.1111/eip.12739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 08/12/2018] [Accepted: 09/09/2018] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Kubra Goz
- Orygen, the National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | | | | | | | - Brian O'Donoghue
- Orygen, the National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Orygen Youth Health, Melbourne, Victoria, Australia
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23
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Eblin A. Reducing seclusion and restraints on the inpatient child and adolescent behavioral health unit: A quality improvement study. JOURNAL OF CHILD AND ADOLESCENT PSYCHIATRIC NURSING 2019; 32:122-128. [DOI: 10.1111/jcap.12248] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/17/2019] [Accepted: 07/18/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Amanda Eblin
- Medical University of South Carolina Charleston South Carolina
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24
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Groleau R, Da Silva Guerreiro J. Agression en milieu psychiatrique fermé : identification des déclencheurs qui précèdent les agressions contre les intervenants. ACTA ACUST UNITED AC 2019. [DOI: 10.7202/1060006ar] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Robert Groleau
- Institut national de psychiatrie légale Philippe-Pinel. Correspondance : Institut national de psychiatrie légale Philippe-Pinel, Direction des soins infirmiers et des services multidisciplinaires, 10905 Henri-Bourassa Est, Montréal (Québec), H1C 1H1
| | - Joao Da Silva Guerreiro
- Département de psychologie, Université du Québec à Montréal
- Centre de recherche de l’Institut national de psychiatrie légale Philippe-Pinel
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Rice TR, Shah LD, Trelles P, Lin SK, Christensen DS, Walther A, Sher L. Mental health of the male adolescent and young man: the Copenhagen statement. World J Pediatr 2018; 14:224-232. [PMID: 29679360 DOI: 10.1007/s12519-018-0155-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 03/20/2018] [Accepted: 03/27/2018] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Timothy R Rice
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA.
| | - Lesha D Shah
- New York University School of Medicine, New York, NY, USA
| | - Pilar Trelles
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA
| | - Shih-Ku Lin
- Taipei City Hospital and Taipei Medical University, Taipei, China
| | - Dinne Skjærlund Christensen
- Department of Public Health, Center for Healthy Aging and Section of Environmental Health, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Walther
- Biological Psychology, TU Dresden, Dresden, Germany
- Clinical Psychology and Psychotherapy, University of Zurich, Zurich, Switzerland
| | - Leo Sher
- James J. Peters VA Medical Center and Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Daraiseh NM, Summerville LA, Lin L, Tucker D, Hill AK, Salisbury K, Lind MA. Selection of employee personal protective equipment based on aggressive behavior in pediatric neuropsychiatry. Dev Neurorehabil 2018; 21:32-39. [PMID: 27792401 DOI: 10.1080/17518423.2016.1238968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Nancy M Daraiseh
- a Research in Patient Services , Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , USA.,b James M. Anderson Center for Health Systems Excellence , Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , USA
| | - Lauren A Summerville
- b James M. Anderson Center for Health Systems Excellence , Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , USA
| | - Li Lin
- a Research in Patient Services , Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , USA
| | - DaVona Tucker
- b James M. Anderson Center for Health Systems Excellence , Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , USA
| | - Adam K Hill
- c Department of Patient Services , Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , USA
| | - Katherine Salisbury
- c Department of Patient Services , Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , USA
| | - Michael A Lind
- d Center for Behavior Analysis and Language Development , Shabani Institute , Santa Monica , California , USA
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Hulvershorn L, Parkhurst S, Jones S, Dauss K, Adams C. Improved Metabolic and Psychiatric Outcomes with Discontinuation of Atypical Antipsychotics in Youth Hospitalized in a State Psychiatric Facility. J Child Adolesc Psychopharmacol 2017; 27:897-907. [PMID: 28880609 DOI: 10.1089/cap.2017.0040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Leslie Hulvershorn
- 1 Department of Psychiatry, Indiana University School of Medicine , Indianapolis, Indiana
| | - Samantha Parkhurst
- 1 Department of Psychiatry, Indiana University School of Medicine , Indianapolis, Indiana
| | - Shannon Jones
- 2 Evansville Psychiatric Children's Center , Indiana Family and Social Services Agency, Evansville, Indiana
| | - Kristin Dauss
- 1 Department of Psychiatry, Indiana University School of Medicine , Indianapolis, Indiana
| | - Caitlin Adams
- 1 Department of Psychiatry, Indiana University School of Medicine , Indianapolis, Indiana
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Eltink EMA, Ten Hoeve J, De Jongh T, Van der Helm GHP, Wissink IB, Stams GJJM. Stability and Change of Adolescents' Aggressive Behavior in Residential Youth Care. CHILD & YOUTH CARE FORUM 2017; 47:199-217. [PMID: 29527107 PMCID: PMC5834580 DOI: 10.1007/s10566-017-9425-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- E. M. A. Eltink
- Department of Forensic Child and Youth Care Sciences, University of Amsterdam, P.O. Box 15780, 1001 NG Amsterdam, The Netherlands
| | - J. Ten Hoeve
- Department of Institute of Social Work, University of Applied Sciences of Utrecht, Utrecht, The Netherlands
| | - T. De Jongh
- Department of Forensic Child and Youth Care Sciences, University of Amsterdam, P.O. Box 15780, 1001 NG Amsterdam, The Netherlands
| | - G. H. P. Van der Helm
- Youth Expert Centre, Leiden University of Professional Sciences, Leiden, The Netherlands
| | - I. B. Wissink
- Department of Forensic Child and Youth Care Sciences, University of Amsterdam, P.O. Box 15780, 1001 NG Amsterdam, The Netherlands
| | - G. J. J. M. Stams
- Department of Forensic Child and Youth Care Sciences, University of Amsterdam, P.O. Box 15780, 1001 NG Amsterdam, The Netherlands
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Asogwa K, Okudo J, Idowu J. The use and effectiveness of pro re nata psychotropic medications in children and adolescents: A systematic review. Indian J Psychiatry 2017; 59:264-274. [PMID: 29085084 PMCID: PMC5659075 DOI: 10.4103/psychiatry.indianjpsychiatry_34_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Kenneth Asogwa
- University Hospitals Cleveland Medical Center, Division of Child and Adolescent Psychiatry, Cleveland, Ohio, USA
| | - Jerome Okudo
- University of Texas School of Public Health, Houston, Texas, USA
| | - Joel Idowu
- Richmond University Medical Center, Department of Psychiatry, Staten Island, New York, USA
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West M, Melvin G, McNamara F, Gordon M. An evaluation of the use and efficacy of a sensory room within an adolescent psychiatric inpatient unit. Aust Occup Ther J 2017; 64:253-263. [DOI: 10.1111/1440-1630.12358] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Monique West
- Monash University Centre for Developmental Psychiatry & Psychology; Notting Hill Victoria Australia
| | - Glenn Melvin
- Monash University Centre for Developmental Psychiatry & Psychology; Notting Hill Victoria Australia
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Furre A, Falk RS, Sandvik L, Friis S, Knutzen M, Hanssen-Bauer K. Characteristics of adolescents frequently restrained in acute psychiatric units in Norway: a nationwide study. Child Adolesc Psychiatry Ment Health 2017; 11:3. [PMID: 28096898 PMCID: PMC5234258 DOI: 10.1186/s13034-016-0136-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 12/06/2016] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Astrid Furre
- Division of Mental Health and Addiction, Centre for Forensic Psychiatry, Oslo University Hospital, Oslo, Norway ,Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway
| | - Ragnhild Sørum Falk
- Oslo Centre for Epidemiology and Biostatistics, Oslo University Hospital, Oslo, Norway
| | - Leiv Sandvik
- Oslo Centre for Epidemiology and Biostatistics, Oslo University Hospital, Oslo, Norway
| | - Svein Friis
- Division of Mental Health and Addiction, Department of Research and Development, Oslo University Hospital, Oslo, Norway
| | - Maria Knutzen
- Division of Mental Health and Addiction, Centre for Forensic Psychiatry, Oslo University Hospital, Oslo, Norway
| | - Ketil Hanssen-Bauer
- Division of Mental Health Services, Akershus University Hospital, Lorenskog, Norway ,Division of Health Service Research and Psychiatry, University of Oslo, Oslo, Norway
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Carubia B, Becker A, Levine BH. Child Psychiatric Emergencies: Updates on Trends, Clinical Care, and Practice Challenges. Curr Psychiatry Rep 2016; 18:41. [PMID: 26932516 DOI: 10.1007/s11920-016-0670-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Beau Carubia
- Department of Psychiatry, University of Colorado, Aurora, CO, USA. .,B. Harrison Levine, MD, Inc., Denver, CO, USA.
| | - Amy Becker
- Department of Psychiatry, University of Colorado, Aurora, CO, USA.,Psychiatric Emergency Service, Children's Hospital Colorado, Aurora, CO, USA
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A nationwide study of why and how acute adolescent psychiatric units use restraint. Psychiatry Res 2016; 237:60-6. [PMID: 26921053 DOI: 10.1016/j.psychres.2016.01.067] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 11/20/2015] [Accepted: 01/27/2016] [Indexed: 12/28/2022]
Abstract
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.
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Tremmery S, Danckaerts M, Bruckers L, Molenberghs G, De Hert M, Wampers M, De Varé J, de Decker A. Registration of aggressive incidents in an adolescent forensic psychiatric unit and implications for further practice. Eur Child Adolesc Psychiatry 2014; 23:823-33. [PMID: 24682593 DOI: 10.1007/s00787-014-0534-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 02/27/2014] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- S Tremmery
- Department of Child Psychiatry, Psychiatric Centre Campus Kortenberg, University Hospitals Leuven, Leuvensesteenweg 517, 3070, Kortenberg, Belgium,
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Duke SG, Scott J, Dean AJ. Use of restrictive interventions in a child and adolescent inpatient unit - predictors of use and effect on patient outcomes. Australas Psychiatry 2014; 22:360-365. [PMID: 24789849 DOI: 10.1177/1039856214532298] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Suzanne G Duke
- Kids in Mind Research, Mater Research, Mater Health Services, South Brisbane, QLD, Australia
| | - James Scott
- Kids in Mind Research, Mater Research, Mater Health Services, South Brisbane, QLD and; Metro North Mental Health, Royal Brisbane and Women's Hospital, Herston QLD and; Discipline of Psychiatry, The University of Queensland Centre for Clinical Research, Herston QLD, Australia
| | - Angela J Dean
- Kids in Mind Research, Mater Research, Mater Health Services, South Brisbane, QLD 4101 Australia, School of Medicine, The University of Queensland, Herston, QLD, Australia
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