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

Art therapy is associated with a reduction in restrictive practices on an inpatient child and adolescent mental health unit

BACKGROUND

The elimination of restrictive practices, such as seclusion and restraint, is a major aim of mental health services globally. The role of art therapy, a predominantly non-verbal mode of creative expression, is under-explored in this context. This research aimed to determine whether art therapy service provision was associated with a reduction in restrictive practices on an acute inpatient child and adolescent mental health services (CAMHS) unit.

METHODS

The rate (events per 1,000 occupied bed days), frequency (percent of admitted care episodes with incident), duration, and number of incidents of restrictive practices occurring between July 2015 and December 2021 were analysed relative to art therapy service provision. The rate, frequency and number of incidents of intramuscular injected (IM) sedation, oral PRN (as-needed medication) use, and absconding incidents occurring in conjunction with an episode of seclusion or restraint were also analysed.

RESULTS

The rate, frequency, duration, and total number of incidents of seclusion, the frequency and total number of incidents of physical restraint, and the rate, frequency and total number of incidents of IM sedation showed a statistically significant reduction during phases of art therapy service provision.

CONCLUSIONS

Art therapy service provision is associated with a reduction in restrictive practices in inpatient CAMHS.

Physical and Pharmacologic Restraint in Hospitalized Children With Autism Spectrum Disorder

OBJECTIVES

Children with autism spectrum disorder (ASD) have high rates of cooccurring conditions and are hospitalized longer and more frequently than children without ASD. Little is known about use of involuntary physical or pharmacologic restraint in hospitalized children with ASD. This study compares use of restraint because of violent or self-injurious behavior during inpatient pediatric hospitalization in children with ASD compared with typical peers.

METHODS

This retrospective cohort study examines electronic health records of all children aged 5 to 21 years admitted to a pediatric medical unit at a large urban hospital between October 2016 and October 2021. Billing diagnoses from inpatient encounters identified ASD and cooccurring diagnoses. Clinical orders identified physical and pharmacologic restraint. Propensity score matching ensured equivalency between ASD and matched non-ASD groups on demographic factors. Logistic regression determined the odds of restraint in children with ASD compared with children without ASD, controlling for hospitalization factors and cooccurring diagnoses.

RESULTS

Of 21 275 hospitalized children, 367 (1.7%) experienced restraint and 1187 (5.6%) had ASD. After adjusting for reason for admission, length of stay, and cooccurring mental health, developmental, and behavioral disorders, children with ASD were significantly more likely to be restrained than children without ASD (odds ratio 2.3, 95% confidence interval 1.6-3.4; P < .001).

CONCLUSIONS

Hospitalized children with ASD have significantly higher odds of restraint for violent or self-injurious behavior compared with children without ASD after accounting for reason for admission, length of hospitalization and cooccurring diagnoses. Work is needed to modify the hospital environment for children with ASD to reduce behavioral dysregulation and restraint.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A systematic mapping review identifying key features of restraint research in inpatient pediatric psychiatry: A human rights perspective

INTRODUCTION

Restraints, a highly regulated and contentious measure in pediatric psychiatry, have significant negative impacts on children. The application of international human rights standards, such as the Convention of the Rights of the Child (CRC) and the Convention of the Rights of Persons with Disabilities (CRPD), has spurred global efforts to reduce or eliminate the use of restraints. However, a lack of consensus on definitions and terminology, as well as quality indicators in this field, hinders the ability to compare studies and evaluate interventions consistently.

AIM

To systematically map existing literature on restraints imposed upon children in inpatient pediatric psychiatry against a human rights perspective. Specifically, to identify and clarify gaps in literature in terms of publication trends, research approaches, study contexts, study participants, definitions and concepts being used, and legal aspects. These aspects are central to assess whether published research is contributing to achieve the CRPD and the CRC in terms of interpersonal, contextual, operational, and legal requirements of restraints.

METHODS

A systematic mapping review based on PRISMA guidelines was conducted, adopting a descriptive-configurative approach to map the distribution of available research and gaps in the literature about restraints in inpatient pediatric psychiatry. Six databases were searched for literature reviews and empirical studies of all study designs published between each database's inception and March 24, 2021, manually updated on November 25, 2022.

RESULTS

The search yielded 114 English-language publications, with a majority (76%) comprising quantitative studies that relied primarily on institutional records. Contextual information about the research setting was provided in less than half of the studies, and there was an unequal representation of the three main stakeholder groups: patients, family, and professionals. The studies also exhibited inconsistencies in the terms, definitions, and measurements used to examine restraints, with a general lack of attention given to human rights considerations. Additionally, all studies were conducted in high-income countries and mainly focused on intrinsic factors such as age and psychiatric diagnosis of the children, while contextual factors and the impact of restraints were not adequately explored. Legal and ethical aspects were largely absent, with only one study (0.9%) explicitly referencing human rights values.

CONCLUSIONS

Research on restraints of children in psychiatric units is increasing; however, inconsistent reporting practices hinder the understanding of the meaning and frequency of restraints. The exclusion of crucial features, such as the physical and social environment, facility type, and family involvement, indicates inadequate incorporation of the CRPD. Additionally, the lack of references to parents suggests insufficient consideration of the CRC. The shortage of quantitative studies focusing on factors beyond patient-related aspects, and the general absence of qualitative studies exploring the perspectives of children and adolescents regarding restraints, suggest that the social model of disability proposed by the CRPD has not yet fully penetrated the scientific research on this topic.

Clinical Characteristics of Youth with Autism or Developmental Disability during Inpatient Psychiatric Admission

Children with autism spectrum disorder and developmental disabilities (ASD/DD) often experience severe co-occurring psychological and behavioral challenges, which can warrant inpatient psychiatric care. However, very little is known about the characteristics and clinical care of children with ASD/DD within the context of inpatient psychiatric settings. In this paper, we describe factors unique to inpatients with ASD or DD, by drawing on electronic health records from over 2300 children and adolescents ages 4–17 years admitted to a pediatric psychiatric inpatient unit over a 3-year period. Patients with ASD/DD accounted for approximately 16% of inpatients and 21% of admissions, were younger, more likely to be readmitted, more likely to be male, and more likely to have Medicaid insurance, as compared to patients without ASD/DD. Clinically, those with ASD/DD more frequently had externalizing concerns documented in their records, in contrast to more frequent internalizing concerns among other patients. Within the ASD/DD group, we identified effects of patient age, sex, and race/ethnicity on multiple dimensions of clinical care, including length of stay, use of physical restraint, and patterns of medication use. Results suggest the need for psychiatric screening tools that are appropriate for ASD/DD populations, and intentional integration of anti-racist practices into inpatient care, particularly with regard to use of physical restraint among youth.

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

BACKGROUND

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

METHOD

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

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

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

Exploring factors that influence success when introducing "The Safewards Model" to an acute adolescent ward: A qualitative study of staff perceptions

Problem

The Safewards’ model identifies factors that can lead to conflict and addresses these factors, using ten interventions, within inpatient mental health wards aiming to reduce “conflict and containment.” The Department of Health (2014) and Care Quality Commission (2017) supported the use of Safewards to reduce restrictive practice across all mental health settings in the UK, but its application to adolescent mental health remains relatively unexplored. This study therefore aims to address the research question: “What are the factors influencing the success of ten Safewards’ interventions when implemented onto an acute adolescent ward?”

Methods

Eight healthcare assistants and two nurses who had attended Safewards’ training participated in semi‐structured interviews four months after Safewards was introduced to an acute adolescent ward. The interviews were transcribed verbatim and analyzed using thematic analysis. Data analysis was conducted inductively by developing data‐driven themes.

Findings

Many of the factors influencing Safewards’ success in adolescent mental health (e.g., acuity; dependence on nonregular staffing; lack of leadership and operating procedures) paralleled the evidence found in adult services.

Conclusions

This study contributes new information by implementing “mutual help” and “calm down” principles with adolescents, as well as discussing barriers of operational procedures and benefits of patient involvement.

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

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

Designing and Testing a Developmentally Appropriate Intervention for Children in a Psychiatric Residential Treatment Facility

Preadolescent children in residential care have treatment needs that are different from adolescents. An intervention was created using developmental theory to inform decisions about the timing, objectives, strategies, and context best suited to preadolescents in an intensive residential treatment center. Aggressive behavior, seclusions, and restraints data for preadolescents during a 32-month period was used in the analysis. There was a significant decrease in aggressive behavior, seclusions, and restraints for preadolescents during the periods when the developmentally appropriate intervention was used versus the times when they received same intervention as the adolescents.

Nurse and patient factors: Predicting seclusion in adolescent psychiatric units

PROBLEM

Seclusion is considered a necessity when alternatives have failed. There is a consensus that seclusion has no therapeutic benefit, which justifies efforts to reduce the practice. This study aimed to identify nurse and patient variables that are predictive of seclusion on a large adolescent inpatient unit.

METHODS

Nested case controls were used to compare 72 afternoon shifts on which seclusion occurred to 216 afternoon shifts on which no seclusion occurred, between 2010 and 2013, at an Adolescent Psychiatric Inpatient Unit.

FINDINGS

Increased seclusion was predicted by a lower nurse to patient ratio, more male nurses on shift, fewer female nurses on shift, the presence of agency/temporary nurses on shift, greater combined years of mental health experience, and lower total HoNOSCA behavior subscale score. Unique predictors that increased risk of seclusion included greater number of male nurses and the presence of agency/temporary nurses, while a greater number of female nurses decreased risk of seclusion.

CONCLUSIONS

Nurses play a unique role in seclusion outcomes that are separate to patient-factors and act as both protective and risk factors for seclusion. Changes can be made to staffing to reduce seclusion and future research should investigate why these nurse-factors contribute to seclusion.

Risk Factors for Seclusion in Children and Adolescents Inpatient Psychiatry: The Role of Demographic Characteristics, Clinical Severity, Life Experiences and Diagnoses

OBJECTIVE

To understand the risk factors for seclusion in a sample of children and adolescents admitted to an inpatient psychiatry unit looking at demographic, clinical severity, life experience, and diagnostic characteristics.

METHODS

An unmatched case-control retrospective analysis of psychiatric records in a pediatric inpatient unit from December 2011 to December 2015 (N = 1986) RESULTS: Individual characteristics, including demographics, clinical severity, and clinical presentation as per the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) jointly predicted seclusion in adolescents, with younger age, male sex, black race, having a prior admission, and having a disruptive behavior or bipolar and related disorder diagnoses being predictive of seclusion. While demographic and clinical severity factors were predictive of seclusion in multivariate models, clinical diagnoses only added modestly to the variance explained.

CONCLUSIONS

High-risk demographic and clinical characteristics for seclusion events in children and adolescents can provide valuable information to guide interventions to prevent seclusion events during their hospitalization.

Correlates of psychiatric staff's attitude toward coercion and their sociodemographic characteristics

BACKGROUND

A deeper understanding of the nurses' characteristics that influence their positive attitudes toward coercion is necessary if coercive measures rates are to be effectively reduced.

AIM

To identify the difference in psychiatric staff attitudes toward coercive measures in relation to their sociodemographic characteristics.

SETTING

The study conducted at the National Center for Mental Health, which is regulated under the authority of the Jordanian Ministry of Health.

PARTICIPANTS

A total of 85 psychiatric staff recruited from the National Center for Mental Health.

METHODS

A cross-sectional, descriptive, correlational design was used. Data were collected using a self-administered questionnaire, which consisted of 15 items that focused on assessing a staff's attitude toward coercion.

RESULTS

The relationship between clinical unit and attitude toward coercion was significant (r = -.30; P = .006). Similarly, the correlations between gender-based units and attitudes toward coercion were significant (r = -.38; P = .002). Another significant correlation was revealed with different years of experience (r = .22; P = .04).

CONCLUSION

The more years of experience in the field of psychiatric nursing the more positive attitude toward coercion. Moreover, working with male psychiatric patients and in acute psychiatric units increase the risk of coercive measures use.

Six years of national mental health seclusion data: the Australian experience

OBJECTIVES

Reducing or eliminating seclusion from mental health care settings has been a national priority for Australia since 2005. This paper describes Australia's national seclusion data collection, and summarises changes in seclusion rates in Australian public mental health services.

METHODS

Seclusion events per 1000 patient days were calculated from 2009-2010 to 2014-2015 utilising state and territory administrative data sources. Combined national data were used to calculate results for a number of service characteristics, such as target population and location of the service.

RESULTS

The rate of seclusion events decreased by 43% over the 6 years. Child and adolescent services reported consistently higher rates of seclusion, but a shorter duration of seclusion episodes, compared with other service types. There is high variation in seclusion rates between individual services (range 0.0-53.0 seclusion events per 1000 bed days in 2014-2015).

CONCLUSIONS

Seclusion event rates in Australia's specialised public acute mental health hospital services are declining. The use of existing administrative data was instrumental in establishing a national data source to facilitate the monitoring and reporting of progress of seclusion reduction strategies.

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

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

Predictors of Seclusion or Restraint Use Within Residential Treatment Centers for Children and Adolescents

This study identified predictors of seclusion or restraint use among licensed and/or accredited residential treatment centers (RTCs) for children and youth in the United States responding to a federally-sponsored survey of mental health services. 693 licensed and/or accredited child and adolescent RTCs responded to questions about the demographic and admission status of clients served on an identified date, services offered, size, ownership, funding, and their use of seclusion or restraint practices within the preceding 12 months. Logistic regression was used to determine factors predicting facility use of seclusion or restraint. A large majority of licensed and/or accredited child and adolescent RTCs (82 %) reported using seclusion or restraint in the prior year. Contrary to prior research, individual patient characteristics (percent of males, minorities, and involuntary admissions) did not predict the use of coercive techniques. Instead facility and funding variables accounted for approximately 27 % of the variance in the use of seclusion or restraint. Larger, privately-owned RTC's funded primarily through public monies and which offered medication and programming for SED youth were more likely to endorse having used seclusion or restraint in the previous year. Despite visible policy and advocacy efforts to reduce seclusion and restraint use over the past decade, a majority of licensed and/or accredited RTCs for children and adolescents report using such practices. Findings emphasize the importance of examining facility-level variables in predicting their use, and highlight the disconnect between nationally espoused goals and current practices regarding coercive techniques in child and adolescent RTCs.