The use of seclusion and emergency medication in a hospital for people with learning disability

“Is it Meant to Hurt, is it?”

The use of seclusion, restraint, and rapid tranquilization for people with developmental disabilities is controversial. A statistical analysis of 3,767 such incidents, involving 82 clients with developmental disabilities, is presented along with semistructured interview material completed following personal experience of emergency intervention. Women were involved in a disproportionately high number of incidents. It was found that women had a significantly higher probability of being given rapid tranquilization following a violent incident. In contrast, seclusion was more likely to be used with men. Interviews with women demonstrated a commonly held understanding of interventions as punishment and expressions of intense anger and anxiety. The study highlights the importance of including the perspectives of people with developmental disabilities in care planning and staff training.

Thinking on your feet: understanding the immediate responses of staff to adults who challenge intellectual disability services

BACKGROUND

A gap prevails between the conceptualization of good practice in challenging behaviour management and its implementation in intellectual disability services. This study aimed to investigate staff members' perspectives of managing clients with challenging behaviours in residential services.

MATERIALS AND METHODS

Semi-structured interviews were conducted with eleven staff in two services. Additionally, service documents on challenging behaviour management were examined in these services. A qualitative methodology was used to investigate staff members' immediate responses to clients' difficult behaviours and their decision-making processes.

RESULTS

The immediate responses of staff were conceptualized as the result of complex appraisals shaped by their service context involving the core processes of making the right choice and prioritizing the best interests of all involved.

CONCLUSIONS

Staff members' responses were understood as a dynamic and retroactive process, where their past and current challenging behaviour management experiences in the service influenced their responses to clients in the future.

Aggressive behaviour in adults with intellectual disability: defining the role of drug treatment

A complex form of aggression, commonly expanded as 'aggressive challenging behaviour', is reported in one in four adults with intellectual disability and is often treated with antipsychotics, mood stabilizers and antidepressants. Psychological treatments, including anger and behavioural management, person-centred planning and manipulation of the environment (nidotherapy), have also been used when available but to a lesser extent. In this article, the evidence for efficacy for each intervention is examined, with data from randomized controlled trials given primacy. Very little evidence, based on limited data, can be found for the interventions of anger and behavioural management and also for the atypical antipsychotic drug, risperidone; the data available on these interventions come primarily from studies conducted in children in whom the behaviour is part of the autistic spectrum. Antipsychotic drugs, particularly the atypical group, have been the most commonly used interventions in recent years, but a recent independent randomized trial showed no benefits for either risperidone or haloperidol compared with placebo, with some evidence of a better response to placebo than either active drug in the reduction of aggression. In the light of this uncertainty, the clinician must return to the task of collecting a careful history and mental state examination, including awareness of the setting in which the behaviour is shown, which will help with diagnosis and appropriate intervention. The choice of intervention should not be a casual one and is not likely to be chosen well if the clinician relies only on standard guidelines. The paucity of randomized trial evidence is preventing progress in the treatment of persistent aggressive behaviour. On present evidence, the use of drug treatment should be much more sparing and reserved for those patients who are putting themselves and others at particular risk as a consequence of their behaviour; such treatment should be regarded as temporary and as adjunctive to other forms of management. There is an urgent need for larger, randomized studies of psychological interventions, which at present appear to have a higher benefit-risk ratio than drug treatment but that also have a poor evidence base. More care should be taken to avoid the term 'aggressive challenging behaviour' being used as a portmanteau diagnostic pseudonym when it merely represents a diverse oppositional repertoire of many aetiologies.

The reported experience of four women with intellectual disabilities receiving emergency psychiatric services in Canada: a qualitative study

Hospital emergency departments are not well prepared to meet the needs of individuals with intellectual disabilities. Negative experiences can be very traumatic, particularly when the emergency visit is because of a behavioural or psychiatric problem. A focus group study was conducted in 2005 in Toronto, Canada with four women with intellectual disabilities who had paid repeated visits to their local emergency department due to a psychiatric or behavioural crisis. These women spoke about not feeling respected, the trauma of being restrained physically or chemically, and about hospital staff not being comfortable working with women with intellectual disabilities. Clinical implications are discussed and recommendations are presented to improve the experience of women who require emergency services in the future.

Restraint and seclusion in psychiatric inpatient wards

PURPOSE OF REVIEW

Despite the controversy over the use of seclusion and restraint, these measures are commonly used to treat and manage disruptive and violent behaviour. This review summarizes recent research on the use of seclusion and restraint, and measures taken to reduce their use.

RECENT FINDINGS

Lately, prominent international recommendations have aimed to restrict the use of seclusion and restraint, and reminded that they should only be used in exceptional cases, where there are no other means of remedying the situation and under the supervision of a doctor. The use of seclusion and restraint has remained prevalent, but there are serveral innovative programmes that have succeeded in controlling and reducing their use. Staff attitudes about seclusion and restraint have changed little in the last few years.

SUMMARY

There is a need for novel methods to treat violence and the threat of violence on psychiatric wards. Violence is a complex phenomenon that needs to be met with a multiprofessional approach. Customer involvement in this work is required. The assessment of the effectiveness of programmes aiming to minimizing seclusion and restraint has been hampered by the lack of parallel control groups and there is a need for cluster-randomized trials. When studying these interventions, the safety of staff and patients should be included as on outcome measure.

Correlates of restraint use in an institutional population: a replication

BACKGROUND

Reducing inappropriate restraint is an important mission of services for people with intellectual disabilities (IDs).

METHODS

In this study, 52 clients who had been restrained were compared with 52 other clients, individually matched on age, gender and level of IDs. Participants were mostly adults with severe and profound IDs in an institutional setting.

RESULTS

The two groups differed on six Diagnostic Assessment for the Severely Handicapped-II (DASH-II) and three Aberrant Behaviour Checklist (ABC) scales. However, discriminant functional analysis demonstrated that only DASH-II Impulse control disorder and ABC Irritability and Elimination disorder scores predicted group membership but only moderately.

CONCLUSIONS

Individual differences in maladaptive behaviours were only moderately predictive of restraint use.

People with learning disabilities in a low secure in-patient unit: comparison of offenders and non-offenders

BACKGROUND

People with learning disability who exhibit challenging behaviour are frequently segregated from services and local teams are often reluctant to receive them back into their care. This situation is worse in those whose challenging behaviour includes a forensic history, but the difference between those labelled as challenging and those treated as offenders is not clear, and there is a lack of evidence about treatment effectiveness.

AIMS

To test between-group differences in aggression and treatment outcome in people with learning disability and challenging behaviour, with and without a forensic history.

METHOD

Clinical records of 86 former in-patients (45 offenders and 41 non-offenders) of a specialist unit were compared on measures of behavioural disturbance and placement outcome.

RESULTS

People in the offenders group were significantly less likely to be aggressive to others and to use weapons, but significantly more likely to harm themselves compared with the non-offenders group. Both groups had a significant reduction in their challenging behaviour during admission, and there was no significant difference in treatment outcome.

CONCLUSIONS

The negative reputation of people with learning disabilities who offend needs to be reconsidered.

Involuntary medication in psychiatric inpatient treatment

The aim of this study was to examine involuntary medication in psychiatric inpatient treatment. A retrospective chart review of 1543 consecutive admissions of working aged civil patients from well-defined catchment areas to three psychiatric centres were evaluated regarding events of involuntary medication. 8.2% of the admissions included involuntary medication episode(s). Involuntary medication was associated with a diagnosis of schizophrenia, involuntary legal status and having previously been committed. One of the studied centres used less involuntary medication than the other two, even if patients with schizophrenia were over-represented in that centre. Although involuntary medication mainly takes places in the treatment of patients who are conceptualised most ill and perhaps resist treatment most, treatment culture obviously also plays a role. In future, it is important to study the aspects of treatment culture to fully understand the use of involuntary medication in psychiatry.

A study of the use of seclusion in an acute psychiatric service

OBJECTIVE

In recent years, increased attention has been paid to significantly restrictive practices taking place in psychiatric services in New Zealand. The aim of this study was to prospectively examine the frequency of use of seclusion and the factors associated with its use in the acute general adult psychiatric wards serving the Waikato area.

METHODS

Information on the use of seclusion and relevant demographic data were collected over a 9-month period in 2000. The patterns of locked seclusion use and the characteristics of patients who had been secluded were examined. Analysis compared patients requiring one or more episode of seclusion (n = 84) with those never secluded (n = 455).

RESULTS

Of a total of 539 patients admitted to the general adult unit during our study period, 84 (16%) were secluded in 129 seclusion episodes. About two-thirds of the seclusion events were initiated in the first week of the patient's admission, and three-quarters of secluded patients had only one episode. The median duration of seclusion was 14 hours. Comparison of gender and race revealed significant differences between the groups. Diagnosis, but not age, had a significant effect on whether a patient would be secluded. Seclusion was mainly associated with risk of, or actual, violence toward staff, patients or property.

CONCLUSIONS

This study shows that seclusion is regularly practiced in the psychiatric wards of the Waikato area. In the majority of cases, its use was related to actual or threatened violence. Male, non-European patients and patients with certain diagnoses were at particular risk for seclusion. More research is required to examine the most effective use of seclusion and also the development and use of alternative strategies in controlling aggressive behaviour.

Practice parameter for the prevention and management of aggressive behavior in child and adolescent psychiatric institutions, with special reference to seclusion and restraint

This parameter reviews the current state of the prevention and management of child and adolescent aggressive behavior in psychiatric institutions, with particular reference to the indications and use of seclusion and restraint. It also presents guidelines that have been developed in response to professional, regulatory, and public concern about the use of restrictive interventions with aggressive patients with regard to personal safety and patient rights. The literature on the use of seclusion, physical restraint, mechanical restraint, and chemical restraint is reviewed, and procedures for carrying out each of these interventions are described. Clinical and regulatory agency perspectives on these interventions are presented. Effectiveness, indications, contraindications, complications, and adverse effects of seclusion and restraint procedures are addressed. Interventions are presented to provide more opportunities to promote patient independence and satisfaction with treatment while diminishing the necessity of using restrictive procedures.

An inpatient treatment model for adults with mild intellectual disability and challenging behaviour

Following the closure of the large mental handicap hospitals in the UK, the majority of people with intellectual disability (ID) are currently living in the community. However, people with ID who also exhibit challenging behaviour (CB) have been the most difficult-to-place group and use a large amount of service resources. A variety of service options have been proposed for the assessment and treatment of CBs, but there is little information on the effectiveness of these alternatives. The Mental Impairment Evaluation and Treatment Service (MIETS) is one of these service options and the aim of the present study is to describe and evaluate this service. The present authors studied the first 64 patients admitted to MIETS following its opening. A within-subject comparison research design was used. Demographic and clinical data were obtained from case records and the effectiveness of MIETS interventions was evaluated by comparing the number of incidents of challenging behaviour, the use of seclusion, and the place of residence before and after the MIETS intervention. Only 10 (17.5%) of the patients had been admitted from community facilities, but 48 (84.2%) of the patients were discharged to community placements (P < 0.000 I1). The MIETS also significantly reduced the frequency and severity of challenging behaviours (P < 0.0001). It is concluded that the MIETS is an effective treatment model for people with ID and CB, and that there is no place for therapeutic nihilism in this difficult-to-place group of patients.

Practice of seclusion: a five-year retrospective review in north Cheshire

This study examines, retrospectively, the trends and factors associated with the use of seclusion over a five-year period in a regional secure unit located within a large psychiatric hospital that serves the population of North Cheshire. Ninety-four patients (15.3% of total admissions to the unit) spent some time in seclusion on 186 occasions. The average time spent in seclusion was 85 minutes (minimum 15 minutes and maximum 10 hours). Sixty-seven per cent of patients were secluded once, 20% secluded twice, and 13% more than three times. Patients with a clinical diagnosis of personality disorder (11.4%) accounted for 44.2% of seclusions whereas those with a defined mental disorder (55%) accounted for 35% of all seclusions. The rate of seclusion, characteristics of secluded patients, reasons, and average duration spent in seclusion, did not vary significantly over the study period, despite the significant reduction of the unit's admission rate from 150 to 63 per year. The consistent and regular occurrence of the practice over a five-year period may suggest that seclusion of some disturbed patients will inevitably continue to be used as an effective intervention and, probably at times, the only acceptable method that may ensure the safety of patients and staff.