Aggressive behavior is seen in about 3% to 7% of children and adolescents across all clinical settings.1 The percentage can be even higher in certain populations, such as children and adolescents who have neurodevelopmental disorders.2
Aggression is one of the most common reasons for referral to child and adolescent psychiatric inpatient and outpatient services, because it can significantly impair academic achievement, family and peer relationships, and psychological development. The use of restraint and seclusion in the face of aggressive behavior by children and adolescents in health care, school, and juvenile justice systems is controversial.3
Although described as safety interventions, restraint and seclusion are known to affect children and staff adversely: physical injuries, psychological trauma, and deaths have been reported. In 1998, the Hartford Courant published an award-winning series of stories about the use of restraint and seclusion among individuals in psychiatric settings that resulted in injuries and deaths.4 This sparked interest by the public and government agencies, which led to legislative initiatives and federal guidelines for increased standards and oversight.
The prevalence of aggressive behavior among high school students is about 28% in boys and 7% in girls.5 These rates are higher in psychiatric populations and correctional facilities.6
There are few systematic studies of the rates of restraint and seclusion in children and adolescents, and the results vary widely. The prevalence is about 26% for seclusion and 29% for restraint: the range varies depending on the setting and population studied.7 These interventions are frequently used in schools that serve special needs populations, where rates of aggressive behaviors are higher.
The problem of restraint and seclusion is very old in institutional care in psychiatry and remains a challenge. Despite evidence of the adverse effects and advocacy to end these practices, many agree that there is a place for them in certain situations when there is imminent risk of harm to self or others.
The guidelines for restraint and seclusion in different settings have evolved over the years, and all incidents are reviewed and monitored closely.8 The passage of the Children’s Health Act of 2000 established national standards regarding the use of physical restraints with children in psychiatric facilities. The standards include accreditation requirements from governing bodies such as the Joint Commission, the National Association of Psychiatric Treatment Centers for Children, the American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry. These requirements have resulted in extensive training and certification of staff in clinical programs.
There has been no comparable accreditation requirement for schools or many other child care agencies. The lack of commonly accepted guidelines or accreditation standards in schools makes restraint in those settings more likely to involve improper techniques and result in injuries.
Dr. Reddy is Associate Medical Director, Albert J. Solnit Children’s Center, Assistant Program Training Director, Yale Child Study Center/Solnit Center, Child and Adolescent Psychiatry Fellowship; and Assistant Clinical Professor, Yale Child Study Center, Yale University School of Medicine, New Haven, CT. Dr. Hassuk is with the New York State Office of Mental Health and New York University School of Medicine, New York. Dr. Azeem is Chair, Department of Psychiatry, Sidra Medical and Research Center, Doha, Qatar.
The authors report no conflicts of interest concerning the subject matter of this article.
1. Zahrt DM, Melzer-Lange MD. Aggressive behavior in children and adolescents. Pediatr Rev. 2011; 32:325-332.
2. Kanne SM, Mazurek MO. Aggression in children and adolescents with ASD: prevalence and risk factors. J Autism Devel Disord. 2011;41:926-937.
3. Ryan JB, Peterson RL. Physical restraint in school. Behav Disord. 2004;29:154-168.
4. Weiss EM, Altimari D, Blint DF, et al. Deadly restraint: a Hartford Courant investigative report. October 11-15, 1998. http://www.charlydmiller.com/LIB05/ 1998hartforddata.html. Accessed January 4, 2017.
5. Sadock BJ, Sadock VA. Kaplan & Sadock’s Synopsis of Psychiatry. New York: Lippincott Williams & Wilkins; 2003.
6. Renwick L, Stewart D, Richardson M, et al. Aggression on inpatient units: clinical characteristics and consequences. Int J Mental Health Nurs. 2016; 25:308-318.
7. Pogge DL, Pappalardo S, Buccolo M, Harvey PD. Prevalence and precursor of the use of restraint and seclusion in a private psychiatric hospital: comparison of child and adolescent patients. Admin Pol Mental Health Mental Health Serv Res. 2013;40:224-231.
8. US Department of Education. Restraint and Seclusion: Resource Document. May 2012. https://www2.ed.gov/policy/seclusion/restraints-and-seclusion-resources.pdf. Accessed January 4, 2017.
9. Martin A, Krieg H, Esposito F, et al. Reduction of restraint and seclusion through collaborative problem solving: a five year prospective inpatient study. Psychiatr Serv. 2008;59:1406-1412.
10. Greene RW, Ablon JS, Hassuk B, Martin A. Innovations: child and adolescent psychiatry: use of collaborative problem solving to reduce seclusion and restraint in child and adolescent units. Psychiatr Serv. 2006;57:610-612.
11. Azeem MW, Aujla A, Ramerth M, et al. Effectiveness of Six Core Strategies based on trauma informed care in reducing seclusions and restraints at a child and adolescent psychiatric hospital. J Child Adol Psychiatr Nurs. 2011;24:11-15.
12. National Association of State Mental Health Program Directors. Six Core Strategies to reduce seclusion and restraint use. 2008. https://www.nasmhpd.org/content/six-core-strategies-reduce-seclusion-and-restraint-use. Accessed January 4, 2017.
13. Azeem MW, Reddy B, Wudarsky M, et al. Restraint reduction at a pediatric psychiatric hospital: a ten-year journey. J Child Adol Psychiatr Nurs. 2015; 28:180-184.