Bhagya Reddy, MD

Aggressive behavior is seen in about 3% to 7% of children and adolescents across all clinical settings.

 The percentage can be even higher in certain populations, such as children and adolescents who have neurodevelopmental disorders.

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.

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 

 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.

 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.

 These rates are higher in psychiatric populations and correctional facilities.

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.

 These interventions are frequently used in schools that serve special needs populations, where rates of aggressive behaviors are higher.

Trauma-Informed Care to Reduce Psychiatric Restraint

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.

 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.

In some schools, positive behavior supports are used to prevent restrictive interventions. Students who need a higher level of support are identified, and intense support is provided as early as possible to avoid escalation to restraint or seclusion. This program is implemented in many special education settings and has been found to decrease the use of restraint and seclusion as well as to improve academic outcomes.

Parents and advocacy groups such as the National Alliance for the Mentally Ill (NAMI) and the Child Welfare League of America (CWLA) have called for minimum national standards of training in behavior management techniques, especially in de-escalation. These include:

• Standard reporting following a restraint and review of the circumstances that led to the incident to increase supports or accommodations as ways to prevent future restraint use

• Specialized training in conflict de-escalation, crisis prevention, and behavior management techniques for all staff members who work with high-risk students

• Training in the safest methods of physical intervention using minimal force needed to protect from harm or injury and discontinuing the restrictive intervention as soon as possible

• Procedures for notification of parents and authorities

Reducing and preventing restraint and seclusion

Various approaches to reduce and prevent restraint and seclusion in pediatric psychiatric treatment settings have been reported.

These strategies have been helpful in both hospital and residential treatment facilities. Primary prevention principles based on trauma-informed care and strength-based approaches are key elements of treatment.

Trauma-informed care is conceptualized as mental health treatment grounded in a thorough understanding of biological, psychological, and social effects of trauma on children and adolescents and recognition that coercive interventions cause traumatization and re-traumatization and are to be avoided. Trauma-informed care is effective in reducing restraints and seclusions in residential settings.

 It would be useful to study the effectiveness of some of these interventions in school settings.

The Six Core Strategies have been shown to reduce restraint and seclusion in inpatient settings.

 These strategies include a focus on leadership, use of data to inform practice, involvement of youths and families, workforce development, use of prevention tools, and debriefing. At a teaching psychiatric hospital in Connecticut, implementation of the Six Core Strategies reduced restraints and seclusions significantly. This hospital eliminated the use of mechanical restraints and reduced physical restraints by 88% over 10 years.

A program leader’s vision and role in implementing change is crucial, including a focus on prevention. First, a review of policies and procedures to develop a strategic plan toward prevention and reduction of restraint and seclusion is needed. It is helpful to teach de-escalation techniques to calm and support youths in crisis, avoiding the use of physical interventions. A daily review of incidents of restraint and/or seclusion ensures that less restrictive alternatives are considered and restraint is utilized only as a last resort.

It is essential to use data to inform, compare, and track practices, and to allocate resources to areas in need. Real-time data are needed including the number of restraint and seclusion episodes, the time spent in restraint or seclusion, and the number of injuries to staff and youth. These data help expedite corrective interventions and help determine the allocation of resources based on current practices.

Acknowledging progress and emphasizing positive behaviors and changes can serve to motivate staff. Clinical reviews for youth involved in multiple restrictive interventions should include feedback to staff in a nonjudgmental and supportive way with the aim of building strategies to avoid and prevent such occurrences in the future. This also helps identify staff training needs to improve outcomes.

To facilitate a culture change at the grass roots level, it is important to have staff “buy in,” which can be accomplished with training. Key topics include education on the crisis cycle to understand early recognition of escalation and the use of verbal de-escalation. The emphasis in training should be on de-escalation tools rather than on physical intervention techniques. Person-centered and strength-based care should be integral parts of the milieu to engage youths in positive activities. Staff satisfaction surveys can be helpful to monitor staff well-being and self-care and to address vicarious trauma. Regularly scheduled team-building activities, health education groups, and yoga and other relaxation groups can keep the focus on staff well-being.

Positive relationships between youths and staff members, based on mutual respect and dignity, are at the foundation of an effective treatment setting. Each youth should have an individualized treatment plan developed by the treatment team using primary prevention principles. The plan identifies individualized goals, target behaviors, triggers, early warning signs, coping tools, calming strategies, and safety plans. Specific interests, hobbies, coping skills, and motivators are incorporated into the plans.

The crisis cycle is used to understand interventions at each stage during a crisis. Good communication between child care staff and clinical staff is key to effective implementation of treatment plans. Plans are revised regularly as triggers, early warning signs, and calming strategies are identified during treatment. Youths should have access to comfort rooms and equipment for sensory integration, including tools such as sensory brushes, occupational therapy balls, and play dough. Music, art work, and walks with staff can be valuable calming activities. Working with youths to build skills and express creativity can instill confidence, boost self-esteem, and improve relationships. Recreational activities, including basketball, tennis, ping-pong, swimming, and walking, and access to a gymnasium can engage children and adolescents in a positive way.

Families should be welcomed. The trust built between families and staff contributes to a deeper understanding of specific strengths and needs of both the family and the youth. Family involvement is a key element of successful treatment plans and helps prevent the use of restraint and seclusion. Various activities can facilitate increased family participation, including family visits to the facility before admission as well as unrestricted visits after, regular family meetings, and involvement of families in the facility’s advisory council. A youth council provides an opportunity for children and adolescents to discuss their concerns and request improvements. Regular surveys can help identify strengths of the services provided and areas in need of improvement. Discussions with state-wide advocacy personnel can help with problem-solving.

Mandatory debriefing after each episode of restraint or seclusion allows staff members to review information and plan prevention strategies for future similar situations. The debriefings are done in a non-punitive and supportive manner with a focus on the staff and the youth involved.

Two types of debriefing can be done after an incident. One is an immediate response after the incident to gather and process information, check for injuries or trauma, and manage the milieu. The other is a more formal, rigorous problem-solving and planning meeting held within 48 to 72 hours. This includes staff involved in the incident, clinical staff, the youth and, at times, the administration. The incident is discussed in detail, including review of antecedents and triggers before the event, de-escalation strategies used, and any other contributing factors. Staff should focus on information learned that can be used for effective interventions in the future. Youth debriefing focuses on chain analysis of the incident, understanding the triggers, what was helpful, and what can be done differently next time to prevent a similar incident.

Three examples illustrate the potentially serious harm that can result from restraint or seclusion.

 A 12-year-old girl describes the experience of mechanical restraint: “I hated it. You people need to do better. Time off getting held does not mean you go straight to the restraint bed. You know me better than that. I hate the restraint bed. It makes me think of my past. How some things happened to my mom. You people do not understand that talking about your past can be very hard to do. I am sorry if I hurt any staff, but you all know me. I do not mean to hurt you.”

 A 15-year-old girl refused to hand over a family photograph considered to be “an unauthorized personal item” and died of asphyxiation while being held in a face-down restraint after resisting an aide at a residential facility.

 A 9-year-old boy had his leg broken during a restraint on his first day at a program. After surgery, he returned to the program with a walker. His leg was broken for the second time. After 18 months in the program, he died of asphyxiation at age 11 while being restrained during a “routine physical hold.”

The use of restraint and seclusion for aggressive behavior is on the decline with better oversight, guidelines, and regulations in pediatric psychiatric treatment settings. Trauma-informed and strength-based programs need to be increased nationally and internationally with the goals of preventing the use of these restrictive interventions and improving care.

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.

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