Janice LeBel

Child and Adolescent Inpatient Restraint Reduction: A State Initiative to Promote Strength-Based Care

OBJECTIVE To reduce the use of restraint and seclusion with children and adolescents in psychiatric inpatient units by promoting a preventive, strength-based model of care. METHOD The State Mental Health Authority used data analysis, quality improvement strategies, regulatory oversight, and technical assistance to develop and implement system change over a 22-month period. No changes in regulation or policy were undertaken. RESULTS Comparative data collected before and after the interventions demonstrated substantial reductions in the use of restraint and seclusion. Child units (age 5-12) decreased from 84.03 to 22.78 episodes per 1,000 patient days (72.9%), adolescent units from 72.22 to 37.99 episodes (47.4%), and mixed child/adolescent units from 73.37 to 30.08 episodes (59%). CONCLUSIONS The use of restraint and seclusion in child and adolescent inpatient settings can be reduced through a systems approach, which may have applicability to other settings and systems.

Multinational experiences in reducing and preventing the use of restraint and seclusion.

Restraint and seclusion (R/S) have been used in many countries and across service sectors for centuries. With the recent and increasing recognition of the harm associated with these procedures, efforts have been made to reduce and prevent R/S. Following a scathing media exposé in 1998 and congressional scrutiny, the United States began a national effort to reduce and prevent R/S use. With federal impetus and funding, an evidence-based practice, the Six Core Strategies to Prevent Conflict, Violence and the Use of Seclusion and Restraint, was developed. This model was widely and successfully implemented in a number of U.S. states and is being adopted by other countries, including Finland, Australia, and the United Kingdom. Recently, the first cluster randomized controlled study of the Six Core Strategies in Finland provided the first evidence-based data of the safety and effectiveness of a coercion prevention methodology. Preliminary findings of some of the international efforts are discussed. Reduction in R/S use and other positive outcomes are also reported.

Restraint and Seclusion Use in U.S. School Settings: Recommendations From Allied Treatment Disciplines

Restraint and seclusion (R&S) are high risk, emergency procedures that are used in response to perceived violent, dangerous situations. They have been employed for years in a variety of settings that serve children, such as psychiatric hospitals and residential treatment facilities, but are now being recognized as used in the public schools. The field of education has begun to examine these practices in response to national scrutiny and a Congressional investigation. The fields of mental health and child welfare were similarly scrutinized 10 years ago following national media attention and have advanced R&S practice through the adoption of a prevention framework and core strategies to prevent and reduce use. A review of the evolution of the national R&S movement, the adverse effects of these procedures, and a comprehensive approach to prevent their use with specific core strategies such as leadership, workforce development, and youth and family involvement in order to facilitate organizational culture and practice change are discussed. Proposed guidelines for R&S use in schools and systemic recommendations to promote R&S practice alignment between the child-serving service sectors are also offered.

Tied up and Isolated in the Schoolhouse.

In 1999, the United States General Accountability Office (USGAO) investigated restraints and seclusion use in mental health settings and found patterns of misuse and abuse. A decade later, it found the same misuse and abuse in schools. Restraints and seclusion are traumatizing and dangerous procedures that have caused injury and death. In the past decade, restraints and seclusion have gone from being considered an essential part of the psychiatric mental health toolkit to being viewed as a symptom of treatment failure. In most mental health settings, the use of restraints and seclusion has plummeted due to federal regulations, staff education, and concerted effort of psychiatric national and local leadership. The purpose of this article is to provide a background to and an overview of the present imbroglio over restraints and seclusion in public and private schools, articulate their dangers, dispel myths and misinformation about them, and suggest a leadership role for school nurses in reducing the use of these procedures.

An organizational approach to reducing and preventing restraint and seclusion use with people with acquired brain injury.

INTRODUCTION Seclusion, restraint (S/R) and coercive practices are used across human service populations, settings, with people of all ages. Their use has been increasingly scrutinized by the public, federal government and the media. Alternatives, interventions, and organizational approaches to these forms of containment are now emerging and advancing practice. AIM/PURPOSE This article provides an overview of the work conducted to reduce the use of coercion restraint, seclusion and other invasive practices in behavioral health settings that often include the defacto admission of persons with Acquired Brain Injury (ABI). The article also examines treatment culture factors that can exacerbate behavior dysfunction and how to moderate such challenges to prevent the use of S/R procedures among people with ABI. CONCLUSION Seclusion and restraint can be avoided and greatly reduced in settings serving people with ABI. When S/R use is recognized as an inadequate organizational response to harmful behavior that maintains patterns of aggression or harm, leadership-driven core strategies can be implemented to disrupt the behavioral sequence. The Six Core Strategies© provide a prevention based framework to anticipate challenge, intervene early, and analyze the factors that contribute to maintaining the cycle of violence if S/R is used.

Regulatory, clinical, and educational approaches to eliminating restraint and seclusion

Background In response to national media attention on restraint and seclusion (R/S), state and national efforts in the USA have organized around the goal of eliminating their use. Several states/organizations have significantly reduced and stopped using these violent procedures. Participants will learn: 1) How some states/organizations changed treatment practice to prevent inpatient violence, 2) Why an understanding of trauma and factors contributing to treatment violence are essential, 3)Why the consumer and family voice is of key importance, 4) What state and national data indicates about the success of these efforts.

First randomised controlled-trial research on seclusion and restraint reduction achieves intent

Seclusion and restraint (SR) are centuries-old, frequently used psychiatric practices which lack an evidence base establishing their therapeutic efficacy.1 They are emergency containment procedures in which staff use physical force, the environment and/or devices to control patient behaviour. Their use creates substantial risk of physical and emotional harm, increases violence, claims significant time and resources and prolongs treatment and recovery from mental illness. For these reasons, reducing and preventing SR use is a growing focus in psychiatric services.2