Christopher Bellonci, M.D.
When President Bill Clinton signed the Children’s Health Act (CHA) in October 2000, he was signing a document that codified two levels of oversight regarding seclusion and restraint. One level was established for so-called Psychiatric Residential Treatment Facilities (PRTFs)— those attached to a psychiatric or general hospital and receiving direct funding from Medicaid—and the other for community-based residential treatment facilities. This was the result of advocacy from community residential programs that function largely without medical oversight, do not use mechanical restraints, and typically have no seclusion rooms. The community residential settings have increased oversight of their restraint practices as a result of the CHA, but collectively there was a sigh of relief that they would not be held to the same standards as their PRTF cousins. Community-based programs were concerned that if physicians were required to sign every restraint order, they would be forced to close or exclude children with a referral for aggressive behavior, the population most urgently in need of residential treatment.
The CHA required that community-based residential treatment programs have a supervisory or senior staff person with training in seclusion and restraint conduct a face-to-face assessment as soon as practicable but not less than one hour after the initiation of the seclusion and restraint. The staff person must then remain with the child for the duration of the restraint or seclusion. Mechanical and chemical restraints were prohibited in these facilities. These requirements are less rigorous than those applied to PRTFs. The CHA requires that PRTFs utilize seclusion and restraint only upon the written order of a physician or other licensed practitioner permitted by the state. The order must specify the duration and circumstances under which restraints are to be used. These standards are still less onerous than those applied to inpatient hospital settings that must respond to the notorious “one-hour rule” (See Dr. Charles Devitt’s article on this topic in the Seclusion & Restraint column in AACAP News, September/October 2002.)
The CHA has resulted in two levels of care within the residential treatment community based on the notion that these programs were designed to serve different populations and with different treatment philosophies. PRTFs were outgrowths of psychiatric hospitals developing long-term facilities with a rehabilitative focus and treatment model. These programs largely adhere to a medical treatment philosophy. Community-based residential treatment facilities are frequently former orphanages that are retooled to serve children with trauma, neglect, and abandonment. They have been slow to incorporate psychiatric consultation, believing the change agent for these children is the therapeutic milieu (Redl and Wineman, 1951).
Reimbursement for these divergent services follow the theoretical models. PRTFs are largely funded by insurance, either private or Medicaid and Medicare funds. Community-based RTCs typically do not receive funds for psychiatric services in their day rate and must devise other revenue streams to fund psychiatric consultation, typically developing a relationship with a provider who develops a “clinic” at the RTC but is not incorporated into the administrative or organizational structure. Not only does this create problems for the direct service work of the psychiatrist—the psychiatrist will find it challenging to benefit from the accumulated knowledge a RTC has about a child—it also deprives the facility of psychiatric input into the design of the program itself. In this system, the psychiatrist is relegated to a more strictly prescription writing role.
Though the different levels of care may make sense from a systems perspective, the question remains, do they make sense from the perspective that restraints are dangerous and regulations are needed to protect children from harm? Why would a restraint in a community-based setting not need the same level of oversight as in PRTFs or for that matter as in hospital settings? One might argue that mechanical restraints carry a greater level of risk and therefore require greater oversight. Increased oversight might then be tied to the restraint method rather than the treatment facility. Unfortunately we are in the position of having regulatory decisions based on non-existent data. We simply don’t know if mechanical restraints are associated with any greater risk of harm than physical holds. There is a belief that seclusion is safer but this is also largely unsupported by data. Research by AACAP members in this regard would be very welcome as this debate continues.
The question that emerges is whether all restraints, regardless of whether they are mechanical or involve physical holding, are made safer by the intervention of a psychiatrist in the ordering process. If so, what does this mean for community-based residential settings? Increasingly, these long-term facilities have become referral centers for children who may have previously been managed in hospitals with longer lengths of stay. With the advent of managed care, these complex children have been receiving treatment in community-based RTCs. No longer are these facilities merely home to children who have been abandoned and neglected. Increasingly they have also become the default placement for children with major psychiatric impairment such as early-onset schizophrenia and juvenile bipolar disorder. Is this the best setting for these children? Will the regulatory process regarding oversight of restraints mean that community-based RTCs will no longer be able to treat our most psychiatrically fragile children because they are unable to accommodate the ordering and monitoring requirements associated with the physical management of these children? If we believe these programs are appropriate and important components of our systems of care for children with major mental illness, how do we reconcile a different level of oversight for restrictive management interventions? After all, isn’t a hold or restraint the same regardless of the setting in which it occurs?
In response to the CHA, states will begin to collect data that will be essential to answer some of the questions raised by the Act itself. We need to know which restrictive behavioral interventions carry the greatest risk of harm to the children we are treating. We need to understand better how to mitigate these risks. And we will need to understand how to balance the desire to mitigate risk while preserving community-based, less restrictive options in our developing systems of care.
Dr. Bellonci is Medical Director of the Walker Home and School, in Needham, Massachusetts.