Kim J. Masters, M.D.
For at least 300 years seclusion and restraint have been the most restrictive interventions in the prevention and management of aggressive behavior. Residential treatment facilities have preferred restraint, particularly for children, while psychiatric hospitals have not had a clear preference for either. However, it appears that, at least from one report, attempts to ban seclusion resulted in an increase in the use of restraint (Swett et al, 1989). Differences between residential facility and psychiatric hospital practice at times are baffling. For example, the use of prone restraint is taught as a favored intervention by a widely used aggression management training program for residential treatment facilities (TCI 1980, 1999). This program’s headquarters are in New York, a state that bans the use of prone restraint in psychiatric hospitals! (New York State, 1997).
In the past, the governing cultures of residential treatment appeared to be influenced by therapeutic philosophies emerging from The Other 23 Hours (Treischman A., et al., 1969), which sees physical restraint as a corrective emotional experience and seclusion as abandonment. This approach is supported in some states that prohibit the use of seclusion in these facilities, because of the risk for PTSD with prolonged isolation and neglect, and the rooms’ potential to be a fire trap.
A rekindling of the seclusion vs. restraint debate occurred when it was tragically discovered that both children and adolescents died during restraints. Fatalities occurred with prone restraint, the basket hold, and supine restraint. During a restraint, staff may unintentionally compress patients’ airways, restrict circulation, decrease oxygenation and promote the development of fatal arrythmias (irregular heart beats). Medications that could act synergistically with restraint in the development of these fatal arrythmias may include: 1) those with anticholinergic side effects, such as tricyclic antidepressants, 2) possibly alpha adrenergic agents like clonidine which may affect blood pressure and pulse, 3) thioridazine [mellaril] and other drugs which may prolong qt/qtc intervals, and 4) stimulants which may increase heart rate.
What can be said of the medical dangers of seclusion? Screaming, yelling, and pacing all promote compensatory cardiovascular mechanisms, including increased breathing in response to the need for more oxygen. This, in turn, decreases the risk for arrythmias. Restraint, on the other hand, inhibits these compensatory responses because it decreases the child’s mobility while at the same time increasing heart rate and hampering blood flow, often without permitting him to breath adequately to meet increased oxygen needs. This would explain what I have often observed, that during a restraint a child often demands, “Let me go, I can’t breathe!” What exactly causes death from seclusion? The only case I am aware of resulted from a child being put in seclusion after a restraint. However, there is always a risk of a medical crisis from medication reactions, or selfinduced trauma if patients are not continuously observed during these times . Since sometimes the child is put in a seclusion or “time out” room on these occasions, it may incorrectly be assumed that seclusion is the culprit if a fatality occurs.
There is, however, a risk of self injury during seclusion, particularly in inadequately padded rooms. There are similar risks for patient injury during the initiation and premature termination of restraint use. The damage occasionally reported in severely psychotic adults— genital or eye mutilation—has not been reported in the child and adolescent literature I reviewed.
There is a risk of injury during transport of a patient to seclusion. However, if the child is taught the role of brief seclusion time in regaining self control, he may choose seclusion in preference to restraint and go to the room willingly. As an added inducement, the child could have the freedom of unlocked seclusion, if he can keep his anger within the confines of the room.
Overall, for patient safety, seclusion is clearly favored as a restrictive intervention over the use of any type of restraint, because of decreased physiologic stress on the child or adolescent and a far lower mortality associated with its use.
The stresses and risk for staff injury in carrying out a seclusion also should be less than those generated by a physical or mechanical restraint, because of the briefer time required in direct patient contact for the procedure.
What of the oft cited psychological damage from seclusion? The literature about the development of PTSD from the seclusion room experience dates from Wadeson and Carpenter’s (1976) report, which described patients isolated for prolonged periods, up to a day or more, akin to solitary confinement in a prison. I am not aware of literature demonstrating PTSD from a 5 to 15 minute seclusion. This is its expected length, when there are active prevention and management strategies for aggression control known and practiced by children and taught by staff. Instead, this could be a benign opportunity for a child or adolescent to regain self control.
The critics of the use of seclusion often place it in a 300-year-old procrustean bed, unchanged since its description by Phillipe Pinel in his work at the Bicetre Hospital in Paris in 1794. However, in 2002, seclusion times should be brief, and the rooms should be well ventilated, of adequate size, attractively colored, well padded, and have doors that unlock in case of fire. The rooms can have calming music and visual inputs as well. The role of seclusion should be to distract a person from his anger until he can calm himself. Maybe with audio and visual inputs we can accelerate this process, resulting in 5-10 minute seclution periods rather than 10-15 minute ones?
In summary, as part of a comprehensive preventive aggression management program, 296 AACAP NEWS locked seclusion, offers more opportunities for children and adolescents to regain self control and avoid injury and death.
Dr. Masters is Medical Director of Focus by the Sea, a private psychiatric hospital on St. Simons Island, GA. He is also coauthor of AACAP’s Practice Parameter on the prevention of aggressive behavior.
New York State Office of Mental Health Work Group on Preventive and Restrictive Interventions (1997), Management of Out of Control Behavior in Children and Adolescents: A Comprehensive Training Guide, pp. 1–52, 63.
Swett C., Michaels A., Cole, J. (1989), Effects of a State Law on Rates of Restraint on a Child and Adolescent Unit. Bull Am Acad Psychiatry Law 17:165–169.
TCI (1980), Residential Child Care Project: Therapeutic Crisis Intervention. Cornell University, Ithaca, New York, pp. 377.
TCI (1999), Safety Brief, Therapeutic Crisis Intervention Residential Child Care Project.
College of Human Ecology, Cornell University, Ithaca, New York, pp. 1-2.
Treischman A, Whittaker J, Brendtro, L (1969), The Other 23 Hours: Child Care Work in a Therapeutic Milieu. Hawthorne, NY: Aldine de Gruyter.
Wadeson H., Carpenter, W. (1976), Impact of the Seclusion Room Experience. J Nerv Men Dis 163:318-328.
Suggested Reading: American Academy of Child and Adolescent Psychiatry (2002), Practice Parameter For the Prevention and Management of Aggressive Behavior in Child and Adolescent Psychiatric Institutions with Special Reference to Seclusion and Restraint /J. Am Acad Child Adolesc Psychiatry 41 (suppl) 4s-25s.