ABSTRACT

This parameter reviews the current state of the prevention and management of child and adolescent aggressive behavior in psychiatric institutions, with particular reference to the indications and use of seclusion and restraint. It also presents guidelines that have been developed in response to professional, regulatory, and public concern about the use of restrictive interventions with aggressive patients in regard to personal safety and patient rights. The literature on the use of seclusion, physical restraint, mechanical restraint and chemical restraint is reviewed, and procedures for carrying out each of these interventions are described. Clinical and regulatory agency perspectives on these interventions are presented. Effectiveness, indications, contraindications, complications, and adverse effects of seclusion and restraint procedures are addressed. Interventions are presented to provide more opportunities to promote patient independence and satisfaction with treatment while diminishing the necessity of using restrictive procedures.

Key Words: seclusion, restraint, chemical restraint, preventing aggressive behavior.

This parameter was developed by Kim J. Masters, M.D., Christopher Bellonci, M.D., and the Work Group on Quality Issues: Valerie Arnold, M.D., Joseph Beitchman, M.D., R. Scott Benson, M.D., : William Bernet, M.D., Chair, Oscar Bukstein, M.D., Joan Kinlan, M.D., Jon McClellan, M.D., and David Rue, M.D., Jon A. Shaw, M.D., and Saundra Stock, M.D., AACAP Staff: Kristin Kroeger.

This summary and the full text of the Practice Parameter for the Prevention and Management of Aggressive Behavior in Child And Adolescent Psychiatric Institutions With Special Reference to Seclusion and Restraint is available to AACAP members on the World Wide Web (www.aacap.org) and will appear in a future supplement to the JAACAP. This parameter was made available to the entire AACAP membership for review in September 2000 and were approved by the AACAP Council on May 13, 2001. It is available to AACAP members on the World Wide Web (www.aacap.org). Reprints requested by the AACAP Communications Department, 3615 Wisconsin Ave., NW, Washington, D.C. 20016.
© 2001 by the American Academy of Child and Adolescent Psychiatry

INTRODUCTION

The scope of this practice parameter is to: examine methods of preventing aggressive behavior in institutions before the need for seclusion or restraint is necessary; review the current state of literature about the safe implementation of seclusion and restraint; illustrate ways of using patient and staff processing of seclusion or restraint events to promote the use of alternative strategies and therefore lessen further need for these interventions; and identify current research questions, which will help improve clinical practice with these interventions.

The effective use of prevention strategies can help children and adolescents master the difficult developmental skills of coping with internal distress and external conflict. When prevention strategies are ineffective and a child or adolescent is in danger of hurting themselves or others, seclusion or restraint is indicated.

This parameter describes recommended clinical practice. At times, these recommendations are different from regulatory guidelines and will be noted as such. Familiarity with federal, state, and other regulatory agency and institutional regulations is necessary to ensure that treatment requirements mandated by these agencies are met. For the purpose of this parameter, "parent" is used to mean biologic, foster, and adoptive parent, as well as legal guardian.

EXECUTIVE SUMMARY

The executive summary provides an overview of the most important points and recommendations that are made in this practice parameter. The treatment of patients who may require seclusion or restraint requires the consideration of many factors that cannot be conveyed fully in a brief summary. The reader is encouraged to review the pertinent portions of the entire practice parameter. Each recommendation in the executive summary is identified as falling into one of the following categories of endorsement, indicated by an abbreviation in brackets in the list below. These categories indicate the degree of importance or certainty of each recommendation.

[MS] "Minimal Standards" are recommendations that are based on substantial empirical evidence (such as well-controlled, double blind trials) and/or overwhelming clinical consensus. Minimal standards are expected to apply more than 95% of the time, i.e., in almost all cases. When the practitioner does not follow this standard in a particular case, the medical record should indicate the reason.

[CG] "Clinical Guidelines" are recommendations that are based on empirical evidence (such as open trials, case studies) and/or strong clinical consensus. Clinical guidelines apply approximately 75% of the time. These practices should always be considered by the clinician, but there are exceptions to their application.

[OP] "Options" are practices that are acceptable, but not required. There may be insufficient empirical evidence to support recommending these practices as minimal standards or clinical guidelines. In some cases, they may be appropriate but, in other cases, should be avoided. If possible, the practice parameter will explain the pros and cons of these options.

[NE] "Not endorsed" refers to practices that are known to be ineffective or contraindicated.

PREVENTION OF AGGRESSIVE BEHAVIOR

Intake and Assessment
Collecting the history regarding aggressive behavior may begin with the intake phone call, continue through the admission process, and be part of the psychiatric, nursing and social work assessments [CG]. Intake staff, admission staff, and program staff should systematically communicate to patients and their families that patients will be encouraged and expected to make every effort to manage their own behavior [MS].

The management of aggressive behavior begins with diagnosing and treating the underlying psychiatric illness. The evaluation of a patient should include a review of aggressive behavior, including triggers, warning signs, repetitive behaviors, response to treatment, and prior seclusion and restraint events that are associated with aggressive acts [MS]. Cultural factors may influence the triggers and expression of aggression by patients and the response to aggression by staff and these factors should be considered in treatment facilities [CG]. Cognitive limitations, neurological deficits and learning disabilities should be noted during intake evaluations [MS]. A medical evaluation of the patient should identify factors that may require modification of seclusion and restraint procedures [MS].

Treatment Planning
The treatment plan should include strategies to prevent aggressive behavior, de-escalate behavior before it becomes necessary to use restrictive interventions, and initiate psychological and psycho-pharmacological treatments for treating the underlying psychopathology [MS].

Patients with a history of aggressive behavior may benefit from anger management, problem-solving and psychoeducational programs [CG].

Staff Training
Repeated training in the management of aggressive behavior is necessary to develop the high degree of competence this work requires [MS]. Good training promotes the retention of qualified staff. Training should include updated information about seclusion and restraint practices, assessment of acuity levels to allow changes in staffing on a shift by shift basis as needed for patient safety, frequent practice in using restraint equipment, training in documentation, training in seclusion and restraint audits, and annual certification in cardiopulmonary resuscitation. Facilities, staff, and physicians should update themselves at least annually on seclusion and restraint information from academic, regulatory, patient advocacy and professional resources [MS].

CRISIS MANAGEMENT

De-escalation Strategies
Each unit should have its own de-escalation program that helps patients manage angry outbursts [CG]. Anger management and stress reduction techniques are important components of prevention in psychiatric facilities and should be a component of a psycho-education program for children and adolescents. If less restrictive options have failed or cannot be safely applied, seclusion and restraint procedures may be required.

Indications for the Use of Seclusion or Restraint
The only indications for the use of seclusion and restraint are to prevent dangerous behavior to self or others and to prevent disorganization or serious disruption of the treatment program including serious damage to property. Measures promoting the child's self-control or less restrictive options must have failed or are impractical [MS].

Seclusion and restraint should not be used as punishment for patients, for the convenience of the program, where prohibited by state guidelines, to compensate for inadequate staffing patterns, or instituted by untrained staff [NE]. When it becomes necessary to implement seclusion and restraint the autonomy and dignity of the patient must be preserved as much as possible [MS].

Ordering and Monitoring Seclusion and Restraint
The decision on when to seclude or restrain a patient must be made by the professionally trained staff working with the patient at the time of the aggressive behavior in consultation with a physician [MS]. Seclusion, physical restraint, and chemical restraint should not be ordered on a prn (pro re nata = as the occasion may arise) basis [NE]. All patients in seclusion or restraint must be monitored continuously. All restrained patients should have their pulse, blood pressure, and the range of motion in their extremities checked every 15 minutes [MS]. The need for nutrition, hydration, and elimination and the physical and psychological status and comfort of the patient should be monitored and responded to once these needs are identified [MS]. The patient's family should be informed of use of seclusion or restraint [MS]. Once the child or adolescent is settled and has regained self-control, the seclusion or restraint should be terminated [CG].

Physical and mechanical restraints that cause airway obstruction must not be employed (e.g. choke holds or covering the patient's face with a towel, bag, etc.) [NE]. With supine restraints, a patient's head must be able to rotate freely. With prone restraints, the patient's airway must be unobstructed at all times (i.e. not buried), and the patient's lungs must not be restricted by excessive pressure on the patient's back [MS].

Chemical restraint is the involuntary use of psychoactive medication in a crisis situation to help a patient contain out-of-control aggressive behavior. Chemical restraint is to be distinguished from the pharmacological management of a patient's underlying illness. The decision to order a chemical restraint must consider the available medical and psychiatric history of the patient, including concurrent medications being used [MS]. Chemical restraints must be administered and continuously monitored by trained nursing personnel. In general, oral medication should be offered prior to the administration of parenteral medication. In order to avoid aspiration, oral medication must always be given when the patient is sitting up or standing.

HCFA (Health Care Financing Administration) regulations require that a licensed independent practitioner have face-to-face contact with the patient within one hour of the initial order for seclusion or restraint. Additionally the patient's treating physician must be consulted as soon as possible if the treating physician is not the practitioner who ordered the seclusion or restraint.

JCAHO (Joint Commission on Accreditation of Healthcare Organizations) standards allow qualified, registered nurses or other qualified, trained staff to initiate the use of seclusion or restraint. An order for the seclusion or restraint must be obtained from a licensed independent practitioner as soon as possible but no longer than one hour after the initiation of the seclusion or restraint. In Medicare/Medicaid funded programs a physician or licensed independent practitioner must conduct a face-to-face evaluation of the patient within one hour of the initiation of a restraint or seclusion as required by the HCFA interim final rule for Patients Rights, August 1, 1999. In other facilities the initial evaluation of patients in seclusion and restraint is 2 hours for a patient age 17 and under and 4 hours for ages 18 and over. If the patient is no longer in seclusion or restraint when the original order expires the licensed independent practitioner must conduct an in-person evaluation of the patient within 24 hours of the initiation of the seclusion or restraint. Verbal and written orders are limited to one hour for children under age 9 and 2 hours for individual's ages 9-17. The order for continuation of a restraint or seclusion can be made by a qualified registered nurse or other qualified trained individual who has been authorized by the organization to perform this function. However, a licensed independent practitioner must perform an in-person reevaluation at least every 4 hours for individuals 17 years and younger.

JCAHO standards for restraint and seclusion do not apply: when a staff person physically redirects or holds a child, without the child's permission, for 30 minutes or less; when the individual is restricted for 30 minutes or less from leaving an unlocked room (time-out) or when an individual is restricted to an unlocked room or area.

The HCFA regulations and JCAHO standards were current at the time of the publication of this parameter. However, this is an area of regulatory oversight that has been in rapid evolution and practitioners should stay informed of the new regulations and standards as they are announced. (see www.jcaho.org, www.hcfa.gov).

PROCESSING STRATEGIES

The use of seclusion and or restraint should be followed by a debriefing discussion that allows the patient to process and understand what has happened [MS]. The staff should review with the patient the events that triggered the seclusion or restraint; discuss with the patient alternate strategies to avoid similar incidents and arrange whenever possible for the patient to make amends or do restitution to those who have been injured. Every episode of seclusion and restraint must be documented in the patient's medical record [MS]. JCAHO requires that patients be allowed written comment about the experience. Staff participating in a seclusion or restraint should review the episode in a separate debriefing session and document recommendations and findings for the facility's committee that reviews seclusion and restraint reports [MS].

Administrative Oversight
Strong clinical leadership is essential in the management of aggressive behavior in order to minimize the need for seclusion and restraint. Facilities must have a committee that provides oversight of the practice of seclusion and restraint [MS]. This may include a review of restrictive interventions; restraint equipment; staff training; staff retention; patient and parental concerns about seclusion and restraint; and peer review of the application and use of seclusion, mechanical and chemical restraint, and restraint equipment. A patient and family ombudsman should also be available to review concerns about restrictive interventions [OP].

SPECIAL POPULATIONS

This parameter may have applications for children and adolescents in general hospitals, detention centers, and group homes that employ aggression management programs. However, modifications may need to be made for individuals with developmental disabilities, individuals treated within emergency departments and individuals in pediatric units. For children and adolescents who have a trauma history the use of physical and mechanical restraint are discouraged; seclusion may be used preferentially.

REFERENCES

American Academy of Child And Adolescent Psychiatry (2001), 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, (In Press).