Dr. Anthony James is a child psychiatrist at Oxford University in the United Kingdom (UK). He has been extremely helpful in his commentaries about my writings on seclusion and restraint since 1995. He was kind enough to review a draft of AACAP’s Practice Parameter on the "Prevention of Aggressive Behavior in Psychiatric Institutions" and he is very knowledgeable about seclusion and restraint practices in the UK. He has kindly agreed to share some of his observations with us. I hope you will find them of interest.
Kim Masters, M.D.
Anthony James, M.D.
The U.S. Practice Parameter for the Prevention and Management of Aggressive Behaviour (2002) published by AACAP indicates a considerable convergence between the United Kingdom (UK) and U.S. practice of seclusion and restraint; nevertheless, differences remain. A related, but nonetheless important underlying difference is in the number of inpatient psychiatric units per head of population. Indeed, in the UK there are only 84 child and adolescent psychiatric units for a population of 55 million. With generally fewer psychiatric units and the lack of an evidence-base for residential treatment of conduct disorder, patients with severe conduct disorder are not often admitted to UK psychiatric units, but rather treated as outpatients, in therapeutic fostering, or accommodated in social services children’s homes or secure units.
Children presenting with severe behavioural disturbance, who are accommodated in a local authority children’s home or secure unit can be restrained and placed in their room with supervision, in accordance with guidelines of the Children Act, a social welfare legislation. In secure units the young person’s room can be locked. The use of medication, however, in social services establishments, solely for control of behaviour, is not practised.
Legislation and Code of Practice
In UK psychiatric units the Mental Health Act provides the legal framework for the use of compulsory treatments. There is no lower age limit for its use, although parental consent for younger children is permissible. The code of practice of the Mental Health Act (1999) lays down guidelines for the use of restraint and seclusion. It also qualifies the involvement of the multidisciplinary team, in particular expert psychology oversight for time out programmes. Strict guidelines exist for use of time out, which must form part of a treatment programme, and require that the patient should never be in a locked room, and that the time out be limited to 15 minutes. Seclusion is meant to be used as a last resort, for the shortest possible time, and never as part of a treatment programme or where there is a risk of self-harm or suicide. The Code of Practice specifies that the patient must be continuously observed with regular reviews by medical and nursing staff. The guidelines also mention the need for training of staff in restraint; adequate staffing levels; reviews of staff skill mix; and patient mix, as important factors in the prevention and management of challenging behaviours. Records of restraint should be audited. All units are subject to regular, sometimes unannounced, inspections by the Mental Health Act Commission.
Sedative medication is used to control severe agitation and aggression. Oral medication is always offered first, with the option of intramuscular use, if the oral route is refused. Although there is a risk of paradoxical increase in agitation with benzodiazepines, lorazepam is used commonly. As in the U.S. (Barnett et al, 2002), medication is used largely independent of diagnosis. For example, oral chlorpromazine is effective for sedation, even in non-psychotic disorders. However, caution is to be exercised with the use of neuroleptics. For example, droperidol is prohibited in the UK because of the cardiac effects associated with lengthening of the QT interval. Although there is less risk of extrapyramidal side effects with the atypicals, experience of their use for control of aggression in the UK is limited.
In the UK seclusion is rarely used for children under the age of 12, instead therapeutic holding is practised.
In the UK there are two major forms of restraint; one is called SCIP (Statutory Crisis Intervention and Prevention), which uses no punishing or painful holds and has been advocated for the care of children. There have been criticisms of this practice, as it involves holding, sometimes in the prone position, for prolonged periods. This may be particularly problematic for children who have been sexually abused. The other methods of restraint such as C & R (Control and Restraint) for older adolescents include the use of some limited, painful holds, for example forced flexion of the hand at the wrist.
There is likely to be considerable agreement between UK and U.S. clinicians upon use of level 1 and 2 interventions for the prevention and deescalation of violent incidents. Indeed, a Maryland schema (Barnett et al, 2002) for the progressive use of interventions accords with UK practice. A major difference, however, lies in the level 3 interventions, with the use in the U.S. of mechanical restraints (AACAP Practice Parameter, 2002). In none of the units in the UK, even in secure hospital forensic units are these devises used. They are generally regarded as draconian, antiquated and inhumane.
The practice of restraint in the UK appears fairly safe with no reported deaths or severe complications in the last two years in health service or social services facilities. Indeed, this must raise the question whether the use of mechanical restraints is really necessary.
Individuals wishing to correspond with Dr. James can do so at: Dr. Anthony James, Consultant Psychiatrist, Highfield Adolescent Unit, Warneford Hospital, Oxford OX3 7JX, UK. A
Barnett, S.R., dosReis, S., Riddle, M.A., The Maryland Youth Practice Improvement Committee for Mental Health. Journal of the American Academy of Child and Adolescent Psychiatry, 2002, 41, 897-905.
Code of Practice: Mental Health Act (1983) Department of Health and Welsh Office. (1999) London: The Stationery Office.
Practice parameter for the prevention and management of aggressive behavior in child and adolescent psychiatric institutions, with special reference to seclusion and restraint. Journal of the American Academy of Child and Adolescent Psychiatry, 2002, 41 (2 Supplement) 4S-25S.