A CHRONICLE OF SECLUSION AND RESTRAINT IN AN INTERMEDIATE-TERM CARE FACILITY

Adolescent Psychiatry, 2003 by Petti, Theodore A, Somers, John, Sims, Linda

The use of restrictive practices, particularly seclusion and mechanical restraint (S&MR), in psychiatric hospitals and residential treatment centers for children and adolescents has generated considerable controversy and consternation for policymakers, providers, consumers, and other interested parties. Health and mental health professionals have argued for employment of these restrictive interventions as therapeutically necessary. Advocacy and consumer groups have lobbied strenuously for their attenuation (American Psychiatric Association, 2001). The Joint Commission on the Accreditation of Hospital Organizations (JCAHO) has been urging reductions of restrictive practices in hospitals and residential treatment centers for many years through their standards. The Health Care Financing Administration (HCFA), in a sudden and surprising move, changed the entire landscape with regulations promulgated in August 1999. These regulations have had a major impact on S&MR utilization policies and practices. Confusion and widespread changes in procedures resulted from these changes in hospital and residential treatment of adolescents with severe psychiatric disorders.

The use of seclusion as a form of control has its roots deep in American history. The practice of seclusion for disruptive behavior can be dated to the first schoolhouse in the United States, located in what is now the historical district of St. Augustine, Florida. There, down an alley, can be found the building, with a closet specifically designated for managing unruly youth. The modern use of S&MR as medical or nursing interventions evolved following a pattern described by Gair (1980). He describes their initial use as measures to ensure the safety of youth in residential care. These measures evolved to become standard psychiatric treatment. Gair notes the poorly articulated rationale for this standard of practice. He considers seclusion to be a therapeutic necessity that becomes an endpoint of limit-setting following the failure of alternative interventions to control dangerous or disruptive behavior toward self or others. Restraint serves as a means to interrupt determined efforts at self-mutilation. S&MR have become routine practices in most institutional and residential programs for juveniles (Zusman, 1997). There are no rigorous methodological studies comparing S&MR to other interventions for youth undergoing psychiatric treatment or residential placement; only case reports, program descriptions, and overviews are available (Cotton, 1989; Garrison et al., 1990; Troutman et al., 1998; Singh et al., 1999; Petti et al., 2001; American Academy of Child and Adolescent Psychiatry, AACAP, 2002).

The paradigm shift reflected in rising S&MR utilization since the 1970s and accompanying concerns of advocacy groups suggested a need for S&MR reassessment. Since 1995, JCAHO has issued many Type 1 recommendations for noncompliance following accreditation reviews indicating that immediate improvement needs to be addressed to JCAHO standard on S&MR (Zusman, 1997). Guidelines for the use of S&MR continue to be promulgated in the tug-of-war between practitioners allied with professional organizations and consumers allied with advocacy groups. To date, HCFA and JCAHO regulations and standards seem more stringent than those desired by many professionals and providers, and less stringent than those desired by patient advocacy groups. The AACAP has developed the "Practice Parameter for the Prevention and Management of Aggressive Behavior in Child and Adolescent Psychiatric Institutions, with Special Reference to Seclusion and Restraint" (2002) to address this issue. We present a university-affiliated, intermediate-term state hospital's successful efforts, initiated in 1995 and continuing to this time, to decrease S&MR utilization. We expect that the approaches employed and lessons learned in the process are similar to those experienced by many programs in managing the increasing numbers of more severely ill, destructive, violent, and dangerous youth in settings that must adjust to the changing fiscal and political climate in the human services system. We intend to chronicle these efforts and provide insights to those interested in understanding and learning from these experiences and advancing the field to be more effective and efficient in the care of such youth.

THE HOSPITAL AND ITS HISTORY

The evolution of the hospital, regarding the population of patients it serves and the dramatic shifts in role within the system of care in which it operates, is similar to that experienced by many other state hospitals throughout the nation. In the 1960s to 1980s, the Youth Service (YS) of Larue Carter Hospital (LCH) served youngsters of average intelligence who were often acutely disturbed or belonged to special clinical populations and came from relatively intact family systems. In the 1980s, the burgeoning public mental health centers and private hospital beds to serve these youngsters resulted in increasing referrals of more treatment-resistant, developmentally disabled patients. In the 1990s, the hospital began admitting droves of more severely ill youngsters who had demonstrated ineffective response to multiple acute, brief hospitalizations, residential and out-of-home placements, and/or prescription of multiple psychotropic agents and intensive outpatient treatment. Many of these youth had been physically and/or sexually abused. The adolescents included those who had been sexual predators, those who were severely violent and aggressive towards others, and those with dangerous self-injurious behavior, including females who would ingest foreign objects (e.g., paper clips, staples, tooth brushes, plastic utensils, batteries). Many had histories of injuring hospital or residential staff and/or regular S&MR utilization to control their behavior.