Residential programs that serve child welfare youths with mental health needs are charged with maintaining a safe and therapeutic treatment environment. Managing difficult and often aggressive behaviors of these youths is a challenge. Physical restraint is a tool many programs utilize to promote safety. However, restraint itself is a high risk intervention, with potential danger to the youth and staff involved.
The use and monitoring of restraint and seclusion is an issue for residential programs across the globe. The UN Conventions on the Rights of the Child emphasize the responsibilities of the government in providing for youth in care in a manner that upholds dignity and self-respect (1989). The use of restraint is not specifically mentioned in this covenant, leaving individual countries and programs to apply these abstract principles in practice. Review papers of restraint practice recommendations can be found in England (Hart and Howell, 2004), Scotland (Davidson, McCullough, Steckley and Warren, 2005), Australia (Joanna Briggs Institute, 2002) and the United States (Huckshorn, 2005).
The use of physical restraint in mental health facilities rose to a national concern in the United States following a 1998 five-part series in the Hartford Courant that estimated between 50 and 100 persons died each year as a result of physical restraint (Weiss, Altimari, Blint and Megan, 1998). This finding was especially notable because of the lack of regulation directed at this practice. Despite the potential risks involved in restraint, formal reporting or oversight for this intervention was not well-developed. A 1999 GAO report on restraint described the regulation efforts as "inconsistent" and the data collection and reporting efforts as "fragmentary" (USGAO, 1999, p. 5). This report also raised the concern that children may be at greater risk than adults because some findings suggest that youths are more likely to be restrained and more likely to be injured during restraint. As evidenced by a more recent GAO report on certain residential treatment programs, gaps in regulatory efforts and licensing practices resulted in a youth death from a prolonged, face-down restraint in a wilderness treatment program (2007).
Literature about restraint rates for facilities serving youth focus primarily on inpatient hospitalization programs. Studies of inpatient psychiatric programs for youths report incidence rates ranging from 46%-60% (Delaney and Fogg, 2005; Donovan, Plant, Peller, Siegel and Martin, 2003). However, little information is provided about what restraint procedures are used. In an empirical study of restrictive practices in Finland, younger youth were more likely to receive a less restrictive holding technique, while older youth were more likely to experience seclusion and mechanical restraints (Sourander, Ellilä Välimäki and Piha, 2002). Restraint can vary from a minimally invasive transport technique (e.g., a youth is escorted to a time-out room) to a face-down floor restraint, a position considered most dangerous due to asphyxiation risk. A growing trend connected with restraint is the use of "as needed" or PRN medication to decrease agitation. Limited studies have found that PRN medication was administered prior to restraint in 38%-69% of restraint incidents (Delaney and Fogg, 2005; Donovan, Plant, Peller, Siegel and Martin, 2003; Petti, Mohr, Somers and Sims, 2001).
Few studies have incorporated the views of program stakeholders in evaluating restraint. Youth opinions on restraint in residential programs were assessed in a qualitative study in Scotland. Findings suggest that although youths had concerns about how restraints were sometimes conducted, youths recognized that restraint can be the most appropriate intervention to ensure safety (Steckley and Kendrick, 2005). A study from the field of developmental disabilities found that consumers had a more negative reaction to restraint practices than staff members (Cunningham, McDonnell, Easton and Sturmey, 2003).
Because of the potential dangers of restraint, several initiatives to reduce the use of and tighten the standards for physical restraints have been promoted in the United States. The effort sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) has garnered the most attention (Huckshorn, 2005). This model suggests six core strategies for reducing the use of physical restraint in residential programs: (1) leadership by agency administrators for organizational change; (2) data collection and monitoring; (3) workforce development; (4) de-escalation; (5) consumer involvement in reduction efforts; and, (6) debriefing to learn from each restraint. Several programs have demonstrated that the utilization of these strategies has successfully minimized restraint (Farragher, 2002; Johnson, 2004; Jonikas, Cook, Rosen, Laris and Kim, 2004; LeBel et al., 2004; Nunno, Holden and Leidy, 2003).
With a growing interest in quality assurance and risk management, the state child welfare system in Missouri was interested in building knowledge about restraint in youth residential programs. The purposes of this study were to: 1) identify variation in rates and types of physical restraint use across residential programs; 2) assess stakeholders' perspectives on the use of restraint; and 3) outline effective restraint reduction efforts in these programs.
Cunningham, J. McDonnell, A.; Easton, S. and Sturmey, P. (2003). Social validation data on three methods of physical restraint: Views of consumers, staff and students. Research in developmental disabilities, 24, 4. pp. 307-316.
Davidson, J.C.; McCullough, D.; Steckley, L. and Warren, T. (Eds.). (2005). Holding safely: Guidance for residential child care practitioners and managers about physically restraining children and young people. Glasgow: Scottish Institute for Residential Child Care.
Delaney, K.R. and Fogg, L. (2005). Patient characteristics and setting variables related to use of restraint on four inpatient psychiatric units for youths. Psychiatric Services, 56, 2. pp. 186-192.
Donovan, A.; Plant, R.; Peller, A.; Siegel, L. and Martin A. (2003). Two-year trends in the use of seclusion and restraint among psychiatrically hospitalized youths. Psychiatric Services, 54, 7. pp. 987-993.
Farragher, B. (2002). A system-wide approach to reducing incidents of therapeutic restraint. Residential Treatment for Children and Youth, 20, 1. pp.1-14.
Hart, D. and Howell, S. (2004). Report on the use of physical intervention across children's services. London: National Children's Bureau.
Huckshorn, K.A. (2005). A snapshot of six core strategies for the reduction of S/R. National Technical Assistance Center, National Association of State Mental Health Program Directors.
Joanna Briggs Institute. (2002). Physical restraint part 1: Use in acute and residential care facilities. Best Practice, 6, 3.
Johnson, K. (2004). Achieving better outcomes for children and families: Reducing the use of restraint and seclusion. Residential Group Care Quarterly, 5, 2. pp. 1-2.
Jonikas, J.A.; Cook, J.A.; Rosen, C.; Laris, A. and Kim, J. (2004). A program to reduce use of physical restraint in psychiatric inpatient facilities. Psychiatric Services, 55, 7. pp. 818-820.
LeBel, J.; Stromberg, N.; Duckworth, K.; Kerzner, J.; Goldstein, R.; Weeks, M.; Harper, G.; LaFlair, L. and Sudders, M. (2004). Child and adolescent inpatient restraint reduction: A state initiative to promote strength-based care. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 1. pp.37-46.
Nunno, M.A., Holden, M.J. and Leidy, B. (2003). Evaluating and monitoring the impact of a crisis intervention system on a residential child care facility. Children and Youth Services Review, 25, 4. pp. 295-315.
Petti, T.A.; Mohr, W.K.; Somers, J.W. and Sims, L. (2001). Perceptions of seclusion and restraint by patients and staff in an intermediate-term care facility. Journal of Child and Adolescent Psychiatric Nursing, 14, 3. pp. 115-127.
Sourander, A.; Ellilä, H., Välimäki, M. and Piha, J. (2002). Use
of holding, restraints, seclusion and time-out in child and adolescent
psychiatric in-patient treatment. European child and adolescent
psychiatry, 11, 4. pp. 162.
Steckley, L. and Kendrick, A. (2005). Young people's experience of physical restraint. Examining the Safety of High-Risk Interventions for Children and Young People, International Symposium. Cornell University, Stirling University & Child Welfare League of America. Ithaca, NY.
UN General Assembly. (20 November 1989). Convention on the rights of the child. United Nations: Treaty Series 1577, 3.
United States General Accounting Office (USGAO). (1999). Mental health: Improper restraint or seclusion use places people at risk. Washington, D. C.: United States General Accounting Office GAO/HES-99-176.
United States General Accounting Office (USGAO). (2007). Residential treatment programs: Concerns regarding abuse and death in certain programs for troubled youth. Washington, D.C: United States General Accounting Office GAO-08-146T.
Weiss, E.M., Altimari, D., Blint, D.F. and Megan, K. (1998). Deadly restraints: A nationwide pattern of death. The Hartford Courant.
Lee, B.R.; McMillen, J.C. and Fedoravicius, N. (2007). Use and views of physical restraint in select residential treament programs. International Journal of Child and Family Welfare, 10, 3-4. pp. 139-140.