Probably somewhere on here, but I've been reading this today...from NAMI.
Child and Adolescent Inpatient Restraint Reduction:
A State Initiative to Promote Strength-Based Care
Janice LeBel, Ed.D., Nan Stromberg, R.N., C.S., Ken Duckworth, M.D., Joan Kerzner, M.S.P.A., Robert Goldstein, Ph.D., Michael Weeks, B.A., Gordon Harper, M.D., Lareina LaFlair, M.P.H., Marylou Sudders, A.C.S.W. From the Massachusetts Department of Mental Health (J.L., N.S., K.D., J.K., R.G., M.W., G.H.); formerly with the Department (L.L., M.S.).
"To detain maniacs in constant seclusion, and to load them with chains...is... more distinguished for its convenience than for its humanity or its success." (Goshen, 1967) (p. 264)[/b]
Despite intermittent efforts since Pinel removed chains from the insane in 18th-century France (Weiner, 1992), restraint and seclusion (R/S) have remained prominent in psychiatric practice (Rothman, 2002). Opinions differ as to its utility and efficacy. In the last decade, concern has focused increasingly R/S use in psychiatric treatment, particularly with children and adolescents. Some have argued that R/S is a necessary safety measure, perhaps even a necessary part of child/adolescent treatment (Cotton, 1989; Gair, 1980,1984). This practice has been challenged by a body of published evidence and by criticism in both lay and professional communities. But there have been few reports of effective strategies to curtail or provide alternatives to R/S use with children and adolescents. This paper describes such an initiative by the State Mental Health Authority (SMHA) in Massachusetts, and its effects.
In the media, a Pulitzer Prize-winning series in The Hartford Courant reported 142 deaths, over ten years, of patients who were being restrained. More than 26% of these deaths involved children and adolescents, nearly double the proportion of these cohorts in psychiatric institutions nationwide (Weiss, 1998).
The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) set the following goal in its Behavioral Health Care Restraint and Seclusion Standards (JCAHO, 2001):
Because restraint and seclusion have the potential to produce serious consequences, such as physical and psychological harm, loss of dignity, violation of an individual?s rights, and even death, organizations continually explore ways to prevent, reduce, and strive to eliminate the use of restraint and seclusion through effective performance initiatives.
Trauma[/b]
The use of R/S poses increased risks for children and adolescents whose histories often include physical, sexual and emotional trauma. In one study, trauma histories were present in up to 93% of hospitalized adolescents, 32% of whom met the criteria for posttraumatic stress disorder (Lipschitz et al., 1999). Another study concluded that children with a history of acute trauma retained psychological sequelae from the experience of R/S that continued to affect their mental and physical health (Lewandowski and Baranoski, 1994). In addition, the failure to recognize childhood trauma and abuse produces iatrogenic effects (Carmen et al., 1996; Jennings, 1994). Finally, for those with childhood trauma histories, using R/S makes the hospital, the intended site of healing, a place of new trauma (Carmen et al., 1996; Jennings, 1994; Rosenberg et al., 2001). One consumer advocate described how the experience of restraint recapitulated her childhood trauma:
Rather than deterring anything, these episodes perpetuated a vicious cycle. The more I was restrained, the more humiliation I felt. The more shame and humiliation I felt, the more I dissociated, self-injured, and was restrained. (Prescott, 2000) (p. 98)
Staff perspective[/b]
Staff see R/S more favorably than child and adolescent patients, even when acknowledging the lack of evidence of its benefit (Allen, 2000). Some concede that R/S may be harmful to children, adolescents, adults and staff but see it nonetheless as effective in preventing injury and agitation (Fisher, 1994). There is evidence that their gender, level of education, and degree of clinical experience affect staff's decision to use R/S with children and adolescents (Busch and Shore, 2000; Garrison, 1984).
