Gordon Harper, M.D.

The practice of restraining and secluding children and adolescents is being redefined.

While restraint and seclusion have for centuries been controversial parts of the management of mentally ill people, in the last quarter century these interventions have often been seen as part of the treatment of disturbed children and adolescents. Reflecting this view, many residential and inpatient treatment facilities have restrained children at rates far higher than those used with severely disturbed adults. Despite therapeutic intentions, practice has often been rigid, punitive, and excessively rule-based.

These practices are changing. The ideas behind them are being challenged. New ways of regulating seclusion and restraint are being implemented. We are seeing a paradigm shift that involves:

• A new way of thinking about the use of seclusion and restraint.
• Analyzing use of restraint and seclusion as a characteristic of programs rather than of the children, sometimes called “high restraint users.”
• Program leadership emphasizing examination of values and culture, training, and continual self-review.
• A change in the relationships of staff and children, of staff and parents, and of staff to their work.
• A change in administrative oversight from case-by-case regulation of “a necessary component of care” to initiatives to replace the use of restraint and seclusion with a strengths-based, partnership approach to care.

How did this change happen?
Starting in the 1950’s, clinicaldevelopmental rationales were published for the use of restraint and seclusion with disturbed children. In the decades that followed, in many residential and inpatient programs, children and adolescents were restrained or secluded more often than adults. In Massachusetts in the 1980’s, for example, state-licensed facilities were restraining children four to sixteen times more often than adults. A practice parameter from the American Academy of Child and Adolescent Psychiatry in 2002 advocated measures to “decrease the necessity” of restraint and seclusion but did not challenge their prevalent use.

Challenges to restraint and seclusion came from the following sources: the media, human rights advocates, lack of evidence of efficacy, clinical experience with trauma survivors retraumatized in restraint or seclusion, the testimony of children who reported fear and humiliation but little sense of benefit, program leaders who wanted to reduce injuries to patients and staff, and public mental health administrators troubled by high use and high program-toprogram variation.

In response, in the last five years, the National Association of State Mental Health Program Directors (NASMHPD), the Center for Medicaid and Medicare Services (CMMS, formerly the Health Care Financing Administration), and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), on behalf of adults as well as children, defined restraint and seclusion as lastresort safety interventions, not treatment, and issued new standards for monitoring their use.

States are exercising their regulatory role in new ways. Pennsylvania shared restraint data and offered training to program leaders; the hours adults spent in restraint or seclusion fell by 96% in five years. Massachusetts, focusing on child and adolescent facilities, used standard-setting and educational approaches. Over two years, incidents of restraint and seclusion fell by 47% to 73%. Some programs are not restraining children at all and adolescent programs are moving toward norestraint practice.

To share and sustain this progress, with support from the Substance Abuse and Mental Health Services Administration (SAMHSA), NASMHPD has initiated National Executive Training Institutes. Twenty states have been selected to participate. Their representatives receive training and learn from each other.

Change has also occurred on several levels:

• On the individual level, children are being restrained and secluded much less. The child’s preferences for “cooling down,” wrýtten documents to use ýn de-escalatýon, become the basis of care. Family members are included, helping with their children during crises and joining the team in planning meetings. Children describe a change in their relationships with program staff, from control and fear to partnership and support.
• On the program level, leaders are emphasizing strength-based, individualized care. Program culture is defined around the values of learning, nurturance and support, rather than control and rules. Staff receive assistance in developing the necessary knowledge, skills, and attitudes. Post-incident debriefings shift from reciting features of the child that “justify” restraint (“blamethe- victim”) to an inquiry: What can we learn about our practice to support this child in a different way and avoid restraint?” Direct-care staff enjoy work again. Injuries decrease.
• On the administrative level, state mental health authorities set standards, use aggregate data, and offer technical assistance and training. They provide data comparisons, visits to no-restraint programs, and best practice conferences presenting successful approaches. In Massachusetts, each licensed or contracted program is required to develop its own strategic plan for restraint reduction. Individual child and adolescent psychiatrists, long marginalized partners, albeit legally responsible, in “hands-on” care, are re-examining their role in this part of treatment.

This paradigm shift is bringing child psychiatry back to forgotten roots. For two decades, reductionistic approaches to illness have too often made the child an object rather than a partner. And a decontextualized view of the patient has interfered with appreciation of what Stanton and Schwartz called “institutional participation in illness.” Restraint reduction is one way to regain an appreciation of the social construction of behavior and a sense of partnership with the child.

Dr. Harper is Medical Director for Child and Adolescent Services at the Massachusetts Department of Mental Health and Associate Professor of Psychiatry at Harvard Medical School. He was the founding chair of the AACAP Committee on Child Psychiatric Hospitalization.