Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Successful Seclusion and Restraint Prevention Efforts in Child and Adolescent Programs

Beth Caldwell, MS; Chantell Albert; Muhammad W. Azeem, MD, DFAACAP, DFAPA; Susan Beck, MSW; David Cocoros, MS; Trish Cocoros, BS; Raquel Montes, BS; Bhagya Reddy, MD

Abstract

The current article presents the experiences of three different child- and family-serving programs in the United States that have successfully implemented interventions to prevent the use of restraint and seclusion (R/S) in their respective facilities. The article also provides family and youth perspectives on the impact of and recommendations for preventing R/S. Over the past decade, a significant shift has occurred toward preventing the use of R/S within programs serving children and adolescents. National efforts have included the work of the Building Bridges Initiative, as well as growing interest and support for the implementation of trauma-informed environments of care. [Journal of Psychosocial Nursing and Mental Health Services, 52(11), 30–38.]

Ms. Caldwell is Director, National Building Bridges Initiative, Housatonic, Massachusetts; Ms. Albert is Outreach Coordinator, Parent Professional Advocacy League, Boston, Massachusetts; Dr. Azeem is Medical Director and Chief of Psychiatry, and Ms. Reddy is Child and Adolescent Psychiatrist, Albert J. Solnit Children’s Center, Middletown, Connecticut; Ms. Beck is Executive Director, Mount Prospect Academy, Plymouth, New Hampshire; Mr. Cocoros and Ms. Cocoros are Co-Executive Directors, Youth Development Institute, Phoenix, Arizona; and Ms. Montes is Transition Coordinator and Senior Youth Advocate, Casa Pacifica Centers for Children and Families, Camarillo, California. Dr. Azeem is also Associate Clinical Professor and Dr. Reddy is also Clinical Instructor, Yale Child Study Center, Yale University School of Medicine, Middletown, Connecticut.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Beth Caldwell, MS, Director, National Building Bridges Initiative, PO Box 712, Housatonic, MA 01236; e-mail: bethcaldwell@roadrunner.com.

Received: August 05, 2014
Accepted: September 03, 2014
Posted Online: September 30, 2014

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Abstract

The current article presents the experiences of three different child- and family-serving programs in the United States that have successfully implemented interventions to prevent the use of restraint and seclusion (R/S) in their respective facilities. The article also provides family and youth perspectives on the impact of and recommendations for preventing R/S. Over the past decade, a significant shift has occurred toward preventing the use of R/S within programs serving children and adolescents. National efforts have included the work of the Building Bridges Initiative, as well as growing interest and support for the implementation of trauma-informed environments of care. [Journal of Psychosocial Nursing and Mental Health Services, 52(11), 30–38.]

Ms. Caldwell is Director, National Building Bridges Initiative, Housatonic, Massachusetts; Ms. Albert is Outreach Coordinator, Parent Professional Advocacy League, Boston, Massachusetts; Dr. Azeem is Medical Director and Chief of Psychiatry, and Ms. Reddy is Child and Adolescent Psychiatrist, Albert J. Solnit Children’s Center, Middletown, Connecticut; Ms. Beck is Executive Director, Mount Prospect Academy, Plymouth, New Hampshire; Mr. Cocoros and Ms. Cocoros are Co-Executive Directors, Youth Development Institute, Phoenix, Arizona; and Ms. Montes is Transition Coordinator and Senior Youth Advocate, Casa Pacifica Centers for Children and Families, Camarillo, California. Dr. Azeem is also Associate Clinical Professor and Dr. Reddy is also Clinical Instructor, Yale Child Study Center, Yale University School of Medicine, Middletown, Connecticut.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Beth Caldwell, MS, Director, National Building Bridges Initiative, PO Box 712, Housatonic, MA 01236; e-mail: bethcaldwell@roadrunner.com.

Received: August 05, 2014
Accepted: September 03, 2014
Posted Online: September 30, 2014

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The Six Core Strategies©, approved as an evidence-based practice by the National Registry of Effective Programs and Practices in 2012, provides a framework that guides efforts toward preventing restraint and seclusion (R/S) (National Association of State Mental Health Program Directors [NASMHPD], 2014). Leaders from the child- and family-serving programs profiled in the current article describe how the implementation of the Six Core Strategies continue to guide successful efforts toward preventing R/S and provide implications for practitioners and policy makers, including nurses acting in various roles.

The current article shares information about how three different child- and family-serving programs successfully implemented prevention strategies to reduce R/S using the Six Core Strategies to prevent the conflicts that lead to violence and the use of R/S in residential and inpatient mental health programs. The three programs highlighted below were selected because of their willingness and availability to participate as leaders in their commitment to (a) turn the tide regarding the use of R/S and (b) embrace values and practices that result in sustained positive outcomes for youth and families served. Included with these program reports are perspectives on this national work; perspectives are authored by a family member and a youth advocate who were willing to share their personal views.

The past decade has seen a ground-swell of programs serving children and adolescents (hereafter referred to as children or youth) that are engaged in preventing/reducing the use of R/S. These programs include many types (e.g., day, residential, hospital), thus representing all child- and family- serving systems, such as child welfare, juvenile justice, education, and mental health. Although no national data repository tracks and reports the actual numbers for the many and different child-serving program types and systems, a number of federal agencies, such as the Substance Abuse and Mental Health Services Administration (SAMHSA) and the U.S. Department of Education, and many national associations, such as the Child Welfare League of America and the National Association for Children’s Behavioral Health, have dedicated human and financial resources to preventing the use of R/S in child-serving programs. Many professionals in the field would acknowledge that the tide has changed regarding R/S, and more programs are committed to preventing the use of R/S than ever before (Gary M. Blau, personal communication, July 30, 2014).

The tide has changed in many ways and not just in regard to preventing the use of R/S, which are widely acknowledged to be aversive, traumatizing, and, in worst case scenarios, deadly (Azeem, Aujla, Rammerth, Binsfeld, & Jones, 2011). Nationally, the overall approach and core values that direct the care of children with behavioral and emotional challenges are changing. For example, many child-serving programs, especially residential and hospital programs, have historically focused on behavioral approaches (Lieberman & den Dunnen, 2014). These approaches often included the use of point and level privilege systems, which have been found to be ineffective and lacking in an evidence-base (Mohr, Martin, Olson, Pumariega, & Branca, 2009) and are widely acknowledged to be in-consistent with what are considered to be best practice values (i.e., strength-based, family-driven, youth-guided, culturally and linguistically competent, and trauma-informed) (Blau et al., 2010; Huckshorn & LeBel, 2013).

New national initiatives, such as the Building Bridges Initiative (BBI; access www.buildingbridges4youth.org), and other federally supported initiatives to integrate the principles of trauma-informed care have begun to change the face of how services for children and their families are provided (Blau et al., 2010; Huckshorn & LeBel, 2013). The BBI is a national initiative that promotes evidence-informed practices in residential and community child- and family-serving programs, with the goal of achieving sustained positive outcomes for youth and families. Both the BBI and principles of trauma-informed care present different treatment strategies from those still being used in many treatment and support settings (Blau et al., 2010; Huckshorn & LeBel, 2013).

Trauma-informed care is a “strengths-based framework that is grounded in an understanding of and responsiveness to the impact of trauma; that emphasizes physical, psychological, and emotional safety for both providers and survivors; and that creates opportunities for survivors to rebuild a sense of control and empowerment” (Hopper, Bassuk, & Olivert, 2010, pp. 81–82). The BBI framework is similar: it is a value-based initiative that requires organizations to assess every program practice and all staff competencies/skills against specific best practice values that have emerging evidence of effectiveness not just in preventing the use of R/S and other coercive interventions (LeBel, Huckshorn, & Caldwell, 2014), but also in realizing sustained positive outcomes for youth and families served (Levison-Johnson et al., 2012). Outcomes include, but are not limited to, family-driven and youth-guided care, decreased readmissions to out-of-home care, living with a safe and supportive family, success in school, and having meaningful support networks (Dougherty, Strod, Fisher, Broderick, & Lieberman, 2014).

The only evidence-based framework focused on preventing the use of R/S (i.e., the Six Core Strategies) was approved as an evidence-based practice in 2012 by the National Registry of Effective Programs and Practices (NASMHPD, 2014). Although leaders across the country have used different models and frameworks to achieve significant reductions, approximately all have used several or all of the Six Core Strategies to achieve these reductions.

Albert J. Solnit Children’s Center—Middletown, CT

Albert J. Solnit Children’s Center (Solnit) has 52 youth hospital psychiatric beds. Children admitted come from tertiary care hospitals and emergency departments throughout Connecticut, have failed inpatient stabilization, and have often experienced multiple R/S events before admission to Solnit. Using the Six Core Strategies, mechanical restraints (one of the most traumatizing interventions) was eliminated, and physical restraints and seclusions were significantly reduced. Solnit’s mechanical restraint beds were deconstructed, and a symbolic “healing bench” was built from the leftover materials to serve as a reminder to staff, children, and families of the work that has been done to reduce restraint use (Figure 1). This bench’s healing qualities are not in its construction; rather, the bench is a metaphor, demonstrating to staff, children, and families that this facility has moved beyond reliance on restraint interventions in a concrete manner.

The “healing bench,” built from the wood of mechanical restraint beds used in the past, serves as a reminder to children, families, and staff that mechanical restraint is no longer used at the Albert J. Solnit Children’s Center.

Figure 1.

The “healing bench,” built from the wood of mechanical restraint beds used in the past, serves as a reminder to children, families, and staff that mechanical restraint is no longer used at the Albert J. Solnit Children’s Center.

Leadership Toward Organizational Change

Executive leaders at Solnit set a goal to eliminate mechanical restraints, and this goal is now a reality. Leadership interventions that led to these positive outcomes included developing a strategic plan built around the Six Core Strategies. As part of the plan, each executive leader adopted one or more of the facility’s treatment units and was readily available for support and consultation on complex situations. Leaders strongly emphasized primary prevention, with a focus on culture change of the milieus toward being trauma-informed and strength-based (Azeem et al., 2011). The topic of R/S became a standing agenda item in all staff meetings. Joint Commission and Centers for Medicare & Medicaid policies that were more than one decade old were revised, and higher standards were created compared with national standards. One of the keys to success was the organization’s leadership, which held the unwavering belief that these goals were achievable.

Use of Data to Inform Practice

Data play an integral role in performance improvement. The data collected at Solnit included the number of R/S events per month, average time in R/S, number of youth involved, interventions by day/shift, number of injuries to youth/staff, and use of intramuscular psychotropic medications. “Dashboards” for each unit and facility were shared in real time with all staff. Knowing the data in real time helped expedite corrective interventions.

Youth and Family Inclusion

Solnit leaders found the youth and family inclusion core strategy to be key to the success of effective treatment and prevention of R/S. Staff strove to implement Solnit’s mission statement (i.e., “Caring, Healing and Teaching—Partnering with Children, Families and Communities to Build Hope and Create Opportunities” [Albert J. Solnit Children’s Center Strategic Plan, March, 2012]). No set visiting hours were established; families are welcome any time of the day. Many families are reimbursed for travel to meetings, and monthly family dinners occur. The Solnit Advisory Committee includes parent members. When possible, staff visit family homes to support the successful transition of these youths. The children make welcome signs for new youth coming to the unit. The Youth Council has youth representatives from each unit, who bring their concerns to be passed to the executive team for resolution. In addition, regular youth and family surveys help identify areas of service and care in need of improvement.

Workforce Development

Engaging staff at all levels was another critical component in the shift toward a treatment culture change. All staff were offered training on trauma-informed care, and the use of various verbal de-escalation techniques was emphasized. Perspectives of staff and youth involved in restraints were shared. New employee orientation was revised to include proactive approaches to engage youth through various coaching activities. The principles of trauma-informed and person-centered humanistic care, respect, dignity, use of strength-based language, and partnerships became an integral part of the milieu (Smith et al., 2005). Staff surveys were used to monitor staff satisfaction and training needs. A team of staff called the ASAP Team provided peer support and immediate support for staff who experienced trauma. Team building activities were scheduled on a regular basis to keep focus on positive health of staff.

Prevention Tools

Positive relationships between youths and staff, which are based on mutual respect and dignity, have become the foundation of services because children learn to live what they experience. Staff visit children with complex issues who are transferring from other facilities to begin the process of engagement and ease their transition into Solnit. Each child has an individualized treatment plan, which lists individualized goals, individual strengths, triggers, early warning signs, coping tools, and safety plans. Children’s specific interests, hobbies, coping skills, and motivators are incorporated into their plans. Staff is educated on each child’s history, trauma, and family dynamics during team meetings. The occupational therapy (OT) staff use tools (e.g., sensory brushes, weighted blankets/vests, OT balls, Play-Doh®), as have been supported in the literature (Champagne & Stromberg, 2004). Pet therapy, visits to the local animal shelter, and therapeutic horseback riding are examples of activities used to engage children who love animals. Rehabilitation services, such as music therapy, art/pottery, cooking, and swimming, are used.

Debriefing

The implementation of debriefing processes has afforded staff the advantage of processing information after an untoward incident and planning for prevention strategies if similar situations arise. Specifics of the incident are discussed; particularly, triggers leading up to the event are illuminated, and de-escalation strategies that had been attempted are reviewed. Youth debriefing focuses on chain analysis of the incident, as well as understanding what was upsetting, what was helpful, and what can be done differently the next time to prevent the incident.

Outcomes

Between 2005 and 2013, Solnit successfully eliminated mechanical restraints and significantly reduced physical restraints and seclusions (Table 1).

Solnit Results from Initial Implementation

Table 1:

Solnit Results from Initial Implementation

Youth Development Institute—Phoenix, AZ

Youth Development Institute (YDI) is a private, Joint Commission-accredited, not-for-profit agency founded in 1996. YDI serves children ages 10 to 18 referred through state juvenile justice, child welfare, and Medicaid behavioral health systems for intensive treatment of serious emotional disturbance; YDI also has a specialized program for youth with sexually abusive behaviors. The institute provides a range of services, including (a) 84 secure residential treatment center beds; (b) 48 therapeutic group homes beds; (c) aftercare and outpatient services; (d) therapeutic day treatment for sexually abusive youth; and (e) an on-site school.

Leadership Toward Organizational Change

YDI began efforts to reduce the use of R/S in 2008 when program leaders (D.C., T.C.) were introduced to the Six Core Strategies by a Joint Commission surveyor. In the years since, reduction of R/S remained a management objective, but executive leadership reported never truly understanding the depth of the cultural change required until June 2012, when they were challenged during a site visit by the director of the BBI. Prior to that time, in monthly performance reviews of R/S data, leaders consistently noted that (a) as restraints went down, assaults of staff by youth increased; and (b) increases in the number of restraints could be attributed to “new” admissions, and YDI always had new admissions.

These latter observations became the rationale for continuing to use physical restraint. Each time leaders reiterated the performance improvement objective of reduction of restraint, the program would succeed in reducing but never eliminating restraint. In fact, executive leaders believed that the elimination of restraints was a “great goal” but not a realistic possibility. When challenged during the June 2012 site visit that restraint—no matter how brief and no matter if considered unavoidable—was retraumatizing and caused harm to youth, these rationalizations no longer held up. The executive directors changed their personal beliefs and expectations. They learned that the core strategy of leadership depends on what executive leaders truly believe and on the willingness of executive leadership to make a whole-hearted commitment to those beliefs.

Seclusion and Restraint Prevention Tools

In 2012, YDI leadership work on this goal began anew, but this time with the goal of eliminating the use of restraint. The use of sensory integration prevention techniques to calm and comfort youth became a major focus. YDI converted some R/S rooms into “comfort rooms.” Shortly after admission, in addition to an MP3 player with music of their choice from YDI’s approved music library, youth began to and still receive an individualized “comfort box” of sensory items.

Workforce Development

Leaders also gave significant attention to providing training and support on trauma-informed care and “Collaborative Problem Solving” (Greene & Ablon, 2006) with its paradigm shift of, “Kids do well if they can” (p. 155). Leaders incorporated this paradigm shift into staff training and supervision to support (a) the integration of new skills into staff’s work with youths and (b) staff’s ability to teach the same skills to families.

Child and Family Inclusion

One of YDI’s most effective change strategies was the focus on youth inclusion. Leadership worked with youth to develop a Student Advisory Board, and board members soon began serving as trainers in YDI’s new employee orientation. Initially, these youth began as participants in role-play activities with staff; however, the youth ultimately rewrote the role plays to more specifically and meaningfully address the actual situations that occur at YDI and how to best handle them to avoid escalation to restraint.

Outcomes

As shown in Figure 2, the cultural norm has shifted. YDI is a “hands off” facility. Prospective employees are told at hire and during initial training that crises are handled at YDI without the use of restraint; this practice is then continually reinforced in subsequent staff meetings. New admissions are told from the beginning, by both staff and youth, “We do not restrain here.” Youth who are admitted with a history of restraints are put on a “hug program,” whereby they receive, as much as they can tolerate, “YDI side-hugs” from many of the supervisory and administrative staff they encounter each day. Extremely dysregulated youth receive scheduled and individualized sensory regulation breaks during the day. Youth who have assaulted or been aggressive with a staff are brought into the Intervention Team (a component of the YDI debriefing process for serious incidents), comprised of one or both of the executive directors, the clinical director, the therapist, case manager, and direct care staff, including the staff member who may have been the recipient of the aggression. The goal of this approach is to resolve the conflict that has occurred and ensure planning to repair the relationship. This approach has helped reduce staff assaults from double digits (i.e., more than 35 per month) to single digits.

Youth Development Institute number of restraints per month, beginning January 2012.

Figure 2.

Youth Development Institute number of restraints per month, beginning January 2012.

When asked what advice YDI Student Advisory Board members would give to programs attempting to eliminate restraints, one youth offered these statements and one bit of advice (Charlie Molina, personal communication, July 10, 2014):

  • “Be patient, and talk to us like people.”
  • “Listening to us instead of telling us what to do could have stopped many restraints in places I have been before.”
  • “Stop trying to control us and think that will change us for the better.”
  • “Skilled staff don’t feel like they have to control us all of the time; they adapt and still keep us safe.”
  • “Don’t assume that we are not doing what you want us to do because we are opposing you. There are things going on with us that you do not know about.”

Finally, the best advice provided was “listen to your kids.”

Mount Prospect Academy, Becket Family of Services—Plymouth, NH

The Becket Family of Services (Becket) offers a range of community-based, in-home and residential services. In 2011, Mount Prospect Academy (MPA), Becket’s largest intensive residential program that serves 101 male youths ages 11 to 21 connected to child welfare, juvenile justice, or mental health systems, was selected to participate in New Hampshire’s Youth Transition to Permanency Project (New Hampshire Division for Children, Youth and Families, 2012). Through this project, Becket leadership (S.B.) learned about the BBI and Six Core Strategies to prevent conflict and the use of R/S. The BBI and Six Core Strategies propelled Becket forward and were instrumental in achieving leadership goals that centered on BBI principles, most notably establishing a trauma-informed, family-driven, and youth-guided culture. MPA used all of the Six Core Strategies to create change; however, the current article highlights work in only three of these strategies.

Leadership Toward Organization Change

At the onset, MPA leadership formally adopted the BBI principles. One of the first and most important goals that leadership believed to be vital to creating a trauma-informed, family-driven, and youth-guided culture was to prevent the use of R/S. It became clear that a high priority for the organization’s leaders was a focus on assessing the use of R/S. The agency’s Board of Directors agreed, and the BBI principles essentially became the new organizational mission and template going forward.

Using Data to Inform Practice

The Becket leadership team strongly believes in collecting data to help inform needed improvements. The data also helped focus leadership efforts. For example, it appeared that the behavior modification system was rigid and, at times, contributed to unnecessary restraints. Leadership correctly hypothesized that if the dinosaur approach of behavior modification, which included points and level systems, was eliminated that it would also support reducing restraints. With some reluctance from veteran milieu staff, leadership worked with staff, youth, and families to eliminate points and level systems, which were replaced with a strengths-based, skill-focused support tool.

The new model is simple and easily translated to real-life, in-home situations. A new leadership position was added to focus on data on an ongoing basis to be aware of and analyze what is going on in the milieu in a measurable way. Data that are now tracked include, but are not limited to, (a) the number of restraints or any physical management; (b) overall incident reports; (c) the number of community prosocial events youth partake in; (d) home time data; (e) the number of family contacts; (f) the number of youth and family intake and orientation guides that are being reviewed upon admission; and (g) other measures, such as youth and family satisfaction surveys.

Workforce Development

Becket leadership implemented weekly meetings to ensure that the agency mission and goals, which are centered on BBI principles, were driving all efforts and programming at the operational level. These weekly meetings comprised residential program supervisors, milieu workers, clinicians, permanency coaches, and upper management, who all worked collaboratively to address and eliminate any barriers that may impact success in making agency goals and values a reality. These weekly meetings were critical to getting all staff to join together to become educated on the new principles and practices; they also empowered staff and had a profound impact on agency culture and reducing the number of restraints. Leadership further established policies and procedures on eliminating the use of seclusion and any “timeout” rooms remaining in the school and milieu. An inspiring teacher created an active Student Council (i.e., core strategy of youth inclusion), which has been instrumental in building a youth-guided culture. The council also developed a school store, which replaced the last timeout room.

Outcomes

Between 2011 and 2013, MPA successfully eliminated the use of seclusion and timeout rooms and significantly reduced the use of restraints (Table 2).

Mount Prospect Academy Reduction in the use of Restraint

Table 2:

Mount Prospect Academy Reduction in the use of Restraint

Becket staff believe that there is always room to improve. Executive leaders acknowledge that setbacks and barriers existed along the way. The key was and is to identify such barriers and offer solutions to overcoming them. Some of the most notable barriers that were faced included issues related to lack of information or education, poor planning, rigid thinking, and staff comfort. Rigid thinking and old-school mindsets of staff can result in minimal change. Leadership is key to addressing the rigid thinking and mindset of staff and should be outcome-focused to send the message to the organization that culture change is going to happen, the program is changing, and that staff can be part of this change or not. MPA leadership will constantly challenge themselves to be open and honest about whether a trauma-informed, family-driven, and youth-guided culture is being implemented, using both BBI and the Six Core Strategies. Leadership intends for youth to be empowered to gain control of their lives with learned skills that can transfer to the community.

Voices of Family and Youth Members

The following two sections include the voices of a family member (C.A.) and of youth (shared by R.M.) regarding the use of and need to reduce R/S practices. The new approach to serving children and families addresses the need to involve both youth and families to better direct individualized care and service provision. This approach is an exciting change and reversal from historical practices for children, youth, and families in mental health services. It is also a significant deviation from the past that is informed by new knowledge and literature and represents movement toward a new future of how clients are served and outcomes of services are defined.

Family Perspective

The Massachusetts Parent/Professional Advocacy League, an organization of parents and professionals who advocate on behalf of children with mental, emotional, or behavioral health needs and their families, worked with the Massachusetts Department of Mental Health (MA DMH) to develop a family position statement on R/S prevention (Commonwealth of Massachusetts, 2014). This position statement is important to one of the authors of the current study (C.A.), who is a mother of two young adults (now ages 27 and 20) with mental health challenges. It is because of their experiences that she understands that R/S can be traumatic for a child, and this understanding became especially potent when seeing the impact on one child when he experienced multiple seclusions in his classroom.

Restraints are used to subdue violence in the moment, and in the long run, R/S only further traumatize a child, thus causing violent behaviors to escalate. To develop the Family Position Statement, the MA DMH hosted focus groups with families across the state, whose children were served in hospitals, residential, and/or educational programs and had been restrained and/or secluded. Families in the focus groups provided recommendations, which are included in the position statement. Examples of position statement recommendations from parents include, but are not limited to:

  • Talk with your child’s program and/or school staff, and assess if they are willing to work collaboratively. Learn about the BBI and read about its helpful tools and resources to promote service transformation, and share this information with staff.
  • Write letters to the leadership of the organization that serves your child, explaining the importance of using sensory-based interventions and positive behavioral support practices to prevent and reduce the use of R/S. Encourage training in these areas.
  • Learn about the philosophy of your child’s program and school. Ask for the written materials that describe their approach; review their policies and practices on R/S and their plans to prevent and reduce their use.
  • Ask what kind of training is available for staff and families at your child’s program and school to prevent the use of R/S. Ask for data.
  • Become educated about the harmful effects of R/S. Tell other families at your child’s school or program, and form a task force to help prevent these harmful practices.
  • Read the language in your child’s individualized educational program or treatment/service plan, and ensure that R/S are not written into the plan. If necessary, consult an advocate or visit the TASH Web site (access www.TASH.org), which is focused on disability advocacy.

Advocating for services that result in safer treatment in programs and schools is one way to affect change. Leaders should familiarize themselves with the Six Core Strategies, which support preventing the use of R/S.

Youth Perspective

An immense amount of credibility exists in the words of those who have experienced mental health services first-hand. When assessing services, the voices of those with such experiences should be considered vital to providing input and recommendations for prevention of R/S use. To give credence to youth voices, MA DMH held a series of youth forums in 2009 to develop a Youth Position Statement on R/S (The Massachusetts Statewide Youth Experts, 2010). Participants had experienced R/S within different child-serving systems (e.g., mental health, child welfare, juvenile justice, education). They used their experiences to produce a valuable statement with proposed reasons, practices, and values that can prevent the use of R/S. This statement strongly encourages the use of prevention strategies, and youth feedback was consistent with the prevention tools strategy.

Examples of prevention measures suggested by Massachusetts youths included (a) supporting youth spending individual time with staff; (b) having comfortable environments that are home-like; and (c) using sensory strategies (e.g., comfort/sensory rooms, music) and sensory items (e.g., blanket wraps). Youth peers also recommended appropriate use of staff physical contact, staff encouragement to participate in services, and programs developing opportunities to participate in many activities (e.g., sports, art classes, music) that youth find valuable and/or that match their strengths and interests. Much of the feedback was centered on how adults can offer their support through using nonjudgmental positive language, therapeutic tone of voice, and nonthreatening body language. Furthermore, the use of effective communication and listening skills was encouraged by these youth voices.

When R/S occurs, youth shared how physical injuries affected them and staff. Youth expressed a loss of self-respect and dignity after the event. These situations impact relationships and inform the rest of the milieu, resulting in other youth beginning to have a lack of trust with each other, their care providers, and the environment. It is important to repair relationships and address the changes in the new group dynamics after a significant incident. This reparative process entails acknowledging the loss of internal values (e.g., respect, dignity, trust) and using the incident as an opportunity to make amends and improve communication.

Youth also reported that the simple observation of a physical restraint resulted in feelings of fear and a lack of safety. For one youth in particular, it was not about feeling frightened while watching a containment; rather, it was more about feeling as though “you must defend your peer,” especially when feelings of loyalty or bonds of friendship exist. One young adult recalled her experience: she had the instinct to protect a close friend after watching her become emotionally distraught (Z. Arata, personal communication, June 16, 2014). Perry and Szalavitz (2006) suggested that an opportunity (in the moment) exists to reinforce positive and negative patterns. It is critical for care providers to ensure that preventive measures regarding the use of R/S are implemented in programs, and that a reparative process that can reinforce positive patterns for the youth occurs. The use of these recommendations decreases what youth express to be traumatizing and emotionally stressful experiences for all individuals involved.

Conclusion

Many resources exist to support programs across the country in significantly reducing the use of R/S and improving positive outcomes for children and families served in different service settings. These include the Six Core Strategies; the national BBI; resources available from different national associations, such as the American Association of Children’s Residential Centers (access http://www.aacrc-dc.org); and the growing body of literature on trauma-informed care (access http://www.nctsn.org). In addition, leaders of programs across the United States who have already successfully achieved positive outcomes can mentor those just beginning their journeys. Most importantly, the voices of the families and children served are available to support every program in improving their program practices and outcomes. The tide has changed, but much work must still be done.

References

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  • LeBel, J., Huckshorn, K.A. & Caldwell, B. (2014). Preventing seclusion and restraint in residential programs. In Blau, G.M., Caldwell, B. & Lieberman, R.E. (Eds.), Residential interventions for children, adolescents and families: A best practice guide (pp. 110–125). New York, NY: Routledge.
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  • The Massachusetts Statewide Youth Experts. (2009). Youth position statement on restraint/seclusion. Retrieved from http://www.mass.gov/eohhs/docs/dmh/rsri/kids-position.pdf
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Solnit Results from Initial Implementation

Year Mechanical Restraints (n) Physical Restraints (n) Seclusions (n)
2005 485 3,033 1,150
2006 182 1,634 816
2007 226 1,264 919
2008 159 1,159 1,410
2009 69 909 1,279
2010 20 839 958
2011 1 723 742
2012 0 426 691
2013 0 394 385
Reduction from 2005 to 2013 from baseline (%) 100 87 67

Mount Prospect Academy Reduction in the use of Restraint

Year Restraints (n)
2011 385
2012 216
2013 98
Reduction from 2011 to 2013 (%) 75

Keypoints

Caldwell, B., Albert, C., Azeem, M.W., Beck, S., Cocoros, D., Cocoros, T. & Reddy, B. (2014). Successful Seclusion and Restraint Prevention Efforts in Child and Adolescent Programs. Journal of Psychosocial Nursing and Mental Health Services, 52(11), 30–38.

  1. The evidence-based Six Core Strategies© provide a framework that can guide leaders of programs who want to significantly reduce and prevent the use of restraint and seclusion (R/S).

  2. National initiatives, such as the Building Bridges Initiative and trauma-informed care, can provide leaders with information that will support their efforts in ensuring better outcomes for the youth and families they serve.

  3. Program leaders across the United States have already been successful at significantly reducing and sustaining the reductions in R/S use; their stories and lessons learned can support other leaders in their work to reduce the use of R/S.

  4. To truly achieve and sustain significant reductions in R/S use, and even approach elimination, staff must engage, meaningfully involve, and listen to the voices of the youth and families they serve.

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