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Moving from Coercion to Collaboration in Mental Health Services

Restraint and Seclusion of Children and Adolescents: Developmental Issues

Charles Huffine

I’m going to continue the presentation with a discussion of clinical and developmental issues involved in restraint and seclusion of children and adolescents. The Centers for Medicare and Medicaid Services (CMS) (formerly the Health Care Financing Administration) rules focus on hospitals and residential treatment facilities. Those involved with such facilities get very concerned about these issues, but most children with serious emotional and behavioral problems don’t go to hospitals or residential treatment facilities.

It has been said that we are one of the most violent societies in the world and that we use force too quickly to solve problems in our homes, on the streets, or in our community institutions. I sometimes wonder if the restraint and seclusion issue can’t be really looked at in the much broader social context of using force to solve problems. At any rate, what I want to do is to try to put the seclusion and restraint issue into a broader contextual framework.

A Bewildering and Alienating System

Andrea’s story illustrates an ill-conceived treatment system for children and adolescents, one comprising hospitals and residential care facilities. From my perspective as a child and adolescent psychiatrist, I am concerned when we copy adult models. Adults must be coaxed into accepting clinical recommendations about how they should be cared for. Children usually don’t get to choose. They are forced to accept being pushed through programs that seem alienating, into being an inpatient, into wearing the plastic arm-band. Children are powerless in such systems. They trust their parents to do the right thing. If the facility is respectful, relates well to the young person, the child sees the caregivers as an extension of the parent and gives the parent some credit. However, if the facility is alienating and neglects the youth’s needs, the child will notice and react. This situation can lead to a breach of trust in the parents, possibly unfairly, because the system breaches tr! ust with parents as well. The child may come to believe he or she is worthless and deserves to be locked away.

Similar insensitivities to families and youth exist in juvenile justice programs, social services, drug and alcohol treatment, and schools. In each system, youth receive labels and fit into categories that conform, usually with the rules governing the program and how they get funded. These categorizations are bewildering and alienating for most youth. In reality, we have a system of care for children in our country that is neither family focused nor youth centered. It is often impossible to explain why a child will go to a group home, a treatment foster home, or stay home and work it out. The crucial issue for the child is whether or not she or he is taken out of the home and made to stay somewhere else. For many children, being thrown out of their homes isn’t as distressing as being cared for by strangers.

Families have few choices once a child is in the system. Parents regularly become estranged from a system that they sense is inadequate and over which they have little or no control. From the parent’s perspective, he or she is rejected from the care system entirely with no access to his or her child. When the child gets locked into the system, the system owns the child. The parent is defined as part of the problem and effectively loses the child, even as he or she senses that those caring for the child don’t really care.

A community-based system that allows parents to keep their children at home, meeting their needs in less restrictive alternatives, is a better solution for children and their families. When circumstances demand that a child be placed in a facility outside their home, however, we must do a better job of ensuring that all such facilities and programs are family centered and function in a partnership with their consumers.

System of Care Reform and Restraint and Seclusion

Our guiding values and principles were summarized in the Children and Adolescent Service System Program put together by Stroul and Friedman in the mid-80s. They boil down to four basic ideas: 1) All services for children and families should be family centered. 2) They should be child focused. 3) The services should be culturally competent. 4) The services should be community based and highly integrated.

Getting all these various systems to work together with a single case manager is the goal—a unified system so that a parent isn’t going to appointments all over town when she or he is in multiple systems. This goal formed the basis for the System of Care movement in child and adolescent mental health. As a systems of care reform advocate, I ask the following questions about restraint and seclusion:

• How does the program handle a child in crisis? Do its policies include whether and how to intervene with restraint or seclusion? How do those policies support families in caring for their troubled children?
  
  
• How do the restraint and seclusion policies and crisis plans fit in with this particular child’s individualized care plan, or is the crisis plan generic?
  
  
• Does the program provide normalizing experiences? Does it prepare them to live in their community?
  
  

Developmental issues

First, we must consider developmental status. There is a huge difference between small children, middle-sized children, and teenagers. When someone is restraining or secluding a child, it is an antithetical move considering the nature of the child’s developmental process. In the course of growing up, as younger children move to do things more independently, they may move beyond where they should go or what they should be doing. Their parents intervene and pull them back a little, mindful of a child’s safety. This is the organic cyclical process of pushing toward and pulling back from the goal of becoming increasingly independent. Most parents figure it out pretty well, and most children play into this process pretty well. When a child has a severe psychiatric illness and is in a situation in which he or she is in real danger, somebody may have to intervene physically. As we do what is necessary for safety, we need to keep in mind that we are interfering with and possibly ! damaging the child’s developmental process.

Therefore, we must avoid using force with children and adolescents. In many cases, this practice can be done through better management that includes developing an individualized care plan, building an alliance with the child and her or his family, and understanding that family’s culture. Staff must be trained in all aspects of care that involves crises requiring intervention with force. De-escalation skills and skills at managing one’s own feelings are mandatory. Staff must know the limits in the application of force and skillful techniques to avoid harm to the child. When force has been used, the psychological assault suffered by the child needs to be recognized and repair must begin immediately. Debriefings with the child and his or her family are a must.

Settings of care

There are two kinds of care settings. One is more remote, either geographically distant or inaccessible in terms of restrictions on visiting. This is true in juvenile justice facilities and certain residential treatment programs. The other kind is more integrated into the community. A community-based facility relates systematically to the community programs that work with the children and their families over many months and years. It provides services that are integral to the overall care of the child, often relating to the same care plan. The staff in community-based programs know the staff in the clinics or schools, and they see themselves as part of the larger treatment team. Even children who are treated in even the most ideally conceived community-based residential programs sometimes must be restrained.

In sophisticated systems of care, with comprehensive resources organized within a wraparound process, the need for hospitals and residential programs should disappear or be dramatically reduced. There is not much that happens in hospitals and residential programs that can’t happen in a child’s home or in a homelike setting. This kind of care requires that resources be mobilized immediately and in sufficient quantity to ensure safety. This kind of care also demands a relevant crisis plan that can bring rich resources into the home. It must also allow for respite, including the possibility of a very short stay in a hospital or innovative “23-hour” programs.

These same principles apply to treatment foster homes or other extended care placements that are integrated into the community. The System of Care concept doesn’t eliminate the problem of restraint or seclusion. Restraint or seclusion may emerge. If so, who, in that rich network of well-intended, caring family and friends, neighbors, church members, or paid child care workers, is prepared to use force as an intervention to save the moment? Such a team presents a great training challenge to prevent psychological and physical harm. A well-functioning wraparound process must have the same emphasis on training in crisis care as we have described for residential settings.

Forms of Restraint and Seclusion Applied and Stage of Development

Mechanical restraint, seclusion in a locked padded cell, or chemical restraint are totally inappropriate and should be disallowed in programs working with children. When child care staff are forced to physically intervene with a child, the intervention should be of short duration. Bargaining to end the restraint should begin as soon as it is initiated. It should rarely last longer than it takes to get a licensed professional to come to review the situation. Adolescents are going to recoil most at physical intervention involving body contact, and this aspect of the intervention is best held to a minimum. An adolescent may do better if physically isolated in a room or allowed to go outside, if it is safe and supervised. Holding adolescents can raise the specter of sexual meanings to adolescents. A smaller child may do better if physically held. For them a frightening episode of being physically constrained may be resolved by some nurturing holding with rocking and gentle ve! rbalization.

The application of a particular mode of restraint or seclusion should be based on the child’s assessment, treatment plan, and crisis plan. Each child will have a unique reaction to being restrained or secluded, which should be assessed and anticipated before the use of force becomes necessary. To reduce the length of time in restraint, child care staff should stay with the child emotionally, should demonstrate respect, and should stay calm as they interact with the child.

Another issue involves who has the right to hold a child, which has nothing to do with the law. It is a psychological concept of what a child and a parent together know to be right. No matter how deteriorated a child’s or a parent’s behavior and how hopelessly engaged in fighting a family may be, on some level there is an awareness of what is right, at least until parents have violated a child’s trust with a pattern of gross abuse. With that exception, parents have a right to hold their children. Anyone who has a nurturant role with the child can be given that right by the parent and the child. The people the child knows well have a right to hold that child based on trust between that individual and the parent and child dyad. When a stranger tries to pick up a child, even if the stranger is very skilled at making soothing verbalizations, the child instinctively looks toward her or his parents. Most children intuitively know the rule: Strange “other people” don’t mess with! me when they don’t know me. Staff in treatment settings, hospitals or residential programs, need to understand this principle and obtain that “permission” to hold a child before it becomes necessary.

Children who have suffered gross neglect and abuse, who have no parents, or who are unattached to significant adults often make superficial and quick attachments to staff. They may be eager for staff to hold them, even in a conflict. In such cases, the children may give staff permission to hold them, but this can be problematic. These children have major attachment problems and may be capricious in giving that permission. They may become clingy and crave physical contact. Their desperation for contact may even precipitate a restraint episode, which can be a set-up for a repetition of the child’s re-experiencing abuse.

Monitoring of Restraint and Seclusion: Being Accountable

Whenever people are entrusted with a child in a treatment program, there must be assurance that what is being delivered to that child and family is valid care and not harmful. Such programs should have an active quality assurance (QA) process that is documented and is subject to review. That process must involve attention to such basic clinical issues as the appropriateness and individual nature of treatment plans and the training and supervision of staff. All critical events, including the need to restrain or seclude a child, must be reviewed. The review should be at several levels, administrative, programmatic, and with the client and advocacy community. Debriefing a restraint or seclusion incident with the child involved and with the entire group of young people in a program who had been witness to the drama is a clear best practice defined by the dialogue between professionals and advocates in the national restraint and seclusion discussion. When a death or serious in! jury occurs as a result of restraint or seclusion, it is essential that the review process transcend the agency. An outside review by police or legal authorities may be appropriate, but in all cases some review body that includes both professional and consumer voices should be empowered to conduct an outside review.

Psychiatrists or other licensed mental health professionals should be leaders in the QA process, especially critical incident review. A psychiatric consultant should be prepared to help the agency translate lessons learned from incidents to policy adjustments. These professionals also should be aware of organizational issues that impact staff and their functioning with patients. They can bring such issues to the awareness of staff and administration. Professional leadership is essential for training and support to staff.

Family advocates should be active leaders on boards of agencies and should be involved in QA programs. They should have specific roles in critical incident reviews and grievance procedures to ensure consumer and parent input in such reviews.

Community-based care plans, according to family-centered care principles, are the product of a team process: a group of friends and relatives gathered by a family for support as they face the trials of raising a difficult youth. The family should be in charge. Professionals and support staff are accountable to the family. Programs need to support families in identifying appropriate care and in holding such programs accountable.

Children who lose control in the community may draw police involvement. Police are the ultimate resource for the application of physical force. Police may be well trained and may even provide training in de-escalation and take-down methods. Unfortunately, police often have a poor understanding of mental health issues and no understanding of a child’s individual issues or care plan. Police in community policing programs are often better trained and may be good partners in a community care plan in a system of care for troubled youth. Many communities are holding police to higher standards in their use of force. It would be reasonable for mental health programs to be involved in police accountability programs and in training police to better handle youth with emotional problems.

Those Ultimately Responsible in Situations Involving the Use of Coercive Practices

To be realistic, we must recognize that episodes of restraint or seclusion usually will be initiated by line staff, with no more than shift supervisor support. A youth worker in the community or in a small residential program, confronted with a young person who becomes unsafe, is likely to be alone and with no ready access to professional supports. This situation may be attenuated if the other staff and shift supervisor are working well together, if they are familiar with the treatment plan, and if they can get rapid support by telephone from agency leadership, including a psychiatrist or other clinical leader. However, ultimately, the staff person involved in an incident must rely on training, skills, and intuition in relating constructively to youth in order to de-escalate an out-of-control situation. For this reason, staff training is really the only solution to the dilemmas of the use of force and potential harm. If the incident is being handled well, it will be over ! before a licensed professional can arrive, even if the program can manage the new CMS requirement for an assessment of the incident by a professional within 1 hour. Such a review cannot replace the requirement for staff to be well chosen and well trained.

In this regard, I am an optimist. I believe that programs serving children have access to a large pool of young people who are good spirited and idealistic in their wish to help children and youth. These young people work in all aspects of the system of care for youth, including juvenile justice settings, group homes, therapeutic foster homes, and intensive wraparound programs. They are eager for training and respond well to supportive supervision and consultation. It is the responsibility of agencies organizing care for youth to develop their staffing resources so that they have good jobs with appropriate supports. It is also an agency’s duty to screen out individuals who are not fit to work with youth because of their own unresolved issues, rigid ideas, or sadistic tendencies.

The One-Hour Rule

On this relatively small issue, many progressive psychiatrists have had disagreements with NAMI and have opposed the CMS requirements. There appears to be a misunderstanding of the essential roles psychiatrists and other licensed professionals should play in programs for severely challenged youth. Only in hospitals is there legally defined medical leadership in the care of patients. In these settings, an attending physician is liable in the event of a death or injury due to restraint. The reality is that care is delegated to nursing staff who also bear legal responsibility as the hospital administration does. The concept of psychiatric monitoring of restraint and seclusion in psychiatric hospitals is an attractive one that seems to be congruent with legal and ethical responsibilities of doctors. However, even in medical treatment settings, the one-hour rule contains many misrepresentations of the medical role: 1) Incidents often do not occur when the medical staff are on ! the units. Restraint cannot be “ordered” by a doctor before it happens; it is, by its nature, a nursing staff-initiated event. To await a doctor’s order, even by phone, would be unthinkably dangerous as an incident is proceeding rapidly out of control. 2) Most incidents with children can and should be resolved quickly, in minutes, not hours. A doctor arriving after the fact to assume leadership over a concluded event seems absurd. 3) If an episode of restraint with a child or adolescent persists longer than an hour, then problems may indeed exist in the functioning of the hospital ward. The supervising nursing staff routinely make decisions that involve patient safety. For a psychiatrist to second-guess a restraint or seclusion decision by the nursing staff would be problematic and difficult to justify except in rare instances. It would likely promote tension on the unit that could lead to an escalation of the potential for more incidents and more potential for harm to pati! ents and staff. Psychiatrists should be involved in decisions to prolo ng restraint or seclusion and should participate in critical incident reviews. It makes little sense for them to be required to simply retrospectively approve an order for restraint when the incident is already terminated. 4) Psychiatrists are not well prepared to make safety assessments for youth in restraint. Such assessments might be better made by a hospital emergency physician or anesthesiologist.

Most incidents of restraint and seclusion do not occur in hospitals. They occur in residential programs that may have little or no medical leadership at all, at most a psychiatric consultant who has no primary role in authorizing treatment plans or in providing care. This description applies to wraparound programs, juvenile justice programs, residential drug and alcohol programs, and such social service programs as group homes, treatment foster homes, and other out-of-home placements. These programs assume responsibility for the youth in their care without any pretense of an ultimate medical authority’s bearing legal liability.

Psychiatrists may have important consultative or advisory functions in these programs, but they are even less appropriate as authorizers or monitors of restraint or seclusion incidents than hospital psychiatrists. The same issues apply as noted above in hospitals. The problem for a consulting psychiatrist taking such responsibility for an incident of restraint or seclusion is that it undercuts their more appropriate roles as consultant, reviewer, policy advisor, and support to staff. Through these functions, psychiatrists can more effectively shape safer and appropriate restraint policies.

CMS policy that mandates that psychiatrists follow practices contrary to their training and best judgment is a dangerous impediment to good care. However, it is equally inappropriate for psychiatrists to abdicate responsibility by failing to recognize the problem of death and injury subsequent to incidents of restraint and seclusion. Our task is to engage with our advocate allies to seek the best possible use of psychiatric expertise in the care provided for our most troubled and vulnerable youth and to ensure their care is safe and effective. The issue of restraint and seclusion highlights the need for psychiatrists to be trained in the art and science of consultation and to engage in public policy issues to ensure that our knowledge and leadership will make a difference.