Behavioral Restraints and Isolation: The Child Experience

by Lauren Irvin, DO (’24)

During the pediatric mental health epidemic following the COVID-19 pandemic, the needs of the inpatient pediatric mental health population were pushed to the forefront. Strategies for both patient and staff safety became the focus, with many adaptive and preventative approaches applied in general hospital wards for patients awaiting psychiatric placement. Among these strategies at Hasbro Children’s Hospital were more formalized approaches to deescalation and a more coordinated responses to behavioral escalation. Despite these supportive interventions, restraints either through pharmacologic, physical, or mechanical means continue to be a semi-regular occurrence. This situation is not unique to Hasbro Children’s Hospital, and, in fact, research demonstrates that children are overall more likely to be physically restrained than adults. Research also reveals that the utilization of seclusion and restraints is on the rise, despite the risks associated with these interventions and lack of demonstrated therapeutic benefit.

A literature review of the subject of restraints and seclusion in child and adolescent populations reveals the risks involved in these practices, including trauma, physical injuries, and even death. It further reveals articles on caregiver/staff perspectives and moral experiences in relation to performing these interventions. Less present in these articles are the perspectives of the children and adolescents who experience seclusion and restraint, making it difficult to fully understand the emotional and moral impacts of these interventions.

One article which sheds light on this subject, however, is that by Montrueil, Thibeault, McHarg, and Carnevale (2018). They investigated the moral experience of children experiencing crisis management strategies such as isolation and restraint within a day hospital program. They found that children heavily emphasized that these interventions felt like punishment, were perceived as coercive, and that restraint/seclusion was a negative experience. Distress related to the intervention was increased if the restraint was painful or if the child did not understand why it was happening. The only children who reported that restraints could be beneficial were those who felt safer when another child in the milieu became escalated and was restrained/secluded.

The current general approach to de-escalation/redirection is somewhat standardized; usually comprised of a request being made of the child who is then expected to comply. In this deescalation strategy, noncompliance with the directive/request is responded to with more coercive interventions. This strategy, despite its wide use, does not have strong evidence of therapeutic benefit particularly in children. In the aforementioned study, children reported responding to this strategy with increasing feelings of anger. They also identified these escalated directives as new ‘rules’ which further increased their distress.

Things which children reported as helpful for their de-escalation included finding a calm space and/or talking to someone about the situation. They mentioned it was particularly helpful if a game was played while talking. When children were unable to de-escalate and were ultimately  restrained/secluded, they reported experiencing less distress if staff explained what was happening clearly before, during, and after the event.

Literature in adults has gone further than that in children in confirming that restraint/seclusion should be used as a last resort due to the risk of harms for both patients and staff. Research into alternative strategies has been conducted in adults but is lacking in children, particularly for age groups under 12 years old. Further research is needed to evaluate alternative strategies for deescalation to provide a more evidence-based alternative to restraint/seclusion.

In the meantime, however, to decrease the utilization of restraint/seclusion and decrease the risk of moral or physical injury of children we should ideally attune our responses to behavioral escalation based on an open discussion with the individual child (which should occur prior to the escalation). We should acknowledge that children have agency and should engage each child to identify things that are helpful to them during a behavioral escalation. We should also do our best to explain why interventions are being employed in simple, age-appropriate terms to minimize perception of restraint as punishment. Ultimately, we should be informed of the risk of harm that is associated with seclusion/restraint and only employ it as a last resort and only when there is imminent risk of harm to self or others. In this way, we can aim to minimize harm and improve therapeutic alliance.

References:

Georgadarellis, A.G. and Baum, C.R. (2023). De-escalation techniques for the agitated pediatric patient. Pediatric Emergency Care, 39(7), 535-539.

Montreuil, M., Thibeault, C., McHarg, L., and Carnevale, F.A. (2018). Children’s moral experiences of crisis management in a child mental health setting. International Journal of Mental Health Nursing, 27, 1440-1448.

O’Donoghue, E.M., Pogge, D.L., & Harvey, P.D. (2020). The impact of intellectual disability and Autism Spectrum Disorder on restraint and seclusion in pre-adolescent psychiatric inpatients. Journal of Mental Health Research in Intellectual Disabilities, 13(2), 86-109.

Richmond, J.S., Berlin, J.S., Fishkind, A.B., Holloman, G.H., Zeller, S.L., Wilson, M.P., Rifai, M.A., & Ng, A.T. (2012). Verbal de-escalation of the agitated patient: Consensus statement of the American Association for Emergency Psychiatry Project BETA de-escalation workgroup. Western Journal of Emergency Medicine, 13(1), 17-25.