© 2008 The Royal College of Psychiatrists
Correspondence |
Tailoring seclusion policies to the patient group
Evolve Therapeutic Services, Royal Children’s Hospital, Brisbane, QLD 4029 Australia. Email: james_scott{at}health.qld.gov.au
Kids in Mind Research, Mater Child and Youth Mental Health Service, South Brisbane, Australia
Edited by Kiriakos Xenitidis and Colin Campbell
We welcome the review by Gaskin et al1 of interventions to reduce use of seclusion. Although studies reviewed were conducted in adult and child settings, the authors did not differentiate the developmental needs between these patient populations.
The determinants of emotional distress and aggression may differ between children and adults. In adult psychiatric units, aggression is frequently associated with psychosis. Seclusion may reduce staff injury but increases patient distress.2 In contrast, aggression is typically the most common reason for referral to child psychiatric units. Underlying diagnoses include disruptive behavioural and developmental disorders, and are complicated by high rates of abuse and neglect.3 Admission goals may include learning prosocial behaviour, necessitating use of behavioural management. Community-based studies indicate that parent management training, using contingency reinforcement and consequences such as ‘closed time-out’, are effective in reducing aggressive behaviours.4 Seclusion may function similarly to time-out, in that it can take the child away from a situation reinforcing negative behaviour and it encourages the child to self-regulate.
We agree with Gaskin et al that more evidence is needed to guide use of such interventions. We draw readers’ attention to a recent study reporting reductions in aggression in a child and adolescent in-patient unit, following the introduction of a behavioural management programme.3 The intervention incorporated staff training, contingency management and promoted use of less restrictive interventions. In keeping with current practice parameters,5 if a restrictive intervention was required the preferred intervention was a form of seclusion. This intervention led to a significant reduction in aggressive incidents and injuries to staff and patients. Although the number of episodes of locked interventions did not decrease, there was a significant reduction in the duration of time patients spent in seclusion and a reduction in physical restraint. These outcomes were achieved without reducing admission numbers, changing the types of admissions, increasing staff costs, or increasing utilisation of medication as needed.
We concur with Gaskin et al that seclusion may exert counter-therapeutic effects, and that effective alternatives should be identified.1 However, we remain open to the possibility that predictable, time-limited locked interventions may have therapeutic effects when used within a broader behavioural management programme in young patient populations. In addition, the ultimate goal of interventions in this area should emphasise reducing the demand for seclusion, rather than just the use of seclusion per se. We need to acknowledge that some aspects of the in-patient environment can contribute to patient distress and seek to optimise the therapeutic effects of the in-patient milieu. Protocols for use of seclusion and for reduction in demand for seclusion need to be incorporated into the developmental needs of the specific patient group.
REFERENCES
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1
- Gaskin CJ, Elsom SJ, Happell B. Interventions for reducing the use
of seclusion in psychiatric facilities: review of the literature.
Br J Psychiatry 2007;
191: 298
–303.
[Abstract/Free Full Text] 2 - Steinert T, Bergbauer G, Schmid P, Gebhardt RP. Seclusion and restraint in patients with schizophrenia: clinical and biographical correlates. J Nerv Ment Dis 2007; 195: 492 –6.[CrossRef][Medline] 3
- Dean AJ, Duke SG, George M, Scott J. Behavioral management leads to reduction in aggression in a child and adolescent psychiatric inpatient unit. J Am Acad Child Adolesc Psychiatry 2007; 46: 711 –20.[CrossRef][Medline] 4
- Sanders M. Triple P-Positive Parenting Program: towards an empirically validated multilevel parenting and family support strategy for the prevention of behavior and emotional problems in children. Clin Child Fam Psychol Rev 1999; 2: 71 –90.[CrossRef][Medline] 5
- Masters KJ, Bellonci C, Bernet W, Arnold V, Beitchman J, Benson RS, Bukstein O, Kinlan J, McClellan J, Rue D, Shaw JA, Stock S; on behalf of the American Academy of Child and Adolescent Psychiatry. Practice parameter for the prevention and management of aggressive behavior in child and adolescent psychiatric institutions, with special reference to seclusion and restraint. J Am Acad Child Adolesc Psychiatry 2002; 41: S4 –25.[CrossRef][Medline]
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