Restrictive Practices in Child & Adolescent Mental Health Care

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The worldwide movement to reduce restrictive practices (restraint and seclusion) in mental health care is based on their negative impacts on patients and a lack of evidence of their efficacy. Despite ongoing efforts, these practices continue to be used in the management of imminent danger posed by aggression and self-harm. Child and adolescent mental health (CAMH) units report high rates of restrictive practices in Australia and internationally however, descriptive accounts and the factors associated with their use are largely unknown. Data from two tertiary CAMH units in NSW show that the rates for seclusion are low however, physical restraint rates are high providing the impetus for this study. A descriptive retrospective chart audit of restraint and seclusion data spanning four years (2015-2018) was conducted. Patients were identified from the CAMH unit Restraint and Seclusion Registers. These data were merged with administrative, clinical, and patient-safety data providing a comprehensive account for each episode of restraint and seclusion. Rates and frequencies were calculated, with the types of restraints and seclusions compared to local and national mandatory reporting policy definitions. A multilevel regression analysis determined which variables of interest were associated with restraint and seclusion; statistical significance was set at p≤0.05. There were 109 patients aged seven to 17 years who collectively experienced 484 episodes of restraint and/or seclusion. Almost half reported a history of trauma. A higher proportion of episodes were found in patients aged 12 years or under and in patients with autism. Patients who were aggressive, in an agitated state, or displaying signs of psychosis, were significantly more likely to experience restraint and seclusion as a combined intervention compared to restraint only. A critical analysis of the data determined that 90 episodes of physical restraint did not align with the local or national definitions. This study highlights that (i) aggression, agitation and psychosis represent deterioration in mental state and lead to increased use of restraint and seclusion, and (ii) the current definition for physical restraint is inappropriate for children and adolescents. Episodes of restraint and seclusion are reported nationally using definitions that overlook the developmental needs of CAMH patients, particularly vulnerable populations who report a history of trauma or a diagnosis of autism. This study emphasises that national data quality is essential to provide CAMH clinicians with accurate information about whether strategies for reducing restraint and seclusion are effective.
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