physical restraint Use in Adolescent Residential Treatment Facilities Physical Restraint Use in Adolescent Residential Treatment Facilities Purpose and Scope Physical restraints are used in many facilities for multiple purposes. They are used properly and improperly and have been a subject of controversy in many facilities. Their use has caused injury and even death in some cases. There have been multiple position papers formulated by many individual inpatient facilities as well as, most recently, The American Academy of Child and Adolescent Psychiatry and The American Medical Association on the use of restraints in child and adolescent residential treatment facilities.
Tasks First there will be a description of the various types of restraints that are used in facilities for psychiatric ally impaired adolescents. Second there will be a description of the criteria for the implementation of restraints and the monitoring that takes place while the patient is in restraints. Third, there will be a discussion of restraint use, alternatives and their pros and cons, followed by a summation of what seems to be the most appropriate choice. Forms of Restraints Five-point leather restraints The universally used restraint in facilities for adolescents and indeed many adults consists of system of ‘five-point’ leather cuffs and a waist belt. The wrist and ankle cuffs are three inches wide and made to fit snuggly around the smallest part of the wrist or ankle. They can have locking or non-locking metallic catches that are impossible for the patient to undo with teeth or even one free hand.
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These are secured to opposite sides of a metallic bed frame that is usually bolted to the floor and has a sturdy plastic mattress on it. Mattress has no metallic parts or other surface points that would injure the patient. A three or four inch wide leather belt is fastened around the waist of the patient, either locke or unlocked, and then fixed securely with one inch leather straps to the bed frame. These leather restraints are very thick; about one quarter of an inch, and the metal is riveted on with flush rivets to prevent injury to the patient. The patient is restrained lying down either face up or face down on the bare mattress.
Other restraint systems are used in hospitals and some nursing homes, such as cloth wrist restraints and cloth waist and chest restraints. These restraints are never used with the mentally ill because of the very high possibility that they would be used for self harm. In some juvenile prison facilities five point leather restraints have been utilized with a metal ‘restraint chair’ as a form of coercion and punishment. This is a totally inappropriate use of restraint and its use should be discontinued for these purposes. Seclusion Seclusion is a method of containing adolescents that some mental health providers consider equal to a form of restraint.
Seclusion consists of putting the patient in a room devoid of any features that they could possibly harm themselves with. Fixtures are recessed and inaccessible, there are no windows that are breakable. They can have a bare floor or an indestructible mattress of heavy canvas or plastic that is easily cleaned and cannot be taken apart. There is always some form of observation of the patients’ activities in the seclusion room, either directly through an unbreakable window in the door and / or a video camera setup. The patient is searched for any objects they might harm themselves with. Objects as well as clothing that might be used in self-harm are removed.
Some facilities place the patient in an indestructible canvas, short sleeved gown. The patient is then allowed to be alone after being placed in the seclusion room. The door can be locked or left open depending on the discretion of staff and the volatility of the patients’ behavior. Medication As an alternative to physical restraint, medication with pyschotropic and anti-anxiety drugs is frequently used when patients considered ‘out of control’. The only drugs used are those that would have an immediate effect on the patient at the time of the disturbance and they are usually given by injection in a large muscle, while the patient is physically restrained by staff. Resulting calm can start in a little as ten minutes from the time of the injection.
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Drugs that are currently being used in facilities for this purpose are H aldol, Navan e, Ativan, Isoperidol and Valium. Each year brings a new crop of psychotropic drugs touted to be better than last years by the drug companies that manufacture them. The injectable of choice can vary from year to year, doctor to doctor and certainly from institution to institution. Restraint Use When are restraints used Ideally there are only two reasons for restraint use in any residential treatment facility. The first occurs when the patient is actively attempting to do physical harm to himself and the second is when he is attempting to physically harm another person. A third reason given is that the patient is being uncontrollably disruptive to the milieu.
This reason is open to such broad interpretation that as a policy it should be very carefully looked at in relation to the competence and training of the staff interpreting it. Unfortunately restraints are used too often to prevent a perceived threat of violence or as a form of punishment. Each mental health treatment facility that utilizes restraints is mandated by state law to have a clear-cut, easily followed restraint use policy. This policy states why, how and when restraints are to be used and how the patient is to be monitored while in restraints and under what circumstance the patient is allowed out of those restraints. Monitoring while a patient is in restraints or seclusion is frequently done by observing the patient at fifteen-minute intervals and documenting the behavior in writing on a form for that purpose. Restraining or seclusion is usually done on the order of a designated mental health professional and in the state of Washington must be done on the order of a physician who is contacted at the time of the incident.
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Children and adolescents cannot be put in restraint or seclusion for longer than two hours without a physician order. The patient must be offered liquids to drink and an opportunity to empty the bladder at least once per hour while in restraints or seclusion. This can be done by means of a bedpan or urinal if it is not considered safe to release the individual. Problems with Restraint Utilization In using restraints of any form on a patient, staff is utilizing their own knowledge base, training and system of beliefs to justify that restraint. These criteria tend to vary widely from person to person. One staff member may be scared of a patient that is acting strangely.
Another may perceive a patients’ verbal conversation as an immediate threat of self-harm. While yet a third staff member might decide a definition of self-harm includes the patient refusing to take his noon medications. In each of the above instances staff may feel that they are justified in restraining the patient. Staff need to understand the severity of the choice of utilizing restraints. People of all ages have died as a result of the improper use of restraints, both physical and medical.
Continuous staff training and careful monitoring of every restraint utilized is necessary to prevent inpatients’ rights of ‘least restrictive environment’ from being violated. Another consideration is the patient who finds the only way they get intense staff attention is when they are violent enough to be restrained in some way. The patient then will behave frequently in a violent manner to get attention, even though it is negative attention. The patient may also crave the ‘hands on’ attention to be put in restraints because no other form of touching is available to them. Restraint Choice Five point heavy leather restraints are the most restrictive form of restraint. They prevent most limb and trunk movement and leave the patient virtually helpless and certainly feeling helpless.
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If a patient needs to be restrained from an active self-harming activity such as head banging, swallowing lethal objects or other potentially immediately life-threatening activities, this is the restraint of choice. In some facilities, once restrained, an injectable calming medication is then given to the patient to shorten the time physical restraint is necessary. Ideally this form of restraint should be utilized very infrequently. The potential for physical harm may be alleviated at that time but frequent use of these restraints has the potential to cause psychological harm to the patient. It promotes a feeling of helplessness and underscores to the patient that he is not in control of himself or his situation. Unfortunately in many in treatment facilities for children and adolescents, the choice of restraint, when it becomes an unavoidable necessity, is dictated by what is available.
In a smaller facility without adequate staffing or a safe seclusion room, five point leather restraints often end up being used on the child without adequate justification. Seclusion rooms or as they are sometimes called ‘quiet rooms’ can be an effective way to keep the ‘out of control’ child or adolescent from self harm or harming others. These too have the potential for abuse and their use needs to be justified. A properly set up seclusion room gives the patient an opportunity to vent his feelings on the room instead of himself, his fellow patients or the staff. He can yell, bang on the walls, kick, or otherwise physically vent his frustrations while being observed and unable to hurt himself. He may experience feelings of confinement but not feel helpless.
The seclusion room can also be utilized with an unlocked door. This acknowledges that the patient has some control over his behavior. He can utilize the time alone to think about his feelings and come out when he feels he can control himself. Patients can request to spend time in the seclusion room when they feel out of control or unable to behave with others.
The seclusion room takes on a new use, not as a place of confinement but as a place of safety for the patient. Some of the same pitfalls involved in five point leather restraints are also present with using seclusion rooms. The ‘hands on’ procedure needed to put a violent patient into a seclusion room can provide the touching that some patients crave. Constant observation while in the seclusion room provides an intense form of attention also and some patients’ will act out deliberately to get this attention.
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Medicating patients as a form of restraint has many advocates. It is certainly less labor intensive in the long run and has fairly immediate results and requires no special equipment or rooms. It appears to be ideal form of restraint in many respects and is the restraint method of choice in many inpatient facilities for adults. The problems of utilizing medication restraint on children and adolescents are many. Before any medications are given to children it is recommended that they undergo a thorough physical exam that includes an EKG, EEG, metabolic blood work and a urinalysis to screen out potential problems that may arise from giving the medication. Even with this careful screening and titrating psychotropic medications to begin dosing there can still be side effects that are deleterious to the child.
Few medications are tested by drug companies on the child and adolescent population for obvious reasons and therefore utilizing these on them can be very tricky. So many medications have just appeared on the market for adults we have no idea on how they will effect physical growth, mentation or the long-term effects of giving them to growing children. The legalities of medicating the adolescent inpatient are strictly governed and protected by law whether the child is a ward of the state or has come from a loving family. Parent or guardian must be contacted whenever a new medication is used, its use justified and permission given. Medicating the ‘out of control’ child does not give the child the opportunity to learn to think about, understand and seek to control himself.
It provides an almost instantaneous relief from an uncomfortable situation and leads to the patients’ belief that a solution to uncomfortable feelings and behavior lies in taking a drug of some form. It can also lead to the child feeling helpless, disoriented and further out of control. Conclusion Five point restraints take away the possibility of self-harm but teach the child that staff is in control, leaves them helpless and fosters a distrust of authority figures. It tells the child that they cannot control themselves. Medication, at first glance, has a lot going for it as a method of restraint and certainly staff like it. It is a quick solution and in an adult setting may be the restraint that is most appropriate.
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For the adolescent or child it is just taking too great a health risk to justify its use. Although inpatient child and adolescent populations are being medicated daily with psychotropics it is being done along with a careful continuous monitoring of the patients’ physical and mental state. The child is also taught that the medication is an adjunct to therapy, learning, growing and experience. Medication is not presented as a cure or solution to the problems being worked on. One of the most effective methods for handling the disruptive patient is to have enough adequately trained staff on hand to see an ‘out of control’s situation in the making and skillfully head it off.
This can be accomplished either by talking to the patient, listening to the patient or suggesting that the patient take a ‘time out’ either in their own room or the ‘quiet room’. This takes a staff member out of the picture for monitoring the other residents and requires a good staffing ratio to implement. If and when it becomes necessary to handle an erupting adolescent and help them to regain control the use of seclusion as a restraint seems the most appropriate. It is the least restrictive environment, keeps the child safe from harm and provides them with an opportunity to regain control by themselves.
This begins to teach them that they can control their own behavior with minimal intervention now, and later all by themselves. It becomes apparent with a little investigation that what is convenient method for staff and management to treat disruptive behavior is not necessarily always in the best interest of the patient. References[Type 1 st reference here. Click here & delete this] 1 36 c.