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SAMHSA Helps Reduce Seclusion and Restraint at Facilities for Youth continued (Part 2)

A Range of Approaches

Demonstration sites were chosen with diversity in mind, said SAMHSA project officer Karen Saltus Armstrong, M.S.S.W., J.D., of the Protection and Advocacy Section of the CMHS Division of State and Community Systems Development. "The demonstration sites are quite different in terms of the populations they serve, locations, and other factors," said Ms. Armstrong. "We're hoping to come out of this project with many different training models."

For example, the three Connecticut facilities that joined together for the CMHS grant exemplify the range of models under study. Klingberg Family Centers use a continuing education model, bringing in experts to train staff in specialized topics such as attachment disorder. Riverview Hospital for Children and Youth, within the Connecticut Department of Children and Families, launched a training program in cultural diversity after the facility discovered that staff members were more likely to use seclusion and restraint on minority children. And, the Devereux Glenholme School takes a high-tech approach to training. To help staff members assess their crisis prevention and intervention skills, the facility developed a CD-ROM that presents users with various scenarios and then automatically grades their responses. Background information on each child depicted in the program is available by clicking on the child's image; guidance is available from an on-screen "supervisor."

All the sites view training as just one part of the solution, however.

"Even though this is a training grant, it appears that training isn't everything," explained Principal Investigator Darren Fulmore, Ph.D., a research associate at the Child Welfare League. "Knowledge is only half the battle." What's really important, he said, are the expectations of facility managers as embodied in policies and practices.

In Michigan, the Lakeside Treatment and Learning Center's program takes to heart that kind of comprehensive approach. Ongoing training is a crucial part of the center's effort to reduce the use of restraint and seclusion.

Focusing on crisis prevention, the training program teaches all staff members skills such as how to de-escalate crises verbally, resolve conflicts, avoid power struggles with children, and recognize what triggers incidents. Children who have been sexually abused or witnessed the abuse of others, for example, may come to the aid of peers being restrained and end up being restrained themselves. A child desperate for human contact may actively seek out restraint just to meet that need—a need that could be better met by building appropriate touch into the child's day. The training program also covers such topics as cultural competency, anger management, and the need to increase consumer involvement. Once trained, staff members receive feedback from mentors with proven de-escalation skills.

While underscoring the potential risks of restraint and seclusion, the program also teaches staff how to use such techniques safely and effectively if they become necessary. All direct-care staff undergo annual certification in physical restraint techniques, with interim training as needed.

Focusing on alternatives to the use of restraint and seclusion is the real key.

But training is just one part of an overall strategy to reduce the use of restraint and seclusion, said Ms. Friesner. That commitment permeates every aspect of life at Lakeside. Supervisors, for instance, hire staff who have the temperament for relationship-building and then evaluate them in ways that reward those qualities. The center's group therapist, activities coordinator, and other staff members work to keep the children busy and happy. The children themselves learn coping skills, so they can manage their anger, frustration, and other emotions without misbehaving.

Thanks to this comprehensive approach, Lakeside has seen a steady decline in the use of restraint and seclusion. What's more, Ms. Friesner believes that the approach may represent a solution for the field's notoriously high rate of staff turnover. "Staff members who feel the safest when they feel more in control have resisted the changes," she explained. "But those who believed all along in the primacy of committed relationships have embraced the changes with open arms."

Preliminary Results

The project's implementation phase ended and its evaluation phase began in mid-2002. According to the project's latest National Evaluation Quarterly Report Card, the average number of seclusion incidents has dropped by more than half. Two sites eliminated their seclusion rooms altogether.

The data on restraint use reveal more mixed results. The one site that submitted data on the use of mechanical restraints—devices that reduce or restrict an individual's ability to move his or her arms, legs, or head freely—showed dramatic improvement, with incidents falling from 25 per 1,000 patient days to just under 4. The use of physical restraints—the application of physical force by one or more people to reduce or restrict an individual's ability to move—rose slightly. However, a closer look at the data reveals that one site's consistently higher incident rate is skewing the numbers. And while the use of restraint is up overall, Dr. Fulmore notes that all of the non-medical, community-based sites have reduced its use.

Similarly, the overall number of injuries and rate of injuries per incident are going up for both children and staff members. Again, one site has a disproportionate number of injuries, accounting for almost half of the reported injuries to children and almost 70 percent of injuries to staff.

Behind the Numbers

The Coordinating Center collected valuable data that help explain what's going on behind the numbers. For example, data reveal what kinds of events tend to precipitate interventions. Of the events reported, 60 percent were child-on-staff assaults; 25 percent were property damage; and 22 percent were child-on-child assaults.

Several sites tracking non-physical interventions indicate that nearly 37 percent of incidents requiring intervention were de-escalated successfully. The most frequently used strategies employed to de-escalate crises were redirecting the child's attention, using time-outs, and encouraging the child to use self-calming techniques.

Focusing on crisis prevention, the training program teaches all staff members skills such as how to de-escalate crises verbally and resolve conflicts.

To help sustain the project's gains even after the grant ends, the Federation of Families for Children's Mental Health recently provided advocacy training to nine family members from three of the sites. The goal was to help them understand the value and possibilities for family involvement in the project, identify roles for themselves at their sites, and support them in their efforts to get families involved.

"Research shows us change is possible," said Dr. Fulmore. "Now we're looking to see what factors can help us really sustain those changes.

« See Part 1: SAMHSA Helps Reduce Seclusion and Restraint at Facilities for Youth

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