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,
"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 needa 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
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."
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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.
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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
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
Related MaterialDemonstration Sites »
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