The management of explosive, aggressive behavior on inpatient child units has traditionally been punitive and consequence based. However, over the past few years, an innovative and humane program in Cambridge, Massachusetts, has introduced a new culture to the provision of care for children with serious psychiatric problems.
The Child Assessment Unit (CAU), a locked inpatient child psychiatry unit located at Cambridge Hospital that is fully funded through the hospital's budget, opened in 1989 in response to overwhelming patient demand throughout Massachusetts and the New England region. One of the few units able to accommodate children as young as two years old as well as those up to the age of 13, this 13-bed unit treats patients with serious mental disturbances. Approximately 80 percent of the children admitted to the unit have significant trauma histories, and 95 percent are admitted for severe out-of-control behavior at home or school. The most common diagnoses are posttraumatic stress disorder, mood disorders, other anxiety disorders, pervasive development disorders, and psychotic disorders. Many of the children have complicated family histories. Usually they have suffered major losses in their lives as a result of the death, incarceration, or absence of a parent or caregiver, which has resulted in placements in kinship, foster, or adoptive homes or in residential facilities.
Before the recent changes in the CAU's treatment philosophy, the unit's rate of use of seclusion and restraint was twice the state average for child psychiatric units. As a result, the CAU suffered from poor staff morale, serious staff injuries (and their associated costs), and, ultimately, staff resignations. In such an atmosphere, the staff who continued to work on the unit felt undervalued, unappreciated, and unsafe.
In July 2001 the CAU's new medical director, Bruce Hassuk, M.D. (a child and adolescent psychiatrist) and its nurse manager, Kathy Regan, R.N., sought to provide more humane psychiatric care to children by balancing the dangers associated with aggressive behavior with a desire to manage such behavior with less restrictive interventions. They wanted to move away from a limit-setting, consequence-based culture of "teaching life lessons" to children by punishing them for their behaviors. Together, they developed a set of core values for the way children would be treated on the unit by implementing the Open Arms Program, representing a new culture and a total restructuring of inpatient psychiatric care for children.
In recognition of its success in effecting such a culture change, the Cambridge Hospital CAU was selected as the winner of the 2003 Gold Award in the category of large academically or institutionally sponsored programs. The winner of the award for small, community-based programs is described in a separate article on page 1526. Each winning program will receive a plaque and a $10,000 prize made possible by a grant from Pfizer Inc. The awards were presented on October 29 during the opening session of the Institute on Psychiatric Services in Boston.
The new approach embodied in the Open Arms Program was adopted in collaboration with Ross Greene, Ph.D., a child psychologist at Massachusetts General Hospital. Dr. Greene has published studies of his "collaborative problem solving" (CPS) method of dealing with children and their disruptive behaviors. CPS is a cognitive-behavioral approach that focuses on how adults interact with children in managing the child's behavior.
The basic premise of CPS is that "kids do well if they can": if they are not doing well, it is because they are unable to do so, not because they do not want to. Thus the task of parents and caregivers is to discover the reasons for the child's problems and to try to help the child. Another basic premise of CPS is that most (99 percent) of the children who arrive for inpatient psychiatric care already know that it is wrong to engage in such behaviors as hitting others, swearing, and acting aggressively. The challenge is therefore not to make them stop behaving in these ways, but to identify the circumstances under which they are likely to do such things as hit or swear. A third premise is that "meltdowns" are detrimental to children.
Under CPS guidelines, a child who has lost control and is enraged is said to be at "minus 30." When a child is in such a state, an opportunity to teach has been lost. The greatest opportunity for learning occurs when the child is just beginning to become frustrated about something—at "minus 5." Thus the events that preceded the frustration are of more interest than are those occurring after the child became upset. This framework for approaching aggression and other problem behaviors among children is in stark contrast with the methods of more traditional programs, which focus on what happened after the upset and then set consequences in response to the child's behavior.
Once the specific thinking deficits that have led to a meltdown have been identified, staff and parents can begin to teach children the skills they will need in order to solve problems during times of frustration or stress. Staff members show empathy and ask whether they can help with the problem. They demonstrate a willingness to collaborate with the child and to reach a compromise without having a preconceived solution. Of course, for some children, who have not yet mastered the skills necessary to generate possible solutions to a problem, it is necessary to suggest various options.
In implementing the culture change, the unit's leadership challenged the staff to decrease their emphasis on traditional values of structure and consistency. The traditional core values were thus replaced by new values: providing nurturance, providing an atmosphere of teaching and learning, and providing choices. Staff now use a different vocabulary for describing children's behavior. Terms such as "acting out," "secondary gain," "staff splitting," and "manipulation" have been replaced by language that attributes behavior more to deficits than to intentionality.
With these new core values in place, the CAU developed four main goals: to enhance the ability to conduct a thorough assessment and develop a comprehensive formulation that addresses individual difficulties without resorting to coercive or punitive measures; to provide a nurturing environment that eliminates seclusion and restraint as interventions for managing aggressive behavior; to increase staff satisfaction by reducing the occurrence of staff injury and by building staff cohesion through common core values and procedures; and to develop a partnership with parents in providing care to their children.
The CPS model had not previously been used on inpatient treatment units. In 2001 Dr. Hassuk, Ms. Regan, and Dr. Greene agreed to implement the model though a series of training sessions for staff, redirection of unit policies regarding children and their families, and ongoing staff education about the principles of care. At the same time, the unit undertook an evaluative study to determine whether the new approach was leading to improved patient experiences and outcomes. Variables studied were the use of seclusion and restraint, staff injuries, and staff and patient satisfaction.
Dr. Hassuk and Ms. Regan share a common vision for the CAU and have formed a partnership in leading the unit. This placement of nursing and medical leadership on an equal footing is an important element of the new model and has allowed for sweeping changes in the way care is delivered and staff are hired. In addition to Dr. Hassuk and Ms. Regan, the CAU staff includes a psychologist, two social workers, nurses, milieu counselors, an occupational therapist, a teacher, and an activities therapist. In addition, a number of trainees, interns, residents, and fellows rotate through the unit for various lengths of time.
The staff have been instrumental in making the Open Arms Program a success. Staff are trained to be astute observers of behavior, identifying antecedents to behavioral meltdowns. Although staff continue to expect that aggression and assaultiveness will occur, their response to such behavior has been transformed.
The focus of clinical meetings has been changed to elicit input from all staff members about individual children's behavior. Each child is discussed in depth on a daily basis, and specific goals are developed. Children who are unable to manage the stimulation of a group are monitored closely and helped with individual activities. These children are reassessed frequently to determine whether they are likely to succeed in a group setting.
In keeping with its stated goals, the CAU provides a welcoming environment for families and caretakers. The unit has open visiting hours, with no restrictions, and is the first unit in Massachusetts to use this approach. Family members are encouraged to help their children with their daily self-care in the morning, to eat with them, and to help them settle in the evening. Family members are often seated at the head of the table at meetings, which reflects the degree to which their involvement is valued. Family members sometimes spend an entire day accompanying their child to group sessions. The CAU purchased a sleep chair for parents who elect to spend the night with their child.
Another innovative policy of the program is the use of "positive physical touch" in place of the former protocol of "no physical contact." This approach helps children with serious trauma histories to learn, in a safe environment, the ways in which positive, appropriate physical contact is exhibited by caring adults. The unit has a child-friendly atmosphere—children can be found engaged in a number of activities, including rollerblading in the carpeted hallways.
The CAU is also the first unit in Massachusetts to receive permission from the Massachusetts Department of Mental Health (DMH) to remove the doors from its seclusion rooms. The removal of the doors transformed unfriendly and frightening spaces into fun places for children. Speakers were installed in the quiet rooms as well as in bedrooms, hallways, and the living room to enable staff to develop strategies for managing aggressive behaviors through music and other sounds.
The unit's medical director and child psychiatry staff have been instrumental in changing the context in which children receive medication. When children are aggressive and assaultive, they are considered "not yet workable." In many cases, the thoughtful short-term use of medication to manage aggressive and explosive behavior has facilitated the program's mission of performing a thorough assessment and developing an individual formulation. This approach represents a substantial change for the CAU, where, in the past, medication was often used only as a last resort.
The results of the change in culture implemented in 2001 are evident in a variety of outcomes, including the absence of mechanical restraints, locked-door seclusions, physical holds exceeding five minutes, and level-3 staff injuries (serious injuries requiring treatment). Savings (not yet quantified) have resulted from the dramatic reduction in staff injuries. The program has not required any additional funding but rather has been funded through the existing budget. Staff members report that their job satisfaction has improved as a result of talking and playing with the children and having a common vision instead of constantly setting limits. The children have also noticed differences in staff interactions, making comments such as "You listen to us now."
The unit's leadership faced some challenges in implementing the CPS approach. Initially there was some resistance from longtime staff members. The old consequence-based punitive culture of "teaching lessons" to the children, even at the expense of meltdowns, was difficult to eradicate. Some staff members feared relinquishing seclusion and restraint as tools of control and as symbols that the staff members themselves had the final word. Such reluctance to change led to the loss of one-third of the nursing staff, all of whom had to be replaced during a nursing shortage. For the staff who remained, new competency assessments were incorporated into annual staff performance reviews as a means of demonstrating that the leadership team was serious about implementing the new model.
As a Harvard Medical School teaching site for training child psychiatrists and psychologists, the CAU is making a mark on the way care is provided by current and future mental health professionals. The unit has been an integral part of a DMH initiative, begun in November 2000, to significantly reduce the use of restrictive interventions in child and adolescent acute and continuing care programs throughout Massachusetts. DMH has asked all youth inpatient providers to develop strategic plans and address the incorporation of strengths-based approaches into their treatment settings. The CAU has been instrumental as a "provider leader" in supporting goals related to the initiative and has demonstrated its willingness to serve as a resource for other facilities in Massachusetts. DMH has referred other inpatient clinicians to the CAU's leadership for guidance in applying the program to other units.
Numerous programs nationwide have sought information and requested training in the new model. The program's leadership team has made presentations in various forums, including DMH roundtables for other child and adolescent inpatient psychiatric units, the keynote presentation at a statewide 2002 DMH conference on reducing the use of seclusion and restraint, and the 2002 Massachusetts General Hospital conference "Aggressive, Resistant, and Delinquent Youths—Meeting the Treatment Challenge." A description of the program was presented at the 50th meeting of the American Academy of Child and Adolescent Psychiatry held in Miami Beach in October 2003. The Open Arms Program was recently extended to include an adolescent inpatient unit at nearby Somerville Hospital.
In summary, the Open Arms Program is an exemplary child psychiatric service that has transformed, within a relatively short space of time, an inpatient unit that relied heavily on restrictive measures to one that cares for children and their families through teaching skills, rewarding positive behavior, and involving parents as full partners.
For more information, contact Bruce Hassuk, M.D., or Kathy Regan, R.N., at the Child Assessment Unit, The Cambridge Hospital, 1493 Cambridge Street, Cambridge, Massachusetts 02139; e-mail, firstname.lastname@example.org@challiance.org..