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Reduction of Restraint and Seclusion Through Collaborative Problem Solving: A Five-Year Prospective Inpatient Study

All authors are affiliated with the Children's Psychiatric Inpatient Service, Yale-New Haven Children's Hospital, New Haven, Connecticut. Dr. Martin, Dr. Stubbe, and Dr. Cardona are also with the Yale Child Study Center, 230 South Frontage Rd., New Haven, CT 06520 (e-mail: andres.martin{at}yale.edu).

OBJECTIVE: This study examined usage patterns of restraint and seclusion before and after the implementation of collaborative problem solving (CPS), a manualized therapeutic program for working with aggressive children and adolescents. METHODS: The clinical setting was a 15-bed psychiatric inpatient unit for school-age children. A total of 755 children were hospitalized for a total of 998 admissions from fiscal years 2003 to 2007 (median age=11 years; 64% boys). Data were collected for three years before and 1.5 years after the six-month implementation of the CPS model of care. RESULTS: There were 559 restraint and 1,671 seclusion events during the study period. After implementation of the CPS model there was a reduction in the use of restraints (from 263 events to seven events per year, representing a 37.6-fold reduction, slope [beta]=-.696) and seclusion (from 432 to 133 events per year, representing a 3.2-fold reduction, beta=-.423). The mean duration of restraints decreased from 41±8 to 18±20 minutes per episode, yielding cumulative unitwide restraint use that dropped from 16±10 to .3±.5 hours per month (a 45.5-fold reduction, beta=-.674). The mean duration of seclusion decreased from 27±5 to 21±5 minutes per episode, yielding cumulative unitwide seclusion use that dropped from 15±6 to 7±6 hours per month (a 2.2-fold reduction; p for trend .01 or better for all slopes). During the early phases of implementation there was a transient increase in staff injuries through patient assaults. CONCLUSIONS: CPS is a promising approach to reduce seclusion and restraint use in a child psychiatric inpatient setting. Future research and replication efforts are warranted to test its effectiveness in other restrictive settings.

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