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Pediatric seclusion and restraint increases with ADHD, decreases with PTSD

 

Key clinical point: Children with attention-deficit/hyperactivity disorder and non-suicidal self-harm may need more one-on-one care to stay out of seclusion and restraints on psychiatric units.

Major finding: ADHD and non-suicidal self-harm – cutting and head banging – strongly predict longer seclusion and restraint episodes, sometimes past 2 hours.

Data source: A University of Missouri, Columbia, review of 305 seclusion and restraint episodes from 2011-2014 among 92 children aged 5-18 years old.

Disclosures: The investigators had no industry disclosures.


 

AT IPS 2017

 

– Attention-deficit/hyperactivity disorder and non-suicidal self-harm – cutting and head banging, for instance – strongly predicted longer seclusion and restraint episodes, sometimes past 2 hours, in a review at the University of Missouri, Columbia, pediatric inpatient psychiatric unit.

Meanwhile, children with histories of physical abuse, post-traumatic stress disorder (PTSD), or out-of-home placement were less likely to have multiple seclusion and restraint (SR) episodes during an admission, and had lower numbers of SR events overall. Perhaps hyper-vigilance due to past traumas helped them avoid situations that led to problems. Staff might also have used a lighter touch given the children’s histories.

The investigators reviewed 305 SR episodes from 2011-2014 among 92 children aged 5-18 years old. They plan to expand their study to 2009-2017 and add a prospective arm.

Dr. Marwa Badawy, pediatric psychologist. University of Missouri M. Alexander Otto/Frontline Medical News
Dr. Marwa Badawy
The ultimate goal is one held by many: to “prevent seclusions and restraints because they traumatize children,” lead investigator Marwa Badawy, MD, a pediatric psychiatrist at the university, said at the American Psychiatric Association’s Institute on Psychiatric Services meeting.

It’s well known that SR, a last-ditch effort to prevent physical harm, traumatizes patients, but research on how to avoid it has mostly focused on adults. The Missouri team wants to change that by identifying the children most at risk, so that something can be done beforehand to prevent it. Maybe extra one-on-one care would help, Dr. Badawy said.

The children in the review were an average of 10.5 years old, and most were admitted for 3-7 days. Fifty-five (60%) had multiple SR episodes, 34 in a single admission and 21 across multiple admissions; 71% of the episodes were in boys, 58% in white children, 27.7% in black children, and the rest in multiracial children. Twenty-one percent of the episodes were in children with intellectual problems. ADHD and oppositional defiant disorder were the most common diagnoses, each diagnosed in more than half of the subjects.

When asked how a 5-year-old child can end up in restraints, Dr. Badawy agreed that bad parenting is a factor. Parents who don’t know any better might escalate normal behavior, and others might simply not care that much about their kids, or have much empathy. “In the 5-10 year-olds, I do think a lot of it is parenting. Neglect is the number one form of abuse,” she said, “and it causes instability in children.”

But parents aren’t always the problem. Dr. Badawy mentioned an “extremely depressed” boy who tried to hang himself again and again, at 8 years old. “His parents were supportive and focused on getting him better,” she said. It’s unknown if anything happened to him when they weren’t around.

If SR is related to children’s own behavior, and if they are able to listen to staff afterward and control it, kids seem able to avoid another episode. Those who have PTSD, or who have been through physical abuse or out-of-home placement, seemed particularly adept in the review.

Avoidance seems less likely, however, when children are set off by other kids.

Sometimes there are clues of impending trouble, like the boy who walked around whistling before he lashed out. Staff at the university quickly learned to swoop in and calm him when they heard the whistling.

The investigators had no industry disclosures.
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