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

Abstract

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. 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. 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. 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.