Restraint use in residential programs: why are best practices ignored?

Several states and providers have embarked on initiatives to reduce using restraint and seclusion in residential programs. Restraint and seclusion are associated with harm to youth and staff, significant costs, reduced quality of care, and less engagement of youth and families. Successful reduction/prevention strategies have been identified, implemented, and reported. Both states and residential providers have implemented prevention approaches, made significant changes, reduced restraint/seclusion use, and offered their experience and positive outcomes. Restraint and seclusion continue to be used on children, adolescents, and youth in residential settings at higher rates than on adults in care, often with deleterious effects (LeBeI, 2009b; LeBeI 6c Goldstein, 2005; Weiss, Altimari, Blint, 6c Megan, 1998). These practices are traumatizing and dangerous to both children and staff; costly to agencies in terms of program operations, staff morale, and client outcomes; and inconsistent with researched best practices (e.g., youth-guided and family-driven care; Burns, Goldman, Faw, 6c Burchard, 1999; Courtney, Terao, 6c Bost, 2004; LeBeI 6c Goldstein, 2005). The relationship between using restraint and well-publicized deaths of children in residential care are a particular concern (Kennedy Sc Mohr, 2001; LeBeI, Stromberg, Duckworth, Kerzner, Goldstein, Weeks, Harper, LaFlair, 6c Sudders, 2004; Weiss et al., 1998). The literature has documented the physical and emotional risks that commonly result from these procedures (Johnson, 2007; Mohr 6c Anderson, 2001; Nunno, Day 6c Bullard, 2008; U.S. General Accounting Office, 1999). Moreover, using restraint and seclusion impacts others involved with the youth. One parent recounted, "Seeing my son restrained in front of me was the most traumatizing event of my life; my son was crying for me and I felt helpless. We went to that program for help and we were traumatized instead" (L. Lawrence, personal communicationjune 13,2009). Despite the evidence of serious harm resulting from restraint and seclusion (restraint/seclusion) procedures, these practices continue in many child residential programs as well as other child-serving settings such as juvenile justice centers, foster care homes, and schools (National Association of State Mental Health Program Directors [NASMHPD], 2009). Using restraint and seclusion in many residential programs is particularly disturbing given the evidence-based best practices that have effectively reduced use in an increasing number of residential programs (NASMHPD, 2009). Several states have implemented statewide practices, policies, and legislation to support restraint and seclusion reduction efforts, and the Institute of Medicine (2005) has called on providers to use practices that are evidence-based and preventative in nature. It is time to ensure that every child-serving residential program in the United States uses the available information and tools to prevent and significantly reduce using restraint and seclusion. This paper reviews some best practices associated with this effort that lead to positive outcomes for youth and their families. The literature indicates that when restraint and seclusion are significantly reduced, a number of other positive outcomes are realized including fewer youth and staff injuries, less staff turnover, higher staff satisfaction, shorter lengths of stay, sustained success in the community after discharge, and significant costs savings (LeBeI, 2009a; LeBeI & Goldstein, 2005). Overview of the National Initiative NASMHPD represents the public mental health system in each state/territory As part of the National Call to Action initiated by the Substance Abuse and Mental Health Services Administration (SAMHSA, 2003), NASMHPD's Office of Technical Assistance reviewed the literature and consulted with national experts on restraint and seclusion reduction. The experts identified similar patterns of practice in programs that had successfully reduced these procedures and determined that most of the change-producing strategies were implemented at low or no cost. …