Agitation and Restraint in a Pediatric Psychiatric Emergency Program

Objectives Agitation and restraint among pediatric psychiatric patients are a frequent, yet little studied, source of morbidity and, rarely, mortality in the emergency department (ED). This study examined agitation and restraint among youth patients in a specialized pediatric psychiatric ED, considering clinical and sociodemographic characteristics of those who required restraint to determine the clinical correlates of agitation and restraint in this population. Methods This descriptive study was a 6-year retrospective chart review of all patients restrained for acute agitation. Demographics, clinical characteristics, diagnoses, and reasons for restraint were collected. Relationships between sociodemographic and clinical variables to types of restraints used were examined, along with change over the study period in rate of and mean time in restraint. Results The average restraint rate was 1.94%, which remained fairly consistent throughout study period, although average time in restraint decreased significantly. Restraints were more common in males. Adolescents were overrepresented in the ED population, and after controlling for this, restraint rates were similar in adolescents and younger children. Physical aggression was the most frequent precipitant, although among adolescents verbal aggression was also a precipitant (more so than in younger children). Disruptive behavior disorder diagnoses were most frequently associated with restraint. Conclusions A lower rate of restraint is reported here than has been seen in programs where youths are treated in medical or adult psychiatric EDs. Hospitals without specialized pediatric psychiatric emergency programs should invest in staff training in deescalation techniques and in access to pediatric psychiatric treatment. The finding that, of youth restrained, a significant proportion were under 12 years old and/or carried diagnoses not typically associated with aggressive behavior, indicates that crisis prevention, management, and treatment should include younger populations and diverse diagnostic groups, rather than focusing narrowly on older patients with psychotic or substance use disorders.

[1]  M. Siegel,et al.  Does an Autism Spectrum Disorder Care Pathway Improve Care for Children and Adolescents with ASD in Inpatient Psychiatric Units? , 2018, Journal of autism and developmental disorders.

[2]  N. Malas,et al.  Crisis in the Emergency Department: The Evaluation and Management of Acute Agitation in Children and Adolescents. , 2018, Child and adolescent psychiatric clinics of North America.

[3]  L. Zun,et al.  Treatment Goal for Agitation: Sedation or Calming. , 2017, Annals of emergency medicine.

[4]  S. Horwitz,et al.  Utilization Patterns at a Specialized Children's Comprehensive Psychiatric Emergency Program. , 2017, Psychiatric services.

[5]  L. Zwaigenbaum,et al.  Toward Practice Advancement in Emergency Care for Children With Autism Spectrum Disorder , 2016, Pediatrics.

[6]  C. Correll,et al.  Frequency, characteristics and management of adolescent inpatient aggression. , 2013, Journal of child and adolescent psychopharmacology.

[7]  S. Zeller,et al.  Overview of Project BETA: Best practices in Evaluation and Treatment of Agitation , 2012, The western journal of emergency medicine.

[8]  C. Correll,et al.  Prevalence and correlates of seclusion and restraint use in children and adolescents: a systematic review , 2011, European Child and Adolescent Psychiatry.

[9]  M. Potegal,et al.  The behavioral organization, temporal characteristics, and diagnostic concomitants of rage outbursts in child psychiatric inpatients , 2009, Current psychiatry reports.

[10]  Dhhs Centers for Medicare Medicaid Services.  Medicare and Medicaid programs; hospital conditions of participation: patients' rights. Final rule. , 2006, Federal register.

[11]  S. Mehta,et al.  Restraint Use for Psychiatric Patients in the Pediatric Emergency Department , 2006, Pediatric emergency care.

[12]  B. Kastner,et al.  The Use of Restraint for Pediatric Psychiatric Patients in Emergency Departments , 2004, Pediatric emergency care.

[13]  K. Duckworth,et al.  Child and adolescent inpatient restraint reduction: a state initiative to promote strength-based care. , 2004, Journal of the American Academy of Child and Adolescent Psychiatry.