What is the best rationale for holding a debriefing session with staff after a take down intervention has taken place in an inpatient unit?

Lag. (1991:1128) om psykiatrisk tvångsvård, 6 a §, 19 a §. (The Compulsory Mental Care Act). n.d. https://lagen.nu/1991:1128.
Mohr WK, Petti TA, Mohr BD. Adverse effects associated with physical restraint. Can J Psychiatr. 2002;48:330–7. https://doi.org/10.1177/070674370304800509.
Article Google Scholar
Kersting XAK, Hirsch S, Steinert T. Physical harm and death in the context of coercive measures in psychiatric patients: a systematic review. Front Psychol. 2019;10:400. https://doi.org/10.3389/fpsyt.2019.00400.
Article Google Scholar
Weiss EM, Altimari D, Blint DF, Megan K. Deadly restraint: a nationwide pattern of death. Hartford Courant. 1998.
Masters KJ. Physical restraint: a historical review and current practice. Psychiatr Ann. 2017;47:52–5. https://doi.org/10.3928/00485713-20161129-01.
Article Google Scholar
Chieze M, Hurst S, Kaiser S, Sentissi O. Effects of seclusion and restraint in adult psychiatry: a systematic review. Front Psychol. 2019;10:491. https://doi.org/10.3389/fpsyt.2019.00491.
Article Google Scholar
LeBel J, Goldstein R. Special section on seclusion and restraint: the economic cost of using restraint and the value added by restraint reduction or elimination. Psychiatr Serv. 2005;56:1109–14. https://doi.org/10.1176/appi.ps.56.9.1109.
Article PubMed Google Scholar
Nations TU. Convention on the Rights of the Child. n.d.. https://www.unicef.org/child-rights-convention/convention-text#.
Hottinen A, Välimäki M, Sailas E, Putkonen H, Joffe G, Noda T, et al. Underaged patients’ opinions toward different containment measures: a questionnaire survey in Finnish adolescent psychiatry. J Child Adolesc Psychiatric Nurs. 2012;25:219–23. https://doi.org/10.1111/jcap.12006.
Article Google Scholar
Smith ML. Necessary evil or painful experience? Perceptions of the use of Physical Restraint with Children. 2005.
Whittington R, Bowers L, Nolan P, et al. Approval ratings of inpatient coercive interventions in a National Sample of mental health service users and staff in England. Psychiatr Serv. 2009;60:792–8. https://doi.org/10.1176/ps.2009.60.6.792.
Article PubMed Google Scholar
Vishnivetsky S, Shoval G, Leibovich V, et al. Seclusion room vs. physical restraint in an adolescent inpatient setting: patients’ attitudes. Israel J Psychiatry Relat Sci. 2013;50:6–10.
Google Scholar
Askew L, Fisher P, Beazley P. What are adult psychiatric inpatients’ experience of seclusion: a systematic review of qualitative studies. J Psychiatr Ment Hlt. 2019;26:274–85. https://doi.org/10.1111/jpm.12537.
Article Google Scholar
Strout TD. Perspectives on the experience of being physically restrained: an integrative review of the qualitative literature. Int J Ment Health Nu. 2010;19:416–27. https://doi.org/10.1111/j.1447-0349.2010.00694.x.
Article Google Scholar
Moran A, Cocoman A, Scott PA, et al. Restraint and seclusion: a distressing treatment option? J Psychiatr Ment Hlt. 2009;16:599–605. https://doi.org/10.1111/j.1365-2850.2009.01419.x.
CAS Article Google Scholar
Doedens P, Vermeulen J, Boyette L, et al. Influence of nursing staff attitudes and characteristics on the use of coercive measures in acute mental health services—a systematic review. J Psychiatr Ment Hlt. 2020;27:446–59. https://doi.org/10.1111/jpm.12586.
Article Google Scholar
Muskett C. Trauma-informed care in inpatient mental health settings: a review of the literature. Int J Ment Health Nu. 2014;23:51–9. https://doi.org/10.1111/inm.12012.
Article Google Scholar
Hammer JH, Springer J, Beck NC, Menditto A, Coleman J. The relationship between seclusion and restraint use and childhood abuse among psychiatric inpatients. J Interpers Violence. 2011;26:567–79. https://doi.org/10.1177/0886260510363419.
Article PubMed Google Scholar
Timbo W, Sriram A, Reynolds EK, DeBoard-Lucas R, Specht M, Howell C, et al. Risk factors for seclusion and restraint in a pediatric psychiatry day hospital. Child Psychiat Hum D. 2016;47:771–9. https://doi.org/10.1007/s10578-015-0608-1.

Article Google Scholar
Valenkamp M, Delaney K, Verheij F. Reducing seclusion and restraint during child and adolescent inpatient treatment: still an underdeveloped area of research. J Child Adolesc Psychiatric Nurs. 2014;27:169–74. https://doi.org/10.1111/jcap.12084.
Article Google Scholar
Greene RW, Ablon JS, Martin A. Innovations: Child & Adolescent Psychiatry: use of collaborative problem solving to reduce seclusion and restraint in child and adolescent inpatient units. Psychiatr Serv. 2006;57:610–2. https://doi.org/10.1176/ps.2006.57.5.610.
Article PubMed Google Scholar
Martin A, Krieg H, Esposito F, et al. Reduction of restraint and seclusion through collaborative problem solving: a five-year prospective inpatient study. Psychiatr Serv. 2008;59:1406–12. https://doi.org/10.1176/ps.2008.59.12.1406.
Article PubMed Google Scholar
Dean AJ, Duke SG, George M, Scott J. Behavioral management leads to reduction in aggression in a child and adolescent psychiatric inpatient unit. J Am Acad Child Adolesc Psychiatry. 2007;46:711–20. https://doi.org/10.1097/chi.0b013e3180465a1a.
Article PubMed Google Scholar
Hert MD, Dirix N, Demunter H, Correll CU. Prevalence and correlates of seclusion and restraint use in children and adolescents: a systematic review. Eur Child Adolesc Psychiatry. 2011;20:221–30. https://doi.org/10.1007/s00787-011-0160-x.
Article PubMed Google Scholar
Furre A, Falk RS, Sandvik L, Friis S, Knutzen M, Hanssen-Bauer K. Characteristics of adolescents frequently restrained in acute psychiatric units in Norway: a nationwide study. Child Adol Psych Men. 2017;11:3. https://doi.org/10.1186/s13034-016-0136-1.
Article Google Scholar
Furre A, Sandvik L, Friis S, Knutzen M, Hanssen-Bauer K. A nationwide study of why and how acute adolescent psychiatric units use restraint. Psychiatry Res. 2016;237:60–6. https://doi.org/10.1016/j.psychres.2016.01.067.
Article PubMed Google Scholar
Duke SG, Scott J, Dean AJ. Use of restrictive interventions in a child and adolescent inpatient unit – predictors of use and effect on patient outcomes. Australas Psychiatry. 2014;22:360–5. https://doi.org/10.1177/1039856214532298.
Article PubMed Google Scholar
Pogge DL, Pappalardo S, Buccolo M, Harvey PD. Prevalence and precursors of the use of restraint and seclusion in a private psychiatric hospital: comparison of child and adolescent patients. Adm Policy Ment Hlth. 2013;40:224–31. https://doi.org/10.1007/s10488-011-0396-2.
Article Google Scholar
Baeza I, Correll CU, Saito E, Amanbekova D, Ramani M, Kapoor S, et al. Frequency, characteristics and Management of Adolescent Inpatient Aggression. J Child Adol Psychop. 2013;23:271–81. https://doi.org/10.1089/cap.2012.0116.
Article Google Scholar
Hottinen A, Välimäki M, Sailas E, Putkonen H, Joffe G, Puukka P, et al. Mechanical restraint in adolescent psychiatry: a Finnish register study. Nord J Psychiat. 2012;67:132–9. https://doi.org/10.3109/08039488.2012.699552.
Article Google Scholar
Beghi M, Peroni F, Gabola P, Rossetti A, Cornaggia CM. Prevalence and risk factors for the use of restraint in psychiatry: a systematic review. Riv Psichiatr. 2013;48:10–22. https://doi.org/10.1708/1228.13611.
Article PubMed Google Scholar
Azeem MW, Aujla A, Rammerth M, Binsfeld G, Jones RB. Effectiveness of six Core strategies based on trauma informed Care in Reducing Seclusions and Restraints at a child and adolescent psychiatric hospital. J Child Adolesc Psychiatric Nurs. 2011;24:11–5. https://doi.org/10.1111/j.1744-6171.2010.00262.x.
Article Google Scholar
Azeem MW, Reddy B, Wudarsky M, Carabetta L, Gregory F, Sarofin M. Restraint reduction at a pediatric psychiatric hospital: a ten-year journey. J Child Adolesc Psychiatric Nurs. 2015;28:180–4. https://doi.org/10.1111/jcap.12127.
Article Google Scholar
Cervantes P, Kuriakose S, Donnelly L, Filton B, Marr M, Okparaeke E, et al. Sustainability of a care pathway for children and adolescents with autism Spectrum disorder on an inpatient psychiatric service. J Autism Dev Disord. 2019;49:3173–80. https://doi.org/10.1007/s10803-019-04029-6.
Article PubMed Google Scholar
Kuriakose S, Filton B, Marr M, Okparaeke E, Cervantes P, Siegel M, et al. Does an autism Spectrum disorder care pathway improve Care for Children and Adolescents with ASD in inpatient psychiatric units? J Autism Dev Disord. 2018;48:4082–9. https://doi.org/10.1007/s10803-018-3666-y.
Article PubMed Google Scholar
Wisdom JP, Wenger D, Robertson D, van Bramer J, Sederer LI. The New York State Office of Mental Health positive alternatives to restraint and seclusion (PARS) project. Psychiatr Serv. 2015;66:851–6. https://doi.org/10.1176/appi.ps.201400279.
Article PubMed Google Scholar
Regan KM, Curtin C, Vorderer L. Paradigm shifts in inpatient psychiatric care of children: approaching child- and family-centered care. J Child Adolesc Psychiatric Nurs. 2017;30:186–94. https://doi.org/10.1111/jcap.12193.
Article Google Scholar
Ercole-Fricke E, Fritz P, Hill LE, Snelders J. Effects of a collaborative problem-solving approach on an inpatient adolescent psychiatric unit. J Child Adolesc Psychiatric Nurs. 2016;29:127–34. https://doi.org/10.1111/jcap.12149.
Article Google Scholar
Sams DP, Garrison D, Bartlett J. Innovative strength-based Care in Child and Adolescent Inpatient Psychiatry. J Child Adolesc Psychiatric Nurs. 2016;29:110–7. https://doi.org/10.1111/jcap.12147.
Article Google Scholar
Bonnell W, Alatishe YA, Hofner A. The effects of a changing culture on a child and adolescent psychiatric inpatient unit. J Can Acad Child Adolesc Psychiatry J De L’académie Can De Psychiatrie De L’enfant Et De L’adolescent. 2014;23:65–9.
Google Scholar
Reynolds EK, Grados MA, Praglowski N, Hankinson JC, Deboard-Lucas R, Goldstein L, et al. Use of modified positive behavioral interventions and supports in a psychiatric inpatient unit for high-risk youths. Psychiatr Serv. 2016;67:570–3. https://doi.org/10.1176/appi.ps.201500039.
Article PubMed Google Scholar
Carlson GA, Chua J, Pan K, et al. Behavior modification is associated with reduced psychotropic medication use in children with aggression in inpatient treatment: a retrospective cohort study. J Am Acad Child Psy. 2019;59:632–641.e4. https://doi.org/10.1016/j.jaac.2019.07.940.
Article Google Scholar
Eblin A. Reducing seclusion and restraints on the inpatient child and adolescent behavioral health unit: a quality improvement study. J Child Adolesc Psychiatric Nurs. 2019;32:122–8. https://doi.org/10.1111/jcap.12248.
Article Google Scholar
Seckman A, Paun O, Heipp B, van Stee M, Keels-Lowe V, Beel F, et al. Evaluation of the use of a sensory room on an adolescent inpatient unit and its impact on restraint and seclusion prevention. J Child Adolesc Psychiatric Nurs. 2017;30:90–7. https://doi.org/10.1111/jcap.12174.
Article Google Scholar
West M, Melvin G, McNamara F, Gordon M. An evaluation of the use and efficacy of a sensory room within an adolescent psychiatric inpatient unit. Aust Occup Ther J. 2017;64:253–63. https://doi.org/10.1111/1440-1630.12358.
Article PubMed Google Scholar
Bobier C, Boon T, Downward M, Loomes B, Mountford H, Swadi H. Pilot investigation of the use and usefulness of a sensory modulation room in a child and adolescent psychiatric inpatient unit. Occup Ther Ment Heal. 2015;31:385–401. https://doi.org/10.1080/0164212x.2015.1076367.
Article Google Scholar
Hallman IS, O’Connor N, Hasenau S, Brady S. Improving the culture of safety on a high-acuity inpatient child/adolescent psychiatric unit by mindfulness-based stress reduction training of staff. J Child Adolesc Psychiatric Nurs. 2014;27:183–9. https://doi.org/10.1111/jcap.12091.
Article Google Scholar
Magnowski SR, Cleveland S. The impact of milieu nurse–client shift assignments on monthly restraint rates on an inpatient child/adolescent psychiatric unit. J Am Psychiat Nurses. 2020;26:86–91. https://doi.org/10.1177/1078390319834358.
Article Google Scholar
Tebbett-Mock AA, Saito E, McGee M, Woloszyn P, Venuti M. Efficacy of dialectical behavior therapy versus treatment as usual for acute-care inpatient adolescents. J Am Acad Child Adolesc Psychiatry. 2020;59:149–56. https://doi.org/10.1016/j.jaac.2019.01.020.
Article PubMed Google Scholar
Hodas GR. Responding to childhood trauma: the promise and practise of trauma informed care. 2006.
LeBel JL, Duxbury JA, Putkonen A, et al. Multinational experiences in reducing and preventing the use of restraint and seclusion. J Psychosoc Nurs Men. 2014;52:22–9. https://doi.org/10.3928/02793695-20140915-01.
Article Google Scholar
Greene R, Winkler J. Collaborative & Proactive Solutions (CPS): a review of research findings in families, schools, and treatment facilities. Clin Child Fam Psych. 2019;22:549–61. https://doi.org/10.1007/s10567-019-00295-z.
Article Google Scholar
Johnson MH, George P, Armstrong MI, Lyman DR, Dougherty RH, Daniels AS, et al. Behavioral Management for Children and Adolescents: assessing the evidence. Psychiatr Serv. 2014;65:580–90. https://doi.org/10.1176/appi.ps.201300253.
Article PubMed Google Scholar
Mohr WK, Martin A, Olson JN, Pumariega AJ, Branca N. Beyond point and level systems: moving toward child-centered programming. Am J Orthop. 2009;79:8–18. https://doi.org/10.1037/a0015375.
Article Google Scholar
Hamrin V, Iennaco J, Olsen D. A review of ecological factors affecting inpatient psychiatric unit violence: implications for relational and unit cultural improvements. Issues Ment Health N. 2009;30:214–26. https://doi.org/10.1080/01612840802701083.
Article Google Scholar
Praissman S. Mindfulness-based stress reduction: a literature review and clinician’s guide. J Am Assoc Nurse Pract. 2008;20:212–6. https://doi.org/10.1111/j.1745-7599.2008.00306.x.
Article Google Scholar
Ollendick TH, Greene RW, Austin KE, Fraire MG, Halldorsdottir T, Allen KB, et al. Parent management training and Collaborative & Proactive Solutions: a randomized control trial for oppositional youth. J Clin Child Adolesc Psych. 2015;45:1–14. https://doi.org/10.1080/15374416.2015.1004681.
Article Google Scholar
Duxbury J, Baker J, Downe S, Jones F, Greenwood P, Thygesen H, et al. Minimising the use of physical restraint in acute mental health services: the outcome of a restraint reduction programme (‘REsTRAIN YOURSELF’). Int J Nurs Stud. 2019;95:40–8. https://doi.org/10.1016/j.ijnurstu.2019.03.016.
Article PubMed Google Scholar
Putkonen A, Kuivalainen S, Louheranta O, Repo-Tiihonen E, Ryynänen OP, Kautiainen H, et al. Cluster-randomized controlled trial of reducing seclusion and restraint in secured Care of men with Schizophrenia. Psychiatr Serv. 2013;64:850–5. https://doi.org/10.1176/appi.ps.201200393.
Article PubMed Google Scholar
Drucker PF. The practice of management. Burlington: Butterworth-Heinemann (Elsevier); 1955.
Google Scholar
Bryson SA, Gauvin E, Jamieson A, Rathgeber M, Faulkner-Gibson L, Bell S, et al. What are effective strategies for implementing trauma-informed care in youth inpatient psychiatric and residential treatment settings? A realist systematic review. Int J Ment Health Sy. 2017;11:36. https://doi.org/10.1186/s13033-017-0137-3.
Article Google Scholar
Mittelmark MB, Sagy S, Eriksson M, et al. The handbook of Salutogenesis. 2017.
Rotter JB. Generalized expectancies for internal versus external control of reinforcement. Psychol Monographs. 1966;80(1):1–28.
CAS Article Google Scholar
Antonovsky A. Health, stress and coping. San Fransisco: Jossey-bass; 1979.
Google Scholar
Schimmelmann BG. Seclusion and restraints: a neglected area of research in child and adolescent psychiatry? Eur Child Adolesc Psychiatry. 2011;20:219–20. https://doi.org/10.1007/s00787-011-0170-8.
Article PubMed Google Scholar

Page 2

From: Methods and Strategies for Reducing Seclusion and Restraint in Child and Adolescent Psychiatric Inpatient Care

Author (year)	Intervention – Group 1	Design	Setting	Context	Outcome
Azeem et al. (2015) [33]	Trauma-informed, strength-based care. Focus on primary prevention. The interventions aligned with the Six Core Strategies: Leadership towards org change Use of data to inform practice Workforce development R/S reduction tools Patient and family inclusion Debriefing	Descriptive article of a 10-year quality improvement project 2005–2014. Pre-post measures. Total number of admissions: 178 (2005), 163 (2014).	U.S. 52-bed Pediatric Psychiatric Hospital. Four units.	Youths usually presented with severe aggression and/or self-injurious behaviors, who often required multiple restraints (physical and/or mechanical) at other inpatient settings prior to admission. A large number had experienced repetitive trauma.	Statistical significance not mentioned 100% decrease in mechanical restraints: - 485 in 2005 - 0 in 2014 88% decrease in physical restraints: - 3033 in 2005 - 379 in 2014
Azeem et al. (2011) [32]	A previous evaluation of the Six Core Strategies at the same facility.	Retrospective. Based on about 33 months data collection. Pre-post measures. 458 youths admitted between July 2004–March 2007. Training in Six Core Strategies began March 2005.	U.S. 26-bed child and adolescent unit divided into three units. Patients 6–17 years old.	Patients with disruptive behavior disorders, mood disorders, reactive attachment disorder, substance abuse, pervasive developmental disorder, mental retardation.	Statistical significance not mentioned Pre Six Core Strategies: 93 S/R - 73 seclusions - 20 restraints Post Six Core Strategies: 31 S/R - 6 seclusions - 25 restraints
Wisdom et al. (2015) [36]	Six Core Strategies: Leadership towards org change. Use of data to inform practice. Workforce development. S/R reduction tools. Patient and family inclusion. Debriefing. Based on trauma-informed care.	Descriptive article of the implementation of Six Core Strategies in three children’s mental health facilities 2007–2011. Pre-post measures.	U.S. 1. Children’s psychiatric center 2. Children’s residential treatment facility 3. Private psychiatric hospital for children and adolescents. Patients up to 17 years old.	High utilization of restrictive interventions. Majority of patients with ADHD, conduct disorders or mood disorders.	Statistically significant decrease in use of S/R in all three facilities: 1. 62% (from 67 to 25 S/R per 1000 client days, p = .019) 2. 86% (from 63 to 7 S/R per 1000 client days, p = .001) 3. 69% (from 99 to 13 S/R per 1000 client days, p = .007)
Author (year)	Intervention – Group 2	Design	Setting	Context	Outcome
Regan et al. (2017) [37]	CFCC including CPS and trauma-informed approach. CFCC is a philosophy of care based on treating people with dignity and respect, sharing information with patients/families, and supporting them to build on their strengths and independence and to collaborate in policy/program development.	Descriptive article of an inpatient unit that implemented the principles of CFCC, including CPS and a trauma-informed approach. Pre-post measures.	U.S. 13-bed inpatient child psychiatric unit. Patients 2–12 years old.	Patients with PTSD, anxiety disorders, ADHD, mood disorders, learning disorder, psychotic disorders, pervasive mental developmental disorders. Pre CFCC: The unit used a behaviorally oriented level system where children earned freedom and privileges based on their ability to conform to the rules. Misbehavior led to time-outs and high levels of S/R (twice the state average for child units). Staff unhappy, felt unappreciated.	No mechanical restraints since 2001. No locked-door seclusions or chemical restraints since 2002. 2003 reduction in brief physical holds (under 5 min) from over 100 to 10 or less/months. Significant decrease in staff injuries (P value not mentioned). Reduced staff-turnover. Increased job satisfaction.
Ercole-Fricke et al. (2016) [38]	CPS: Cognitive behavioral approach focused on adult-child decision making. Conceptualizes maladaptive behaviors as the byproduct of lagging cognitive skills. The CPS was modified to suit the population and the “short-stay” environment.	Quantitative, comparative, quasi-experimental design. Retrospective. Compare behavioral outcomes and staff perceptions. Pre-post design including all discharged patients 2008 (pre) and 2012 (post)	U.S. Adolescent acute psychiatric inpatient unit. Patients 12–17 years old.	Pre CPS: The unit used a behavioral model where misbehavior entailed point reduction and loss of privileges, time-outs, or open seclusions.	Statistically significant decrease in: - Punitive strategies and techniques (open-door seclusion decreased from 61 events in 2008 to 0 events in 2012) (p = .001) - Behaviors related to the need for restraints and self-inflicted injury (p = .005) - Need for security staff involvement (p = .001) No significant decrease in restraint episodes but continued to trend downward: 25 restraint episodes 2008, vs 17 in 2012.
Sams et al. (2016) [39]	Strength-Based Care Exploring patients’ goals, strengths, relationships, skills, and family communication. Different interventions: - CPS - Mindfulness groups - DBT group - Animal assisted therapy - ACT - Narrative therapy - Family Movie Therapy	Descriptive article of an inpatient unit’s integration of a strength-based approach with a traditional, medical model of psychiatric care. The unit implemented CPS in 2006.	U.S. 24-bed acute child and adolescent psychiatric inpatient unit. Patients 5–18 years old.	Pre strength-based care: The unit used a behavioral approach (rewards and consequences based on patients’ behavior) and medication management.	Statistical significance not mentioned. 75% reduction in total hours of seclusion and restraint noted over the course of 1-year following the implementation of the strength-based program revisions. Increase in patient, family, and staff satisfaction.
Weldon Bonnell et al. (2014) [40]	External reviewers assessed the unit June 2009 ➔ - Restructuring unit staffing - Regular debriefing sessions - Staff learning CPS - Broad representation of multidisciplinary team members	Retrospective. Pre-post quality assurance assessment, comparing data from Jan 2008-Dec 2009 (pre) to data from Jan-Dec 2010 (post). Admitted patients: 85 in 2008–2009 (pre) 39 in 2010 (post)	Canada. 7-bed child and adolescent inpatient psychiatric facility. Mean patient age 14–15 years.	Majority of patients with mood disorders, ADHD, adjustment disorder, anxiety disorder, psychotic disorder, substance-related disorder. 2008–2009 marked escalation in physical aggression, constant observation, security, staff sick leave.	Statistically significant decrease in constant observation (p = .002). Not statistically significant decrease in seclusion: Mean number of min patients spent in seclusion each month decreased from 49.8 (pre) to 16.7 min (post). Physical restraints were not used at all during the study period. Not statistically significant decrease in incidents (verbal/physical aggression, errors by staff, accidents) and security.
Author (year)	Intervention – Group 3	Design	Setting	Context	Outcome
Reynolds (2016) [41]	M-PBIS: 1. Universal prevention practices. Positively worded behavioral expectations. Rewards for positive behavior. 5:1 positive-negative adult-child interaction ratio. Feedback to staff. 2. Targeted interventions 3. Intensive individualized interventions	Naturalistic, prospective 4-year study Jan 2010-June 2014. 726 admissions (pre) 759 admissions (post)	U.S. 12-bed high-risk youth psychiatric inpatient unit. Mean patient age 13.18 years.	Acute care for youth in crisis, typically involving threats to harm self or others.	S/R events decreased from 543 to 253. Significant decrease in: - Mean seclusion rate (from 1.49 to 0.73 per 1000 patient hours, p = .02) - Percentage of patients placed in S/R (from 19.6% to 13.4%, p = .001) - Mean duration of S/R (from 20.43 to 8.18 min/episode, p = .001) - Percentage of patients who received PRN for agitation (from 42% to 30%, p = .001) Seclusions included both open-door and locked-door seclusions
Carlson et al. (2020) [42]	Pre: BMP with behavioral classroom management, parent training, point system, social reinforcement, time-out. Post: BMP-absent – “No comprehensive treatment approach”. Verbal de-escalation or distraction, teaching coping skills, point system, no limit setting.	Retrospective cohort study. 5 cohorts over 10 years 2008–2018. Total of 661 admissions from the 5 cohorts. Evaluated PRN for agitation and S/R/H.	U.S. 10-bed children’s inpatient unit. Patients 5–12 years old.	77% of the patients admitted for aggression. High rates of ADHD, ODD.	BMP-absent children had significantly higher rates of: - S/R/H (mean value increased from 17 to 65 per 1000 client days, p < .001). - PRN use (mean value increased from 163 to 483 per 1000 client-days) (p < .001)
Eblin (2019) [43]	Decision-making algorithm for initiation of S/R. Behavioral modification plans for patients at risk for S/R. Patient debriefing after S/R.	Quality improvement study. Post-implementation, data collection 3 months Sept-Nov 2018.	U.S. 14-bed inpatient child and adolescent behavioral health unit. Patients 6–17 years old.	Patients with mood disorders, anxiety disorders, neurodevelopmental and eating disorders, trauma, disruptive disorders, impulse-control, and conduct disorders.	Statistical significance not mentioned. 55% decrease in total S/R rates (from 0.031 to 0.0137 per 1000 client days) (62% decrease in seclusions, 18% decrease in restraints, 29% decline in mean duration of time spent in S/R from 69 to 49 min per episode)
Author (year)	Intervention – Group 4	Design	Setting	Context	Outcome
Seckman et al. (2017) [44]	Sensory room 1:1 patient-staff intervention. Staff training included in the intervention.	Plan-do-check-act (PDCA) model with pre-post measures. S/R rate measured 6 months pre and 6 months post sensory room initiation.	U.S. 20-bed adolescent psychiatric inpatient unit. Patients 12–17 years old.	Patients with emotional and behavioral disorders such as mood disorders, adjustment disorders, psychotic disorders, conduct or oppositional defiant disorders, PTSD, autism.	Statistical significance not mentioned. 26.5% reduction in restraint and 32.8% reduction in seclusion incidents. 16.4% frequency reduction in patient aggression. Increase in seclusion duration by 17%, and restraint duration by 31%.
West et al. (2017) [45]	Sensory room 1:1 patient-staff intervention. Staff training included in the intervention.	Open trial. Pre-post design. Retrospective review of medical files. Evaluation period June 2011-Oct 2012. Sample: 56 sensory room users and 56 non-users.	Australia. 20-bed adolescent psychiatric inpatient unit. Patients 12–18 years old.	Patients with mood or anxiety disorders, trauma, personality disorders, psychotic or disruptive disorders, neurodevelopmental disorders, substance-related and eating disorders.	Statistically significant distress reduction following sensory room use (p < .001) Greatest distress reduction among adolescents with a history of aggression (p < .01) No significant difference in seclusion rates.
Bobier et al. (2015) [46]	Sensory room 1:1 patient-staff intervention. Staff training included in the intervention.	Pilot investigation. Evaluation 6 months before, during (Nov 2012-May 2013) and 6 months after introduction of sensory room.	New Zealand. 16-bed specialist mental health facility. Patients up to 18 years old.	Patients with mood or anxiety disorders, trauma, psychotic disorders, disruptive or neurodevelopmental disorders, who could not be treated or managed in other mental health care settings. The unit provided intensive treatment and specialist assessment.	Statistically significant decrease in seclusion episodes (from 73 to 26 or 3.2 to 1.8 per 100 treatment days, p < .001) Full restraint decreased slightly. Statistically significant increase in partial restraints (from 18 to 44 p < .001) (Full vs partial restraint not defined.)
Hallman et al. (2014) [47]	Brief (8 days) MBSR-training of staff: - Waking up from autopilot - Body scanning - Refraining from judgement - Breathing as a stress reliever - Befriending yourself	One-group repeated measure design. Evaluation before MBSR training and 2 months later. 12 participants completed the MBSR. Scales used for evaluation: - Perceived Stress Scale - Toronto Mindfulness Scale	U.S. 14-bed child and adolescent psychiatric acute care unit.	High level of patient acuity. Typical diagnoses included major depression with suicidal ideation, psychosis, and autism spectrum disorders, among others.	Statistically significant stress reduction and increased mindfulness (p < .05) among participating staff post-MBSR. Not statistically significant decrease in S/R episodes (from 30 to 10), decrease in 1:1 (209 to 183) and 2:1 (46 to 0) staff per patient episodes.
Rae Magnowski and Cleveland (2020) [48]	Change in nurse staffing structures: One “milieu nurse” responsible for providing structure, safety, early identification of crisis, consistency, empathy, PRNs, updating client treatment plans, focus on individual client needs. Combining cognitive milieu therapy and nurse presence. No additional resources/costs.	Quantitative, retrospective, comparative project design. Sample: All admitted patients (758) between Jan-May 2016 and Jan-May 2017 who were physically or mechanically restrained (57).	U.S. 20-bed child and adolescent psychiatric inpatient unit. Patients 5–18 years old.	Patients with anxiety or mood disorders, obsessive-compulsive or behavioral disorders, among others. Pre milieu nurse: Average monthly restraint rate: 78.4 per 1000 client days 2015, 54.2 per 1000 client days Jan-Sept 2016. High restraint use lead to frequent staff injuries, restraint recidivism and staff turnover.	Statistically significant decrease in average monthly restraint rate: 72.9 (median 61.2) per 1000 client days during control variable, vs 7.5 (median 6.8) per 1000 client days during the intervention (p = .004).
Author (year)	Intervention – Group 5	Design	Setting	Context	Outcome
Kuriakose et al. (2018) [35] Cervantes et al. (2019) [34]	ASD-CP - Input from caregivers (communication skills, early warning signs of agitation, activity preferences) - Structured schedule, visual support - Teaching and reinforcing patient coping skills - Training staff in features of ASD Evaluated the stability of the ASD-CP study outcomes (described above)	Pre-post design. Data collected Jan 2014-June 2015 and July 2015-Dec 2016. Sample included 74 children with ASD, low language level and/or high disruptive behavior to the degree that patient needed 1:1 staffing. First time admissions. 18-month follow-up Jan 2017-June 2018 compared to the 18-month initial evaluation and 18-month pre-ASD-CP.	U.S. Pediatric psychiatric emergency unit with a brief stabilization unit and 3 inpatient units with a total of 45 beds. Patients 4–17 years old.		Significantly smaller proportion of children experiencing a hold/restraint after the implementation (pre-ASD-CP 38.8%, post ASD-CP 26.3%, p = .039) Not statistically significant, but clinically relevant decrease in the number of holds/restraints (77%), number of intramuscular injections. Significant (p < .05) decrease in: -Total number of holds/restraints across settings - Total intramuscular medication administration - Proportion of children experiencing any hold/restraint.
Author (year)	Intervention – Group 6	Design	Setting	Context	Outcome
Tebbett-Mock et al. (2020) [49]	DBT - DBT coaching - Token economy - Chain and solution analyses for egregious behaviors - Therapeutic environment, resources for coping skills - DBT vocabulary - DBT skills groups - Individual and family psychotherapy - Psychoeducation - Staff training	Retrospective chart review for adolescents receiving inpatient DBT (n = 425) and a historical control group treated on the same unit before DBT (n = 376), receiving treatment as usual (the same seasonal span the year before).	U.S. Coeducational, acute-care inpatient unit within a private psychiatric hospital. Patients 12–17 years old.	Patients with mood disorders, schizophrenia spectrum disorders, anxiety disorders, trauma and stress-related disorders, disruptive disorders, and ADHD, among others. Patients admitted because of imminent safety concerns, including danger to self or others.	Statistically significant decrease in DBT-group vs TAU-group: Number of restraints (Mean 0.14 vs 0.16, p = .01) Not statistically significant decline in number of seclusions.

Interventions designed to reduce the use of seclusions/restraints in child and adolescent psychiatric inpatient care
ACT Acceptance and Commitment Therapy, ASD-CP Autism Spectrum Disorder Care Pathway, BMP Behavior Modification Program, CFCC Child- and Family-Centered Care, CPS Collaborative & Proactive Solutions, DBT Dialectic Behavior Therapy, M-PBIS A modified version of Positive Behavioral Interventions and Supports, MBSR Mindfulness-Based Stress Reduction Training, Monthly restraint rate per 1000 client days, Total monthly restraint events, divided by total monthly client days, multiplied by 1000, PRN Pro re nata or as needed medication, S/R Seclusions/restraints, S/R/H Seclusions/restraints/physical holds, Sensory room, A specialized room where sensory equipment can be used to help promote emotion regulation, Six Core Strategies, 6CS-National Association of State Mental Health Program Directors