Author (year), title | TIC approach | Design | Context | Outcome and implications | ||
---|---|---|---|---|---|---|
Azeem, Aujla, Rammerth, Binsfield, & Jones (2011) Effectiveness of Six Core Strategies based on Trauma Informed care in reducing seclusions and restraints at a child and adolescent psychiatric hospital | 6 core strategies: (6CS-National Association of State Mental Health Program Directors-NASMHPD) Six core strategies are: Leadership Toward Org Change, Use of Data to Inform Practice, Youth & Family Inclusion, Workforce Development, S/R Prevention Tools, Debriefing | Design retrospective chart review of seclusion and restraint data for youths admitted (n = 458) July 2004-March 2007 (implementation of 6CS in final 6 mos) Sample examined S/R episodes for 458 youth (276 females/182 males) Measures age, race, gender, admission dx, LOS, admission status, seclusion, restraint episodes Limitations possible intervening variable: concurrent Dialectical Behavior staff training | 26-bed adolescent unit (9-bed adol girl unit; 9-bed adol boy unit; 8-bed unit boys & girls, aged 6-12) External factors: Centers for Medicare and Medicaid Svcs, Joint Commission issued guidelines regarding use of seclusion and restraint | Marked reduction in use of seclusion and restraint—from 93 episodes (73 seclusions/20 restraints pre-6CS) to 31 episodes (6 seclusions/25 restraints) following implementation of Six Core Strategies Results achieved quickly and maintained over a period of time Emphasized: Leadership commitment Workforce transformation Outcome orientation | ||
Brown, Baker, & Wilcox (2012) Risking Connection Trauma Training: A Pathway Toward Trauma-informed Care in Child Congregate Settings | Risking Connection (RC) trauma training: “The RC training teaches a trauma framework which asserts that childhood trauma…derail the trajectory of development in three critical areas—attachment, brain and nervous system, and self-capacities or self-regulation skills.” | Design: Study examined change in knowledge, beliefs, and self-reported behaviors pre- and post-Risking Connection (RC) training Sample: 261 child congregate care trainees over 17 months in 2008-2009 Measures: Risking Connection Curriculum Assessment, Trauma-informed Belief Measure, Staff Behavior in Milieu Measure Limitations: No observational data | Five youth congregate care agencies (residential, foster, etc.) serving children and youth with serious emotional and psychiatric problems External factors: NASMHPD’s & SAMHSA’s National Child Traumatic Stress Network (NCTSN) promotion of TIC in residential care | Three post-training measures indicated increase in (a) knowledge, (b) increase in beliefs favorable for TIC, and c) increase in self-report of TIC behavior Staff trained as trainers showed maintenance of positive changes in knowledge, beliefs, and behaviors Emphasized: Model selection Workforce transformation | ||
Caldwell, et al. (2014) Successful Seclusion and Restraint Prevention Efforts in Child & Adolescent Programs | 6 Core Strategies: (6CS-National Association of State Mental Health Program Directors-NASMHPD) Six Core Strategies are: Leadership Toward Org Change, Use of Data to Inform Practice, Youth & Family Inclusion, Workforce Development, S/R Prevention Tools, Debriefing | Design: Three site study of 6CS implementation. Qualitative description of 6CS implementation features + outcomes. Sample: Inpatient psychiatric facility with 52 youth beds; secure residential facility with 84 secure beds +48 therapeutic group home beds Measures: Mechanical & physical restraints, seclusions, focus groups with youth Limitations: Article profiles 3 different facilities’ implementation experiences. Descriptive; no methods reported | Site #1: Children’s Center with 52 youth psychiatric beds Site #2: Secure residential facility for youth with serious emotional disturbance Site #3: State of CT largest intensive residential program 100 male youth beds External factors: Part of larger national Building Bridges initiative, which sought to integrate the principles of trauma-informed care in residential and community settings | In Site #1: Between 2005 and 2013, mechanical restraints were 100% eliminated; restraint was reduced by 87%; seclusion reduced by 67% In Site #2: Restraints reduced from 49 in January 2012 to 1 in 2014 In Site #3: Restraint reduced by 75% between 2011 and 2013 Emphasized: Leadership commitment Workforce transformation Community inclusion | ||
Deveau & Leich (2014) The impact of restraint reduction meetings on the use of restrictive physical interventions in English residential service for children and young people | Post Restraint Reduction Meetings (RRM): RRM are routine staff meetings to analyze/evaluate Restrictive Physical Intervention use; after initial training, they ideally occur within 72 h of each restraint episode | Design: Longitudinal pre-post intervention design examined impact of RRM on frequency of restraint Sample: 10 residential/Children’s Home settings Measures: Type, restrictiveness, length of time, & frequency of Restrictive Physical Interventions (RPI) Limitations: Intervention fidelity not monitored; confounding variables not assessed | UK children’s homes & residential full-time homes for looked after children and children with behavioral & emotional disturbance (BESD) External factors: Seclusion and restraint reduction measures in U.S. | Reduced mean frequency of Restrictive Physical Interventions pre- to post-intervention by 31.6% Greatest reduction in most restrictive supine floor restraints Emphasized: Workforce transformation | ||
Goetz & Trujillo (2012) A change in culture: Violence prevention in an acute behavioral health setting | Patient-Focused Intervention (PFI) Model: Nine component model which includes TIC, aggression management, code event review, leadership involvement, quality feedback, recovery orientation, patient assessment, education, collaboration | Design: Pre-posttest, nonequivalent groups Sample: Adults & adolescents admitted during 5-year period from 2005–2010 Measures: S/R data, Code Gray episode data, staff injuries; staff safety survey Limitations: Gross reduction in Code Grey episodes reported but shown only in minutes of restraint usage | 80 bed facility including two adol programs—19-bed adol female tx center; 15-bed acute psychiatric facility for youth 12–18 years old External factors: 2003 manual on reducing violence, & coercive measures by American Psychiatric Assn (APA), American Psychiatric Nurses Assn (APNA), National Assn of Psychiatric Health Systems (NAPHS), & American Hospital Assn (AHA) | Staff injuries decreased by 48% in first year of implementation Seclusion and restraint rates were reduced by 50%; 75% reduction in hours of S/R in first 2 years One full year after implementation, staff survey data showed improvement in 5 of 10 areas, including staff perception of aggression mgmt. program Emphasized: Leadership commitment Outcome orientation Shared maintenance | ||
Greene, Ablon, & Martin (2006) Use of collaborative problem solving to reduce seclusion and restraint in child and adolescent inpatient units | Collaborative Problem Solving (CPS) Cognitive behavioral approach focused on adult-child decision making rather than teaching or motivating children to comply with adult directives | Design: Pretest-post- test; nonequivalent groups Sample: 100 children, mean age 9.14 years, were admitted during study period; 80% significant trauma histories; 95% admitted for severe out of control behavior Measures: Restraint episodes, staff and patient injuries Limitations: Could not control for intervening variables; generalizability may be affected by selecting unit with high pre-training # of S/R episodes | U.S. 13 bed, locked in-patient child psychiatry unit in Massachusetts children serving ages 3–14 years with average stay of 14 days External factors: Evidence of fatalities and other adverse outcomes following S/R use | Reduced S/R from 281 episodes recorded 9 mo pre-training to 1 incident recorded 15 mo post-training Reduced staff and patient injuries from an average of 10.8 per month to 3.3. per month Emphasized: Model selection Workforce transformation Outcome orientation Shared maintenance | ||
Greenwald, Siradas, Schmitt, Reslan, Fierle, & Sande (2012) Implementing trauma-informed treatment for youth in a residential facility: First-year outcomes | Fairy Tale Model: (a) Designed for children, teens, & adults; (b) strong family and community component; (c) incorporates milieu treatment; (d) Included staff education and case mgmt.; (e) scripted interventions including each phase accompanied by telling of Fairy Tale; (f) model encouraged adaptation to agency’s existing culture | Sample: Youth ages 10-21 in facility between 2008-2009 (n = 53) Measures: PTSD sx, presenting problems, time to discharge, type of discharge H1: ↓ PTSD sx H2: ↓Primary presenting probs H3: ↓ Time in residential care H4: Rate of +discharges Limitations: Missing data on PTSD symptoms; delivery of individual therapy was uneven; no treatment fidelity measures; no comparison group due to AB design | Residential treatment facility serving children and youth aged 10–21 External factors: Western NY agency’s desire to address trauma component of clients’ problems. Positive Peer Culture, an evidence informed peer support model, was in place prior to implementation of trauma-informed treatment | Study found a 34% increase in problem reduction; 39% reduction in treatment time, double the rate of positive discharges Emphasized: Model selection Workforce transformation Outcome orientation | ||
Hodgdon, Kinniburgh, Gabowitz, Blaustein, & Spinazzola (2013) Development and implementation of trauma-informed programming in youth residential treatment centers using the ARC framework | Attachment, Regulation, and Competency model: Framework for youth with complex trauma. Nine core building blocks: (1) Caregiver affect mgmt.; (2) attunement; (3) consistent response; (4) routines & rituals; (5) affect identification; (6) modulation; (7) affect expression; (8) executive functions; & (9) self-development Included elements of DBT | Sample: Young women aged 12–22 in two residential settings (n = 126) Measures: CBCL; UCLA PTSD Reaction Index; physical restraints Limitations: Statistically significant reductions in PTSD symptoms but modest clinical improvement, possibly due to uneven delivery of ARC model across programs | Two Massachusetts residential programs for young women ages 12–22, including an Intensive Residential Treatment Program and a residential school External factors Implementation of ARC model for this study was based on Fixsen et al. (2005) implementation stages. Funded by SAMSHA as part of National Child Traumatic Stress Initiative | Significant decrease in overall PTSD symptoms, and decrease in aggression, anxiety, attention problems, rule breaking, depression, thought problems, and somatic complaints based on CBCL scores There was a 50% reduction of use of restraint in the first 6 months and the trend continued downward ARC did not create any statistical difference in rates of PTSD numbing and avoidance Emphasized Leadership commitment Workforce transformation Outcome orientation | ||
Holstead, Lamond, Dalton, Horne, & Crick (2010) Restraint reduction in children’s residential treatment facilities: Implementation at Damar Services | Resource Management Team focused on reducing restraint use. Training in verbal de-escalation. Each staff member experienced a restraint as part of training, and staff heard from patients who had experienced restraint. In 2008, agency declared itself restraint free | Sample: 215 youth with behavioral and developmental problems Measures: # of restraint, length of restraint, staff injury, client injury Limitations: Insufficient methodological information | Private non-profit residential setting for adults and children (N = 215) in Indianapolis, IN. Serves children with behavioral and developmental problems and many failed placements. Children and youth served have had as many as 30 failed prior placements | Reduced restraints from 5000 in 2004 (56 per child) to 786 in 2008 (3.66 restraints per child). Minutes in restraint decreased from 21 min avg to 12 min avg Staff injury rate decreased from .0199 to .0159 per person between 2004 and 2008. Client injury rate decreased from 307 to 145, or 3.49 injuries from restraint to .68 injuries per person Emphasized Leadership commitment Workforce transformation | ||
Hummer, Dollard, Robst, & Armstrong (2010) | Creating Trauma-informed Care Environments Curriculum | Sample: Youth with emotional and behavioral issues Measures: 75 interviews, 33 clinical record reviews, 12 treatment team observations, and reviews of policy and procedure manuals Limitations: Insufficient methodological information | Eight Medicaid-funded residential settings in Florida including a statewide inpatient psychiatric program, therapeutic foster care, and therapeutic group care. External factors: High rate of dependent children and youth in out of home mental health treatment programs and recognition of need for TIC in Florida | The sites studied were found to have varying levels of TIC in their programming. The most successful demonstrated organizational readiness; competent trauma-informed organizational, clinical, and milieu practices; & youth and family engagement in TIC Emphasized: Leadership commitment Model selection Workforce transformation Community inclusion | ||
Martin, Krieg, Esposito, Stubbe, & Cardona (2008) Reduction of restraint and seclusion through collaborative problem solving: A 5-year prospective inpatient study | Collaborative Problem Solving (CPS) Sees child aggressive bx stemming from lagging cognitive skills in the areas: executive functioning, language processing, emotion regulation, cognitive flexibility, and social skills | Prospective study Sample: 755 children hospitalized between 2003-2007 Measures: Seclusion, restraint, duration, staff injuries Limitations: Unable to pinpoint variables responsible for S/R reduction; no empirical measures of aggression; no info on psychotropic meds; no systematic data on child injuries; client injury data limited; no objective measures of adherence to CPS; no assessment of staff, children or family perceptions | Fifteen-bed psychiatric inpatient unit for school age children External factors: Federal legislation to reduce restrictive interventions; local investigations into deaths related to restraint and seclusion; condemnation of S/R by all major child serving professional organizations | 37.6 fold reduction in restraint and a 3.2 fold reduction in seclusion. Mean duration reduced from mean 27 to mean 21 min per episode Black and Hispanic children were 4x and 50% more likely than White children, respectively, to be restrained or secluded. IQ may have been a confounder Restraint reduction was a more achievable initial target for improvement. Changes maintained despite acuity Emphasized: Community inclusion Model selection | ||
Rivard, Bloom, McCorkle, Abramovitz (2005) Implementing a trauma recovery framework for youths in residential treatment | Sanctuary Model: Treatment environment is core modality for modeling healthy relationships among community members. Uses SELF framework (Safety, Emotional mgmt., Loss, Future) Aimed at reducing complex trauma sx among youth in residential settings | Comparison group design, measurement intake, discharge, 6 months Sample: Youth sample (N = 158) Measures: youth demographics, COPES; CBCL, TSC-Children; Rosenberg Self Esteem Scale, Nowicki-Strickland Locus of Control Scale; Inventory of Parent and Peer Attachment; Youth Coping Index; Social Problem Solving Questionnaire Limitations use of 3- month youth self-report measures which may not be sensitive to change | Sixteen residential treatment units for adolescents: 4 self-selected; 4 were randomly assigned; 8 units usual services comparison group External factors: Large nonprofit mental health and social service agency seeking to better meet trauma needs of children and families it serves—including children with serious emotional disturbance | Sanctuary units outperformed comparison units on COPES scale (see Mechanisms for Improvement, left) Few changes observed in youth outcomes, but Sanctuary unit youths showed ↓ verbal aggression and ↑sense of control over their lives compared to service as usual youths Emphasized Workforce transformation Outcome orientation | ||
Russell, Maher, Dorrell, Pitcher, & Henderson (2009) A comparison between Devereux’s safe and positive approaches training curricula in the reduction of injury and restraint | Safe and Positive Approaches (SPA): Comprehensive, multi-component crisis intervention and intervention training program designed to equip staff with knowledge and ability to safely and effectively prevent, de-escalate, and manage crisis situations | Sample: Six programs over 6 years; n = 6361 Data analyzed by quarter rather than unique child Measures: All restraint rate, rate of prone restraints, youth restraint related injuries; staff restraint related injuries Limitations: Variability in definitions regarding restraints and types of restraints and thus data inconsistency | Six residential programs providing treatment to children & youth w/at-risk behaviors, emotional and behavioral disorders, involvement in the criminal justice system, and intellectual and developmental disabilities External factors Regulatory policies at center, state, and federal levels | Restraint rates, prone restraint rates, youth injury rates, staff injury rates lower for SPA users than for comparison group Emphasized Model selection Workforce transformation |