Seclusion

The Child Advocate

Seclusion of Children in Inpatient Treatment

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Jimmy O. Ibikunle, M.D., Paul A. Kettl, M.D., Penn State College of Medicine, Department of Psychiatry, MC H073, 500 University Drive, Hershey, PA 17033, AACAP, October 2000

Objective: Earlier studies¹ agree on utilizing seclusion to ensure safety but are divided on its use as a “therapeutic” intervention.⁴ This study analyzes patient variables related to use of seclusion in children 2 to 14 years-of-age (mean 9.04 years) on a 16-bed university hospital child inpatient unit.

Methods: Consecutive admissions to our unit in 1999 were divided into two groups: the first 137 children who required seclusion and the first 138 who did not. Repeat admissions were excluded. The two groups were compared on demographic, diagnostic, and treatment variables: 1) age; 2) sex; 3) prior psychiatric admission; 4) length of stay; 5) presence of an identified learning problem; 6) number of discharge medications; 7) recent history of aggression; 8) discharge recommendation of intensive in-school and/or in-home services; 9) types of medication; and 10) diagnosis based on DSM-IV criteria. A structured report was logged for each seclusion. This includes date, indication, duration, and nature of seclusion in addition to physician involvement. For the purpose of this study, a learning problem is defined as one of the following: i) a standard score of 80 or less on one or more Woodstock-Johnson Tests of Achievement, ii) a diagnosed learning disability, or iii) a full scale Intelligence Quotient (IQ) score of 85 or less (Pennsylvania Department of Education regards IQ scores 80-85 as borderline intellectual functioning). The Stanford-Binet Intelligence Scale and Weschler Intelligence Scale for Children (WISC-III) were used in ii) and iii). The diagnoses were divided into five categories for statistical analysis: a) attention-deficit/hyperactivity disorder, oppositional defiant disorder, and bipolar disorder, b) depressive disorders, anxiety disorders, and posttraumatic stress disorder, c) pervasive developmental disorders and psychotic disorders, d) reactive attachment disorder, relational problems, and adjustment disorders, and e) other diagnoses. Comparisons were carried out by means of student’s t-test and chi-square analysis.

Results: Male : female ratio is 3.5:1. The means for age, length of stay, and number of discharge medications are higher in children who required seclusion. Indications for seclusion in this sample are threat to self (24.8%) or others (60.6%), and “out-of-control” behavior (86.1%). Mean duration is 46.5 minutes. Unlocked seclusion is more common (71.5%), and repeat seclusion was required in 57.7%. Most occurred (84.7%) in the first half of admission. Children who required seclusion (versus those who did not) are significantly (p<0.05) more likely to 1) be older; 2) have diagnoses of attention-deficit/hyperactivity disorder, oppositional defiant disorder, and bipolar disorder; 3) have a prior psychiatric admission; 4) have a longer length of stay; 5) have an identified learning problem; 6) be treated with a stimulant, mood stabilizer, or antipsychotic; and 7) be on more medications at discharge. Sex, recent history of aggression, and intensity of follow-up recommendations were not significant.

Conclusion: Children who require seclusion are treated with more medications and stay longer in hospital. They also tend to be older³ and have required previous psychiatric hospitalization. These results suggest that in the treatment of sicker children with impulse control difficulties, seclusion use is more likely. Adjustment difficulties may be involved in timing of seclusion and in children with learning problems. Therapeutic options² to seclusion use may be more beneficial in the first half of admission. The lack of association of recent history of aggression, sex, and intensity of follow-up recommendations is noteworthy. Though seclusion of children remains a controversial topic, it appears to have a crucial role in inpatient treatment.

References:

1. Antoinette T, Iyenar S, Puig-Antich J. Is locked seclusion necessary in children under the age of 14? American Journal of Psychiatry, 1990;147:1283-1289.

2. Kalogjeri IJ, Watson WN, Meyer AD. Impact of therapeutic management on use of seclusion and restraint in disruptive adolescent inpatients. Hospital and Community Psychiatry, 1980;40:280-285.

3. Earle KA, Forquer SL. Use of seclusion with children and adolescents in public psychiatric hospitals. American Journal of Orthopsychiatry, 1995;65:238-244.

4. Fassler D, Cotton N. A national survey on the use of seclusion in psychiatric treatment of children. Hospital and Community Psychiatry, 1992;43:370-374.

Additional information from the author at docibik@netscape.net

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