Registration of aggressive incidents in an adolescent forensic psychiatric unit and implications for further practice.

Although aggression is part of daily life in psychiatric units for adolescents, empirical data on its prevalence are sparse. Only few studies have described prevalence of aggressive incidents in adolescent psychiatric wards, and data in forensic psychiatric care are even more limited. Available studies reported high prevalence rates of aggression, ranging from 0.4 to 2.4 incidents of aggression per day across (forensic) child and adolescent psychiatric units. Between 27 and 78 % of all admitted youth committed an aggressive act. In this study, we collected systematically registered data of all aggressive incidents from the first 2 years (2010-2012) on a newly established forensic adolescent psychiatric unit, which used a formal aggression management program embedded in the social competence model, which is based on early intervention in the 'chain of behavior' to prevent any further escalation. The inclusion of also minor aggressive incidents is unique in the literature and the clinical relevance is highlighted. A mean of one incident a day took place, with each adolescent involved in at least one incident. Notably, 1.7 aggressive incidents per month made seclusion of restraint use necessary. Based on the social competence theory, the aggression management model suggests intervening early in the cascade of aggression, in order to prevent further escalation and reduce the need for intrusive interventions. Evidence supported that aggression is a contextual event, as external factors clearly influence the incidence of aggression. Aggression management should be built on both relational and structural security.

[Managing aggression in a forensic psychiatric unit for adolescents: literature review and clinical implementation]. / Agressiebeleid op een forensische psychiatrische unit voor adolescenten; literatuuroverzicht en implementatie in de praktijk.

BACKGROUND: Aggressive incidents are part and parcel of everyday life in a forensic psychiatric unit for adolescents. AIM: To review the literature about the prevalence of aggressive incidents and about aggression management policy in (forensic) child and adolescent psychiatry and to explain and elaborate the aggression management protocol in a newly established unit. METHOD: The literature was reviewed systematically using PubMed and PsycINFO in order to locate studies in English and Dutch published since 1990. RESULTS: Only 10 publications reported prevalence data on aggressive incidents in child or adolescent psychiatric units. Literature about concrete policy guidelines was almost non-existent. 27% to 78% of the youngsters had been involved in some kind of aggression. The lack of clear definitions and the differences in the research designs made a reliable comparison impossible. CONCLUSION: To date, there is no evidence that a greater number of aggressive incidents occur in a forensic psychiatric unit for adolescents than in a regular adolescent psychiatric unit. Further research into both the prevalence and the characteristics of incidents is required in order to provide cues for a good policy. This policy will need to include structural and relational security measures that are firmly supported by the systematic registration of incidents and by continuous risk assessment.