Intervening at the Setting Level to Prevent Behavioral Incidents in Residential Child Care: Efficacy of the CARE Program Model.

The current study examined the impact of a setting-level intervention on the prevention of aggressive or dangerous behavioral incidents involving youth living in group care environments. Eleven group care agencies implemented Children and Residential Experiences (CARE), a principle-based program that helps agencies use a set of evidence-informed principles to guide programming and enrich the relational dynamics throughout the agency. All agencies served mostly youth referred from child welfare. The 3-year implementation of CARE involved intensive agency-wide training and on-site consultation to agency leaders and managers around supporting and facilitating day-to-day application of the principles in both childcare and staff management arenas. Agencies provided data over 48 months on the monthly frequency of behavioral incidents most related to program objectives. Using multiple baseline interrupted time series analysis to assess program effects, we tested whether trends during the program implementation period declined significantly compared to the 12 months before implementation. Results showed significant program effects on incidents involving youth aggression toward adult staff, property destruction, and running away. Effects on aggression toward peers and self-harm were also found but were less consistent. Staff ratings of positive organizational social context (OSC) predicted fewer incidents, but there was no clear relationship between OSC and observed program effects. Findings support the potential efficacy of the CARE model and illustrate that intervening "upstream" at the setting level may help to prevent coercive caregiving patterns and increase opportunities for healthy social interactions.

Children and residential experiences: a comprehensive strategy for implementing a research-informed program model for residential care.

This paper describes an effort to bridge research and practice in residential care through implementing a program model titled Children and Residential Experiences (CARE). The strategy involves consulting at all levels of the organization to guide personnel to incorporate CARE evidence-based principles into daily practice, and fostering an organizational culture and climate that sustains the integration of CARE principles. CARE aims to promote residential care programs that serve the best interests of children.

Learning from tragedy: a survey of child and adolescent restraint fatalities.

OBJECTIVE: This descriptive study examines 45 child and adolescent fatalities related to restraints in residential (institutional) placements in the United States from 1993 to 2003. METHOD: The study team used common Internet search engines as its primary case discovery strategy to determine the frequency and the nature of the fatalities, as well as the characteristics of the children and the adolescents involved. RESULTS: Male children and adolescents were over-represented in the study sample. Thirty-eight of the fatalities occurred during or after a physical restraint, and 7 fatalities occurred during the use of mechanical restraints. Twenty-eight of the deaths occurred in a prone restraint. In 25 of the fatalities, asphyxia was the cause of death. CONCLUSION: In the 23 cases in this study where information is available, none of the child behaviors or conditions that prompted the restraint would meet the standard of danger to self or others: the commonly accepted criteria for the use of a restraint. The study points to deficiencies in fatality reporting, recommends reporting fatalities to established state child fatality review boards, and reinforces that restraints be governed by strict protocol and monitoring. The study also urges caution to policymakers in substituting or changing restraint procedures based on the incomplete data reported in this study.

Should psychiatrists assist in the restraint of children and adolescents in psychiatric facilities?

Psychiatrists in psychiatric hospitals or residential facilities can find themselves involved in patient crises that precipitate a restraint or seclusion. The decision to become directly involved must be made quickly, with little time for administrative or legal consultation. The psychiatrist's decision to participate in physically restraining or secluding a patient, particularly a child or adolescent, may have long-lasting consequences. This Open Forum is offered to promote a discussion on this topic.

Restraint and seclusion use in U.S. school settings: recommendations from allied treatment disciplines.

Restraint and seclusion (R&S) are high risk, emergency procedures that are used in response to perceived violent, dangerous situations. They have been employed for years in a variety of settings that serve children, such as psychiatric hospitals and residential treatment facilities, but are now being recognized as used in the public schools. The field of education has begun to examine these practices in response to national scrutiny and a Congressional investigation. The fields of mental health and child welfare were similarly scrutinized 10 years ago following national media attention and have advanced R&S practice through the adoption of a prevention framework and core strategies to prevent and reduce use. A review of the evolution of the national R&S movement, the adverse effects of these procedures, and a comprehensive approach to prevent their use with specific core strategies such as leadership, workforce development, and youth and family involvement in order to facilitate organizational culture and practice change are discussed. Proposed guidelines for R&S use in schools and systemic recommendations to promote R&S practice alignment between the child-serving service sectors are also offered.