Approach to acute agitation in the pediatric emergency department.

PURPOSE OF REVIEW: The complexity of pediatric mental and behavioral health (MBH) complaints presenting to emergency departments (EDs) is increasing at an alarming rate. Children may present with agitation or develop agitation during the ED visit. This causes significant distress and may lead to injury of the child, caregivers, or medical staff. This review will focus on providing safe, patient-centered care to children with acute agitation in the ED. RECENT FINDINGS: Approaching a child with acute agitation in the ED requires elucidation on the cause and potential triggers of agitation for optimal management. The first step in a patient-centered approach is to use the least restrictive means with behavioral and environmental strategies. Restraint use (pharmacologic or physical restraint) should be reserved where these modifications do not result in adequate de-escalation. The provider should proceed with medications first, using the child's medication history as a guide. The use of physical restraint is a last resort to assure the safety concerns of the child, family, or staff, with a goal of minimizing restraint time. SUMMARY: Children are increasingly presenting to EDs with acute agitation. By focusing primarily on behavioral de-escalation and medication strategies, clinicians can provide safe, patient-centered care around these events.

Patterns of change in restrictive measures in residential care: Trauma-informed staff training benefits children and youth who need it the Most.

BACKGROUND: Implementation of trauma-informed staff training is promising to reduce restrictive measures (restraints, seclusions, and time-outs) used to address problem behaviors in youth in residential care. Previous mixed results may be explained in part by the heterogeneity in the use of restrictive measures among youth. OBJECTIVE: The objective was twofold: (1) to examine whether heterogeneity in the initial number of restrictive measures experienced by youth, before implementing trauma-informed staff training, moderates the effect of the training and (2) to explore whether children and youth's characteristics are associated with the number of restrictive measures. PARTICIPANTS AND SETTING: A trauma-informed staff training was implemented in 44 residential care units in Quebec, Canada. METHODS: This study used administrative data. The sample (n = 297 youth) was divided into three subgroups based on the number of restrictive measures experienced in the six-month period prior to the training: 1) absence or low (52 % of the sample); 2) moderate (23 %); 3) high (25 %). RESULTS: The use of restrictive measures was compared between the subgroups. Main and interaction effects were all significant. None of the slopes for groups 1 and 2 were significant. In contrast, significant decreases from T1 were observed at T2 (-0.18 (0.02), p < .000) and T3 (-0.22 (0.02), p < .000) in group 3. Several children and youth's characteristics distinguished groups. CONCLUSIONS: Implementation was more beneficial to youth who experienced a high number of restrictive measures. Training opportunities can lead to positive changes in measures used to address problem behaviors in youth.

Code De-Escalation: Decreasing restraint use during agitation management in a community hospital emergency department.

INTRODUCTION: Restraint use in the emergency department (ED) can pose significant risks to patients and health care workers. We evaluate the effectiveness of Code De-escalation- a standardized, team-based approach for management and assessment of threatening behaviors- in reducing physical restraint use and workplace violence in a community ED. METHODS: A retrospective observational study of a pathway on physical restraint use among patients placed on an involuntary psychiatric hold in a community ED. This pathway includes a built-in step for the team members to systematically assess perceptions of threats from the patient behavior and threats perceived by the patient. Our primary outcome was the change in the rate of physical restraint use among patients on an involuntary psychiatric hold. Our secondary outcome was the change in the rate of workplace violence events involving all ED encounters. We evaluated our outcomes by comparing all encounters in a ten-month period before and after implementation, and compared our results to rates at neighboring community hospitals within the same hospital network. RESULTS: Pre intervention there were 434 ED encounters involving a psychiatric hold, post-intervention there were 535. We observed a significant decrease in physical restraint use, from 7.4% to 3.7% (ARR 0.028 [95% CI 0.002-0.055], p < 0.05). This was not seen at the control sites. CONCLUSIONS: A standardized de-escalation algorithm can be effective in helping ED's decrease their use of physical restraints in management of psychiatric patients experiencing agitation.

Relationship between perceived coercion and perceived justification of coercive measures - secondary analysis of a randomized-controlled trial.

BACKGROUND: Subjective perception of coercion has gained attention as an important outcome. However, little is known about its relation to patients' appraisal of the justification of coercive measures. The present study aims to analyze the relationship between patients' appraisal of the justification of coercive measures and their level of perceived coercion. METHODS: This study presents a secondary analysis of the results of a multi-center RCT conducted to evaluate the effects of post-coercion review. Patients who experienced at least one coercive measure during their hospital stay were included in the trial. Participants' appraisal of the justification of coercive measures was categorized into patient-related and staff-related justifications. Subjective coercion was assessed using the Coercion Experience Scale (CES) and used as dependent variable in a multivariate regression model. RESULTS: 97 participants who completed the CES were included in the analysis. CES scores were significantly associated with the perception of the coercive measure as justified by staff-related factors (B = 0,540, p < 0,001), as well as with higher level of negative symptoms (B = 0,265, p = 0,011), and with mechanical restraint compared to seclusion (B=-0,343, p = 0,017). CONCLUSIONS: Patients' perceptions of coercive measures as justified by staff-related factors such as arbitrariness or incompetence of staff are related to higher levels of perceived coercion. Multiprofessional efforts must be made to restrict the use of coercive measures and to ensure a transparent and sustainable decision-making process, particularly with patients showing high levels of negative symptoms. Such key elements should be part of all coercion reduction programs.

Restraint or immobilization: A comparison of methodologies for restricting free movement in rodents and their potential impact on physiology and behavior.

Restriction of free movement has historically been used as a model for inducing acute and chronic stress in laboratory animals. This paradigm is one of the most widely employed experimental procedures for basic research studies of stress-related disorders. It is easy to implement, and it rarely involves any physical harm to the animal. Many different methods have been developed with variations in the apparatuses used and the degree of limitation of movement. Unfortunately, very few studies directly compare the differential impact of the distinct protocols. Additionally, restraint and immobilization terms are not differentiated and are sometimes used interchangeably in the literature. This review offers evidence of great physiological differences in the impact of distinct restraint and immobilization procedures in rats and mice and emphasizes the need for a standardized language on this topic. Moreover, it illustrates the necessity of additional systematic studies that compare the effects of the distinct methodologies, which would help to decide better which procedure should be used depending on the objectives of each particular study.

Chronic restraint stress alters rat behavior depending on sex and duration of stress.

Chronic restraint stress (CRS) can have different behavioral effects depending on variables associated with the stressor and the organism. This study aimed to verify the effect of the interaction between sex and duration of the CRS protocol in rats. Sprague-Dawley rats were divided by sex, intervention (CRS; control), and CRS duration (11 days; 22 days). Rats exposed to CRS showed better spatial learning than controls in the Morris water maze test, regardless of sex and stress duration. Males exposed to CRS for 11 days showed a higher rate of behaviors associated with anxiety than males exposed to 22 days of CRS at the elevated plus maze test, but the same was not observed in females. The weight gain of animals exposed to stress decreased in the first 11 days, showing a recovery from day 11 to day 22 of intervention. No effects of CRS were observed on behaviors associated with depression in the sucrose preference test. The results suggest habituation to the protocol, with a progressive decrease in the harmful effects of stress on and maintenance of the beneficial effects. It is possible that females are more resistant to the harmful effects of CRS on anxiety.

The optimal intervention for preventing physical restraints among older adults living in the nursing home: A systematic review.

AIM: This study aimed to evaluate the effectiveness of restraint reduction programs for nursing home care providers in enforcing physical restraint on residents and identify the best strategies for such programs. DESIGN: Systematic Review. METHODS: We searched for randomized controlled trials published until February 2021 for systematic review. The systematic review captured multifactorial interventions, education and consultation measures, including nursing home residents' and care providers' results. Study quality was assessed using the Cochrane Collaboration criteria. RESULTS: In all seven trials, the interventions were led by a nurse specialist or unit leader and targeted at care providers. Five of the restraint reduction programs effectively reduced the rate of physical restraint use; two increased knowledge of restraint reduction for care providers; and one each promoted positive attitudes and behaviours. Duration of at least 6 weeks significantly improved the knowledge of care providers.

Use of physical restraints and its associated risk factors in the aged care facilities: A multicentre cross-sectional study.

AIMS AND OBJECTIVES: To investigate the use of physical restraints in aged care facilities(ACFs)and analyse its associated risk factors. BACKGROUND: Physical restraints have been widely used in ACFs worldwide, but they can cause physical and mental harm to older people. It is important to regulate the use of physical restraint. DESIGN: A cross-sectional observational and correlational multicentre study. METHODS: By convenience sampling method, we selected eight ACFs in four representative regions of Hunan province, China, for this study. The ACF-related information was obtained by interviewing the managers and reviewing records. We conducted investigation and observation on the elderly in the ACFs to understand the use of physical restraints at three different times: 9:30-11:30, 16:00-18:00 and 19:30-21:30 on a working day. The STROBE checklist was followed for this cross-sectional study. RESULTS: This study found that the utilisation rate of physical restraints was 23.2%. The critical risk factors affecting the use of physical restrains include the following: (1) the ratio of nursing staff to the elderly residents; (2)whether there is a dementia care unit at the facility; (3) the number of elderly residents in each room; (4) the elderly residents' age, degree of education, marital status, care dependence and cognitive impairment; (5) whether the elderly has suffered from a stroke or senile dementia; (6) whether the elderly carries medical catheters. CONCLUSION: There is a lack of standardisation in the use of physical restraints in ACFs of central China. Chinese ACFs should develop guidelines and reduction measures to standardise the use of physical restraints, basing on the key factors affecting the use of physical restraints. RELEVANCE TO CLINICAL PRACTICE: The use of physical restraints in ACFs is threatening the safety of the elderly residents. Understanding the implementation of physical restraint in ACFs can provide reference for reducing the use of physical restraint.

Restraint use in residents with dementia living in residential aged care facilities: A scoping review.

AIMS AND OBJECTIVES: To provide an overview of restraint use in residents with dementia in the context of residential aged care facilities. BACKGROUND: Restraints are commonly used in people with dementia living in residential aged care facilities to manage behaviours and reduce injuries, but the concept of restraint use in people with dementia remains ambiguous, and current practices to reduce restraint use in long-term care residents with dementia remain unclear. DESIGN: A scoping review using the methodological frameworks of Arskey and O'Malley and colleagues. METHODS: Nine databases (CINAHL, MEDLINE, EMBASE, PubMed, Scopus, Web of Science, OVID, Cochrane Central Register of Controlled Trials and ProQuest) were searched from 2005 to 20 May 2019. Articles were included if they were written in English, peer-reviewed and used any research method that described restraint use in residents with dementia living in residential care settings. The PRISMA-ScR checklist was used. RESULTS: From 1,585 articles, 23 met the inclusion criteria. There is a lack of a clear definition of restraint use, and the prevalence of restraint use varied from 30.7% to 64.8% depending on the different operational concepts. People with dementia were at a higher risk for restraint use, and the decision-making process for restraint use was largely ignored in the literature. The effect of staff educational interventions to reduce restraint use was inconsistent due to varying delivery duration and content. CONCLUSIONS: The prevalence of restraint use in people with dementia living in residential care settings remains high alongside the absence of a clear definition of restraint use. More research about the decision-making process involved in using restraint and development of effective interventions are needed. RELEVANCE TO CLINICAL PRACTICE: Better education about the decision-making regarding staff, conditions of residents and organisations for restraint use is needed to improve the care for people with dementia living in care settings.

Analysis of remaining motion using one innovative upper airway opening cervical collar and two traditional cervical collars.

The aim of this study was to compare the remaining motion of an immobilized cervical spine using an innovative cervical collar as well as two traditional cervical collars. The study was performed on eight fresh human cadavers. The cervical spine was immobilized with one innovative (Lubo Airway Collar) and two traditional cervical collars (Stifneck and Perfit ACE). The flexion and lateral bending of the cervical spine were measured using a wireless motion tracker (Xsens). With the Weinman Lubo Airway Collar attached, the mean remaining flexion was 20.0 ± 9.0°. The mean remaining flexion was lowest with the Laerdal Stifneck (13.1 ± 6.6°) or Ambu Perfit ACE (10.8 ± 5.8°) applied. Compared to that of the innovative Weinmann Lubo Airway Collar, the remaining cervical spine flexion was significantly decreased with the Ambu Perfit ACE. There was no significant difference in lateral bending between the three examined collars. The most effective immobilization of the cervical spine was achieved when traditional cervical collars were implemented. However, all tested cervical collars showed remaining motion of the cervical spine. Thus, alternative immobilization techniques should be considered.

Observation of rescue behaviour in wild boar (Sus scrofa).

Here, we provide unique photo documentation and observational evidence of rescue behaviour described for the first time in wild boar. Rescue behaviour represents an extreme form of prosocial behaviour that has so far only been demonstrated in a few species. It refers to a situation when one individual acts to help another individual that finds itself in a dangerous or stressful situation and it is considered by some authors as a complex form of empathy. We documented a case in which an adult female wild boar manipulated wooden logs securing the door mechanism of a cage trap and released two entrapped young wild boars. The whole rescue was fast and particular behaviours were complex and precisely targeted, suggesting profound prosocial tendencies and exceptional problem-solving capacities in wild boar. The rescue behaviour might have been motivated by empathy because the rescuer female exhibited piloerection, a sign of distress, indicating an empathetic emotional state matching or understanding the victims. We discuss this rescue behaviour in the light of possible underlying motivators, including empathy, learning and social facilitation.

Decline in Physical Restraint Use Following Implementation of Institutional Guidelines.

OBJECTIVE: To investigate the strategies implemented at our institution to reduce medical restraint use. BACKGROUND: Restraints have been utilized to prevent agitation, self-extubations, and falls, although they are often associated with negative repercussions for nurses and patients. METHODS: The restraint data at our institution were compared with the National Database of Nursing Quality Indicators (NDNQI) benchmark. We also described the measures taken to improve restraint documentation. RESULTS: The number of patients in medical restraints, medical restraint hours, medical restraints/patient-days, and deaths in restraints at our institution all significantly decreased (P < 0.00001). There were 27 self-extubations of restrained patients compared with 11 self-extubations of nonrestrained patients. The percentage of inpatients with restraints in critical care and step-down areas declined and remained below the NDNQI benchmark. CONCLUSIONS: This study reports the processes implemented to reduce restraint use through enhanced communication and increased documentation. Further exploration into factors that may attain a restraint-free environment is warranted.

Prenatal stress and KCl-induced depolarization modulate cell death, hypothalamic-pituitary-adrenal axis genes, oxidative and inflammatory response in primary cortical neurons.

Maternal stress has been described as an important component in the offspring's cerebral development, altering the susceptibility to diseases in later life. Moreover, the postnatal period is essential for the development and integration of several peripheral and central systems related to the control of homeostasis. Thus, this study aimed to evaluate the effects of prenatal stress on the activation of cortical neurons, by performing experiments both under basal conditions and after KCl-induced depolarization. Female mice were divided in two groups: control and prenatal restraint stress. Cortical neurons from the offspring were obtained at gestational day 18. The effects of prenatal stress and KCl stimulations on cellular mortality, autophagy, gene expression, oxidative stress, and inflammation were evaluated. We found that neurons from PNS mice have decreased necrosis and autophagy after depolarization. Moreover, prenatal stress modulated the HPA axis, as observed by the increased GR and decreased 5HTr1 mRNA expression. The BDNF is an important factor for neuronal function and results demonstrated that KCl-induced depolarization increased the gene expression of BDNF I, BDNF IV, and TRκB. Furthermore, prenatal stress and KCl treatment induced significant alterations in oxidative and inflammatory markers. In conclusion, prenatal stress and stimulation with KCl may influence several markers related to neurodevelopment in cortical neurons from neonate mice, supporting the well-known long-term effects of maternal stress.

PET neuroimaging reveals upregulation of dopamine D2 receptor contributes to amygdaloid dysfunction in rat acute restraint stress model.

Acute stress relates to high prevalence of anxiety, depression or even sudden death. Although dopaminergic system in amygdala-medial prefrontal cortex (mPFC) circuit is hyper-responsive to stress-induced anxiety, the mechanisms that control anxiety still remains unanswered. Here, the acute restraint stress model(ARS) was established to develop anxiety-like behavior. The D2-dopamine receptor (D2R) availability in amygdala and mPFC was assessed using [18F]-fallypride positron emission tomography(PET) and immunohistochemical assay. We revealed that ARS paradigm was successfully established, as evidenced by elevated plus-maze test(EPM) and increased corticosterone release. Moreover, PET imaging displayed elevated D2R availability in the amygdala and mPFC in ARS as compared to that in the naives. PET imaging combined with immunohistochemical assay confirmed that amygdaloid D2R was significantly implicated in stress-induced anxiety. Our findings delivered valuable insights into neuromechanism of amygdaloid D2R underlying stress-induced anxiety and might have important implications for developing therapeutics for anxiety by targeting amygdaloid D2R.

The efficacy of manual soft-tissue mobilization in ankylosing spondylitis: A randomized controlled study.

AIM: The aim of this randomized controlled study was to investigate the effect of soft-tissue mobilization in patients with ankylosing spondylitis (AS). METHOD: Twenty-one patients (mean age 44.57 ± 10.40 years) were randomly divided into two groups. There were 13 patients (11 females, 2 males, age 43.69 ± 9.94 years) in the intervention group and 8 patients (5 females, 3 males, age 46.00 ± 11.67 years) in the control group. In the intervention group, soft-tissue mobilization therapy and 20 spinal mobility exercises were applied. The control group received only 20 spinal mobility exercises. The Bath AS Disease Activity Index (BASDAI), Bath AS Functional Index (BASFI), and Bath AS Metrology Index (BASMI) were used for assessment of disease activity, functional level, and mobility, respectively. Nottingham Health Profile (NHP) for quality of life and Roland Morris Disability Questionnaire (RMDQ) were used to determine disability levels. RESULTS: We found significant differences between pretreatment and post-treatment scores of BASDAI (P = 0.049); BASFI (P = 0.009; lateral lumbar flexion (P = 0.005), maximal intermalleolar distance (P = 0.001) and total score (P = 0.001) of BASMI; pain subtest (P = 0.036) and total score (P = 0.036) of NHP; and RMDQ score (P = 0.004) in the intervention group. However, in the control group the BASMI score (P = 0.049) was observed to worsen significantly. Delta values were compared and differences in BASFI (P = 0.039), and in lateral lumbar flexion (P = 0.027), maximal intermalleolar distance (P = 0.045) and total score (P = 0.001) of BASMI were significant in favor of intervention group. Only tragus-to-wall distance (P = 0.039) of BASMI was observed to worsen significantly in the control group. CONCLUSION: We recommend the use of soft-tissue mobilization in addition to the exercises to treat AS patients.

Exercise and crocin prevent adolescent-stress induced impairment of spatial navigation and dendritic retraction in the hippocampal CA3 area in adult male rats.

Adolescent chronic stress has been shown to induce functional, biochemical and morphological modifications of the hippocampus, leading to stress-related disorders in adulthood. The present study investigated the effects of exercise, crocin and their combination on spatial learning and memory impairment and dendritic retraction of the CA3 pyramidal neurons induced by chronic adolescent stress in adult male rats. Rats were exposed to restraint stress 2 h/day for 10 days during postnatal days (PNDs) 30-40. Following this period, separate groups of animals were treated with crocin (25 and 50 mg/kg), exposed to running wheel, and or received the combined treatment during PNDs 41-55. Following the interventions, plasma levels of corticosterone, spatial learning and memory, apical dendritic length of CA3 pyramidal neurons and BDNF levels in the CA3 area were assessed. Findings showed that adolescent stress significantly increased corticosterone levels and caused a tendency to reduce CA3 BDNF levels. Adolescent stress also impaired spatial learning and memory, and retracted apical dendritic length of CA3 pyramidal neurons. Crocin, voluntary exercise, and their combination recovered stress-induced spatial learning and impairment and CA3 pyramidal neurons dendritic length retraction. All treatments also reduced significantly corticosterone levels and enhanced CA3 BDNF levels in the stress groups. Finally, these treatments even increased apical dendritic length of CA3 pyramidal neurons in the non-stress groups. These findings indicate that detrimental effects of adolescent stress on cognitive function and hippocampal morphology in adulthood could be restored by early interventions with physical activity and crocin treatment during adolescent period.

A novel rabbit fixator made of a thermoplastic mask for awake imaging experiments.

This study aimed to develop and validate a novel rabbit fixator made from a thermoplastic mask for awake imaging experiments. When heated in a hot-water bath at 65-70 °C for 2-5 min, the thermoplastic mask became soft and could be molded to fit over the entire body of an anesthetized rabbit (4 ml of 3% pentobarbital sodium solution by intramuscular injection). Twenty rabbits were randomly divided into fixator (n = 10) and anesthesia (n = 10) groups. The animals' vital signs, stress hormones (cortisol and adrenaline), and subjective image quality scores for the computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI) scanning were measured and compared. Phantom CT, MRI and PET studies were performed to assess the performance with and without the thermoplastic mask by using image agents at different concentrations or with different radioactivity. The respiration rate (RR), systolic blood pressure (SBP), diastolic blood pressure (DBP), peripheral capillary oxygen saturation (SpO2) and body temperature (T) decreased after anesthesia (all P < 0.05) but did not significantly decrease after fixation (all P > 0.05). The heart rate (HR), cortisol and adrenaline did not significantly decrease after either anesthesia or fixation (all P > 0.05). The subjective image quality scores for the CT and MRI images of the head, thorax, liver, kidney, intestines and pelvis and the subjective image quality scores for the PET images did not significantly differ between the two groups (all P > 0.05). For all examined organs except the muscle, 18F-FDG metabolism was lower after fixation than after anesthesia, and was almost identical of liver between two groups. The phantom study showed that the CT values, standard uptake values and MR T2 signal values did not differ significantly with or without the mask (all P > 0.05). A novel rabbit fixator created using a thermoplastic mask could be used to obtain high-quality images for different imaging modalities in an awake and near-physiological state.

Protocol for Recording from Ventral Tegmental Area Dopamine Neurons in Mice while Measuring Force during Head-Fixation.

Many studies in systems neuroscience use head-fixation preparations for in vivo experimentation. While head-fixation confers several advantages, one major limitation is the lack of behavioral measures that quantify whole-body movements. Here, we detail a step-by-step protocol for using a novel head-fixation device that measures the forces exerted by head-fixed mice in multiple dimensions. We further detail how this system can be used in conjunction with in vivo electrophysiology and optogenetics to study dopamine neurons in the ventral tegmental area. For complete details on the use and execution of this protocol, please refer to Hughes et al. (2020a, 2020b).

Benefits of tunnel handling persist after repeated restraint, injection and anaesthesia.

Millions of mice are used every year for scientific research, representing the majority of scientific procedures conducted on animals. The standard method used to pick up laboratory mice for general husbandry and experimental procedures is known as tail handling and involves the capture, elevation and restraint of mice via their tails. There is growing evidence that, compared to non-aversive handling methods (i.e. tunnel and cup), tail handling increases behavioural signs of anxiety and induces anhedonia. Hence tail handling has a negative impact on mouse welfare. Here, we investigated whether repeated scruff restraint, intraperitoneal (IP) injections and anaesthesia negated the reduction in anxiety-related behaviour in tunnel compared with tail handled BALB/c mice. We found that mice which experienced repeated restraint spent less time interacting with a handler compared to mice that were handled only. However, after repeated restraint, tunnel handled mice showed increased willingness to interact with a handler, and reduced anxiety in standard behavioural tests compared with tail handled mice. The type of procedure experienced (IP injection or anaesthesia), and the duration after which behaviour was measured after a procedure affected the willingness of mice to interact with a handler. Despite this, compared with tail handling, tunnel handling reduced anxiety in standard behavioural tests and increased willingness to interact with a handler within hours after procedures. This suggests that the welfare benefits of tunnel handling are widely applicable and not diminished by the use of other putatively more invasive procedures that are frequently used in the laboratory. Therefore, the simple refinement of replacing tail with tunnel handling for routine husbandry and procedures will deliver a substantial improvement for mouse welfare and has the potential for improving scientific outcomes.

Restraint, seclusion and time-out among children and youth in group homes and residential treatment centers: a latent profile analysis.

BACKGROUND: Many children and youth living in residential units have experienced multiple traumas that may result in challenging behaviors. Among a range of professional responses, staff may use restraint, seclusion and time-out to manage these behaviors. OBJECTIVE: To enhance our understanding of these restrictive interventions in residential units as a means of improving professional practices involving children and youth in out-of-home care. PARTICIPANTS AND SETTING: Administrative data were used. Restrictive intervention data for 324 children and youth (29 units) over a 6-month period were extracted. METHODS: Latent profile analysis was used to identify subgroups of children and youth with distinct restrictive intervention profiles. Children and youth in these profiles were compared on individual (age, sex, ethnic group, length of stay in unit, reasons for services) and environmental characteristics (unit type, type of services, specialized designation). RESULTS: Restrictive interventions, especially time-outs, were frequent (5136 interventions; 69% time-outs), yet approximately half of the sample did not experience any. Restraints, seclusions and time-outs differed in frequency, duration and reason for use. A two-profile model was favored for children and youth who were subjected to restrictive interventions (classification accuracy = 94%). Children and youth in these two profiles differed from each other, and from those not subjected to restrictive interventions, on numerous individual and environmental characteristics. CONCLUSION: The use of restrictive interventions is frequent, and attention should be paid to individual and environmental risk factors identified in this study (i.e., being a boy, non-Caucasian, taken into care for neglect, and having a longer stay in unit).