Iniatives to reduce the use of seclusion and restraints on people with developmental disabilities: a systematic review and quantitative synthesis

Contrary to the expectations articulated in public policy, restrictive interventions are commonly used in support services for people with developmental disabilities. This systematic review and quantitative synthesis was undertaken to investigate whether the use of seclusion and restraints on people with developmental disabilities can be reduced. Searches of the Academic Search Complete, CINAHL, MEDLINE, and PsycINFO electronic databases returned 7226 records, of which 11 met the inclusion criteria for this review. A further 3 papers were obtained through scanning the reference lists of those articles included from the initial literature search. All 14 studies were single-subject designs focusing on initiatives to reduce physical or mechanical restraint. Between the baseline and intervention phases, there were mean reductions in the frequency and duration of restraint use of 79% (SD = 21%, n = 13 subjects from 7 studies) and 45% (SD = 58%, n = 10 subjects from 6 studies), respectively. For studies in which restraint use to manage agitation and aggression was targeted, there was a 79% (SD = 21%, n = 13 subjects from 7 studies) decrease in the frequency and a 28% (SD = 67%, n = 6 subjects from 3 studies) reduction in the duration of restraint. With respect to studies in which restraint use to prevent self-harm was targeted, there was a 71% (SD = 34%, n = 4 subjects from 3 studies) reduction in restraint use. Effect sizes were calculable, using non-overlap approaches, for 9 of the 14 studies. The magnitudes of the effect sizes suggest that, on average, the interventions were effective in reducing the use of restraints. The effects generated in studies where restraint use for self-harm was targeted were typically more pronounced than those in which restraint use for agitation and aggression was addressed. There were broad variations, however, in the percentage reductions in restraint use and in the magnitudes of the effect sizes. Although the findings of this review are encouraging, more research is needed, in which greater attention must be paid to rigorous research design, application, and analysis.

Isolation and restraint stress results in differential activation of corticontrophin-releasing hormone and arginine vasopressin neurones in sheep

This study investigated sex differences in the stress-induced activation of neurons containing corticotrophin-releasing hormone (CRH), arginine vasopressin (AVP) and enkephalin in the paraventricular nucleus (PVN) of gonadectomized male and female sheep. Groups (n=3) of both sexes were either subjected to 90 min isolation and restraint stress (stress group) or were not stressed. Blood samples were taken every 10 min for 90 min prior to and after stress to monitor cortisol levels in plasma. Brains were harvested after 90 min of stress. Stress caused elevation of plasma cortisol levels to a similar extent in both sexes. Double-labeling immunohistochemistry for Fos and either CRH, AVP or enkephalin was undertaken to quantify the numbers of neurons staining for CRH, AVP and enkephalin that also immunostained for Fos. Stress increased Fos immunostaining in all cell types. There was a greater proportion of CRH than AVP neurons activated in stressed animals. There were no sex differences in the activation of CRH and AVP neurons although females had a greater proportion of enkephalin cells staining for Fos than males in both control and stressed animals. There were no differences between control and stressed animals in the proportion of cells co-staining for CRH and AVP. We conclude that isolation and restraint stress activates neurons producing CRH, AVP and enkephalin in sheep and that CRH may play a greater role than AVP in regulating adrenocorticotrophic hormone secretion in response to this stressor in sheep. Finally, isolation and restraint stress does not influence co-localization of CRH and AVP in sheep.

Activation of the hypothalamo-pituitary-adrenal axis by isolation and restraint stress during lactation in ewes : effect of the presence of the lamb and suckling

We investigated the effect of the presence and absence of lambs and suckling by lambs to attenuate activation of the hypothalamo-pituitary-adrenal (HPA) axis to isolation and restraint stress in lactating sheep. In experiment 1, blood samples were collected every 10 min from nonlactating (n = 5) and lactating (n = 5) ewes for 4 h before and during stress. In experiment 2, ewes (n = 6) were allocated to 1) nonlactating, 2) lactating with lambs absent, 3) lactating with lambs present but unable to suckle, and 4) lactating with lambs present and able to suckle. Blood samples were collected over 8 h with no stress (control day) and for 4 h before and 4 h during stress (stress day). In experiment 1, the mean (±SEM) cortisol concentrations increased significantly (P < 0.05) in nonlactating ewes during stress but did not change in lactating ewes. In experiment 2, cortisol did not vary on the control day or pretreatment of the stress day but increased (P < 0.05) during stress in all groups except lactating ewes with lambs present and able to suckle. The greatest cortisol response occurred in nonlactating ewes followed by lactating ewes with lambs absent and lactating ewes with lambs present but unable to suckle. During stress, the ACTH concentrations increased (P < 0.05) in nonlactating ewes and lactating ewes with lambs absent but not in lactating ewes with lambs present. We conclude that the activity of the HPA axis during isolation and restraint is reduced in lactating ewes and that the presence of lambs increases this level of attenuation.

Seasonal differences in the effect of isolation and restraint stress on the luteinizing hormone response to gonadotropin-releasing hormone in hypothalamopituitary disconnected, gonadectomized rams and ewes

Stress responses are thought to act within the hypothalamopituitary unit to impair the reproductive system, and the sites of action may differ between sexes. The effect of isolation and restraint stress on pituitary responsiveness to GnRH in sheep was investigated, with emphasis on possible sex differences. Experiments were conducted during the breeding season and the nonbreeding season. In both experiments, 125 ng of GnRH was injected i.v. every 2 h into hypothalamopituitary disconnected, gonadectomized rams and ewes on 3 experimental days, with each day divided into two periods. During the second period on Day 2, isolation and restraint stress was imposed for 5.5 h. Plasma concentrations of LH and cortisol were measured in samples of blood collected from the jugular vein. In the second experiment (nonbreeding season), plasma concentrations of epinephrine, norepinephrine, 3,4-dihydroxyphenylalanine, and 3,4-dihydroxyphenylglycol were also measured. In both experiments, there was no effect of isolation and restraint stress on plasma concentrations of cortisol in either sex. During the breeding season, there was no effect of isolation and restraint stress on plasma concentrations of LH in either sex. During the nonbreeding season, the amplitude of the first LH pulse after the commencement of stress was significantly reduced (P < 0.05) in rams and ewes. In the second experiment, during stress there was a significant increase (P < 0.05) in plasma concentrations of epinephrine in rams and ewes and significantly higher (P < 0.05) basal concentrations of norepinephrine in ewes than in rams. These results suggest that in sheep stress reduces responsiveness of the pituitary gland to exogenous GnRH during the nonbreeding season but not during the breeding season, possibly because of mediators of the stress response other than those of the hypothalamus-pituitary-adrenal gland axis.

Examining influences on boys' and girls' physical activity patterns: the a-class project

Understanding children’s physical activity (PA) patterns and the factors that may influence PA are important for developing interventions within this population. One hundred and ten children aged 9–0 years from 8 schools had their PA patterns assessed over 7 days. Physiological and self-report data were also collected. Multilevel analyses revealed that cardiorespiratory fitness was a consistent, significant and positive predictor of weekday and weekend PA, while the availability of home sedentary activities was a significant but negative predictor of PA. Since a range of variables were associated with PA levels, intervention developers should be cognizant of variables that may influence children’s activity

A preliminary investigation of adult defence style and physiological reactivity to infant distress signals

Species whose offspring require extended care-giving ought to be predisposed to being biologically responsive to their infant's signalling. This paper examined the interplay between biological and psychological aspects of adult response to an infant's distress. HR (heart rate) and GSR (galvanic skin response) were recorded continuously, while 50 adults listened to white noise and an infant cry audio recording. Participants completed the defence style questionnaire and the state trait anxiety inventory. HR acceleration occurred in response to the control sound, while HR decelerated in response to the infant cry. GSR responsiveness was positively correlated with immature and neurotic defence styles. When controlling for other variables, immature defence was a unique and independent predictor of GSR change in response to infant distress. Defence demonstrated a stronger relationship than self-reported anxiety, than that with physiological responsiveness. Employing defence mechanisms appears to reduce an individual's perceived anxiety, though it has little effect on physiological arousal levels.

Restrained eaters consume more food only if they are impulsive and male

This study utilised the preload paradigm to evaluate whether dietary restraint, impulsivity, or their interaction significantly predicts heightened food consumption among male and/or female participants. Following a high calorie preload, 79 participants aged 18 to 40 (53 females and 26 males) completed a deceptive taste test and questionnaires measuring restraint and impulsivity levels. A series of hierarchical regressions were run, controlling for self-rated hunger levels. A significant negative association between level of restraint and food consumption post-preload was found for males, but this relationship was not significant for female participants. The hypothesis that impulsivity would directly predict heightened food consumption was not supported for either gender. However, impulsivity was found to significantly moderate the relationship between restraint and food intake in the male sample, but not the female, providing partial support for this hypothesis. Potential reasons for this gender-specific interaction effect of impulsivity and restraint for food consumption are discussed. More broadly, present findings highlight the need for further consideration of the role of impulsivity in undermining food intake of restrained eaters. Future research should also consider how preload effects may differ across gender.

Intervention designed to reduce the use of summary execution in acute psychiatric inpatient settings

Context: Although it may seem preposterous to consider the need to reduce the use of summary executions in acute psychiatric inpatient settings because practitioners simply would not consider using such inhumane treatment, it is sobering that many mental health professionals do not hesitate to use seclusion.

Objectives: We draw attention to the assumption that underlies the thinking of many mental health professionals that seclusion is acceptable simply because it is available.

Key messages: The letter of the law (seclusion is legal) is frequently given precedence over the spirit of the law (seclusion should used as a method of last resort, if at all). The availability of seclusion as an intervention makes its use inevitable. Although sufficient checks and balances exist in society to prevent psychiatric staff from adding summary executions to their ‘‘treatment’’ paradigms, legislators need to set the bar much higher. Outside intervention, in the form of legislation, is needed because the mental health professions seem incapable of discontinuing the use seclusion despite evidence of the trauma it causes to both patients and staff and despite the lack of evidence that it achieves any desirable outcomes.

Conclusion: The use of seclusion is unacceptable and should be as impossible and unthinkable as summarily executing our patients. By the use of what would seem, at first glance, an absurd analogy between seclusion and summary execution we highlight the need for a shift in policy and legislation regarding the use of traumatising interventions.

The addition of depression to the Framingham Risk Equation model for predicting coronary heart disease risk in women

BACKGROUND: Depression is widely considered to be an independent and robust predictor of Coronary Heart Disease (CHD), however is seldom considered in the context of formal risk assessment. We assessed whether the addition of depression to the Framingham Risk Equation (FRE) improved accuracy for predicting 10-year CHD in a sample of women.

DESIGN: A prospective, longitudinal design comprising an age-stratified, population-based sample of Australian women collected between 1993 and 2011 (n=862).

METHODS: Clinical depressive disorder was assessed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID-I/NP), using retrospective age-of-onset data. A composite measure of CHD included non-fatal myocardial infarction, unstable angina coronary intervention or cardiac death. Cox proportional-hazards regression models were conducted and overall accuracy assessed using area under receiver operating characteristic (ROC) curve analysis.

RESULTS: ROC curve analyses revealed that the addition of baseline depression status to the FRE model improved its overall accuracy (AUC:0.77, Specificity:0.70, Sensitivity:0.75) when compared to the original FRE model (AUC:0.75, Specificity:0.73, Sensitivity:0.67). However, when calibrated against the original model, the predicted number of events generated by the augmented version marginally over-estimated the true number observed.

CONCLUSIONS: The addition of a depression variable to the FRE equation improves the overall accuracy of the model for predicting 10-year CHD events in women, however may over-estimate the number of events that actually occur. This model now requires validation in larger samples as it could form a new CHD risk equation for women.

The predictors of diet quality among Australian children aged 3.5 years

BACKGROUND: It is critical to promote healthy eating early in life. OBJECTIVE: The aim of this study was to examine diet quality and its predictors among Australian preschool-aged children. DESIGN: Diet was assessed at age 3.5 years using multiple 24-hour recalls. Diet quality was assessed using an adapted version of the Revised Children's Diet Quality Index (RC-DQI). Potential predictors of diet quality were from questionnaires at age 3, 9, and 18 months and informed by the ecologic model of childhood overweight. Potential predictors included child's sex, age of introduction to solid foods, breastfeeding status, food acceptance, maternal nutrition knowledge, modeling of healthy eating, self-efficacy, education, and home food availability. PARTICIPANTS: Data from 244 children participating in the Melbourne Infant Feeding, Activity, and Nutrition Trial in 2008-2010 and follow-up data collection in 2011-2013 were examined. MAIN OUTCOME MEASURES: Diet quality at age 3.5 years. STATISTICAL ANALYSES PERFORMED: Bivariate logistic regression was performed to assess the relationship between diet quality and each predictor. A multivariable logistic regression model accounting for influences of covariates, treatment arm, and clustering by group tested associations between diet quality and significant predictors from bivariate analyses. RESULTS: RC-DQI scores had a mean±standard deviation score of 62.8±8.3 points out of a maximum of 85 points. Breastfeeding status (odds ratio [OR] 2.34, 95% CI 1.33 to 4.10) and maternal modeling of healthy eating (OR 1.75, 95% CI 1.01 to 3.03) were positively associated with RC-DQI scores. Both breastfeeding status (OR 3.09, 95% CI 1.63 to 5.85) and modeling (OR 2.01, 95% CI 1.04 to 3.88) remained positively associated with diet quality after adjustment for child age, body mass index z score, energy intake, treatment arm, and clustering. CONCLUSIONS: Breastfeeding status and modeling of healthy eating were independently associated with children's diet quality. Early intervention could assist mothers to practice these behaviors to provide support for improving child diet quality.

Predictors of outcomes of psychological treatments for disordered gambling : a systematic review

This systematic review aimed to synthesise the evidence relating to pre-treatment predictors of gambling outcomes following psychological treatment for disordered gambling across multiple time-points (i.e., post-treatment, short-term, medium-term, and long-term). A systematic search from 1990 to 2016 identified 50 articles, from which 11 socio-demographic, 16 gambling-related, 21 psychological/psychosocial, 12 treatment, and no therapist-related variables, were identified. Male gender and low depression levels were the most consistent predictors of successful treatment outcomes across multiple time-points. Likely predictors of successful treatment outcomes also included older age, lower gambling symptom severity, lower levels of gambling behaviours and alcohol use, and higher treatment session attendance. Significant associations, at a minimum of one time-point, were identified between successful treatment outcomes and being employed, ethnicity, no gambling debt, personality traits and being in the action stage of change. Mixed results were identified for treatment goal, while education, income, preferred gambling activity, problem gambling duration, anxiety, any psychiatric comorbidity, psychological distress, substance use, prior gambling treatment and medication use were not significantly associated with treatment outcomes at any time-point. Further research involving consistent treatment outcome frameworks, examination of treatment and therapist predictor variables, and evaluation of predictors across long-term follow-ups is warranted to advance this developing field of research.

The impact of the quality of behaviour support plans on the use of restraint and seclusion in disability services

Background: Behaviour support plan (BSP) quality is known to be an important aspect of the support provided to people with disability who show challenging behaviours and has been found to lead to reductions in challenging behaviour. Preliminary evidence suggests that quality of plans is associated with reductions in the use of restraint
and seclusion.
Method and materials: Quality of a sample of behaviour support plans was assessed using the Behaviour Support Plan – Quality Evaluation II (BSP-QE II) Guide (Browning Wright, Saren & Mayer, 2003). Episodes of restraint and seclusion before and during implementation of plans were examined by comparing restraint and seclusion use between individuals with high quality versus low quality plans.
Results: Compared to individuals with low quality plans, individuals with high quality plans were found to be subjected to less restraint and seclusion over time, while those with low quality plans were subjected to increases. With the exception of one quality component, all components in high quality plans were found to be associated with decreases in restraint and seclusion use.
Conclusions: The results support earlier preliminary findings that quality of behaviour support plans are associated with reductions in restrictive intervention use. The findings are important because they suggest that increasing quality of behaviour support plans may lead to decreases in restraint and seclusion over time.

Individual and organisational factors associated with the use of seclusion in disability services

Background: Seclusion is a restrictive intervention that results in some form of containment and social isolation of a person from others. Little is known about the relationships between individual and organisation factors and the use of seclusion in disability services. Method: The reported use of seclusion in disability services in Victoria, Australia, was examined over a 3-year period, with a focus on the characteristics of those who were secluded (n = 146) and the characteristics of organisations that reported seclusion compared to others who were reported to be restrained but not secluded (n = 2,482). Results: Results from a logistic regression showed that the individual factors of age, the presence of autism and/or a psychiatric disorder put people at risk of being secluded. In terms of organisational factors, receiving accommodation services in institutions or in the community and the location of the organisation were risk factors. Conclusions: The findings are consistent with previous research but add to this literature by showing that certain organisational characteristics are also risk factors for seclusion. Understanding these factors is important in order to help disability support staff find other more ethical and appropriate alternatives to seclusion.

Dietary restraint and negative affect as mediators of body dissatisfaction and bulimic behavior in adolescent girls and boys

Stice's dual pathway model of dietary restraint and negative affect was examined in both adolescent girls and boys. Self-report measures assessing body dissatisfaction, dietary restraint, negative affect and bulimic behavior were administered to 267 girls and 199 boys aged between 12 and 16 years. The findings for the girls were consistent with Stice's model, in that they indicated that both dietary restraint and negative affect mediated the relationship between body dissatisfaction and bulimic behavior. For the boys who desired a thinner body size, only negative affect was found to mediate the relationship between body dissatisfaction and bulimic behavior. On the other hand, for boys who desired a larger body size, both body dissatisfaction and dietary restraint were found to exert an independent effect on bulimic behavior. As boys can aspire to two contrasting and seemingly opposite body size ideals, the findings highlight that the relationship between body dissatisfaction, dietary restraint, negative affect and bulimic behavior are more complex in males than in females. Further research using longitudinal designs is needed in order to test the directional and bidirectional nature of the observed interrelationships.

Restraint as misregulation in drinking and eating

The present study was designed to increase our understanding of the co-morbidity between problem drinking and binge eating. The study investigated both consummatory behaviors in relation to restrained drinking, restrained eating, and a general measure of self-control. The participants were a sample of 658 boys and 414 girls aged between 14 and 17 years. The dimension of restraint, which best predicted the two problem behaviors when examined separately for both boys and girls, was cognitive and emotional preoccupation (CEP) about controlling one's consummatory intake. In addition, evidence was found linking both problem drinking and binge eating to restraint and poor general self-control. The struggle with self-control and the high emphasis on CEP about controlling one's consummatory intake, which characterise restrained drinking and restrained eating, closely resembles Baumeister and Heatherton's notion of misregulation [Psychol. Inquiry 7 (1996) 1]. Discussed are the similarities between restraint and misregulation, and the kinds of strategies that can be used to improve self-control.