The second broad aim of the current study was to replicate previous work and assess which demographic and psychiatric factors contribute to a child being at increased risk of experiencing R/S during their inpatient psychiatric stay. Although EF variables were predictive of R/S independently, this was not true once significant demographic and psychiatric variables were entered into the models. Similar to previous studies, the
George, & Scott, 2007b; Gullick, McDermott, Stone, & Gibbon, 2005; Pogge, Pappalardo, Buccolo, & Harvey, 2013; Stellwagen & Kerig, 2009; Sourander, Ellilä, Välimäki, & Piha, 2002), race/ethnicity (Martin et al., 2008), history of residential placement (Dean et al., 2007b) and history of aggression (Dean et al., 2007b). Unlike previous studies, sex, abuse history, previous hospitalizations, and insurance type were not related to R/S.
Age. In the current sample of children ages 5 to 14 years, the child’s age
significantly predicted Escorts, and reached trend significance in predicting Holds. This finding is in line with much of the previous work, suggesting that younger children are more likely to experience R/S while inpatient. Younger children may have poorer
behavioral regulation skills, and may have more difficulty engaging in coping skills than older children. Additionally, because they are smaller, staff may more readily utilize physical methods of restraining or moving younger children.
Race/Ethnicity. This study’s finding, that even when holding all other psychiatric and demographic variables constant (age, sex, insurance type, residential placement, previous admission, history of aggression, history of abuse) children of color had a 77% higher rate of Holds, is striking although unfortunately not surprising. This same pattern has been documented in previous research (Donovan, Plant, Peller, Siegel, & Martin, 2003; Martin et al., 2008). Although it should be noted that not all studies find evidence of racial/ethnic differences (Delaney & Fogg, 2005).
Previous work has asserted that increased R/S amongst children of color can be attributed to reduced access to mental health services and appropriate treatment for minority groups (Donovan et al., 2003). Mental health service disparity, in all of its
complexity, is well documented (Alegría et al., 2008; Austin and Wagner 2010; Cook, Barry & Busch 2013), and likely plays a role in inpatient presentation. However, there are no studies to date linking reduced outpatient mental health treatment with increased R/S while inpatient. Unfortunately, the current study did not assess the severity of each child’s psychiatric condition upon intake, and thus it is impossible to know whether racial/ethnic disparities are in any way accounted for by the severity of the child’s mental health condition.
It is, of course, additionally important to consider the potential systemic factors at play. Although anecdotally the staff employed at Emma Pendleton Bradley is diverse and mirrors the population it serves, we cannot ignore the vast literature documenting that cultural bias systematically disadvantages youth of color (Paradies et al., 2015; Patcher & Coll, 2009). Recent publications have highlighted a similar pattern in United States’ schools; specifically, that on a national level, children of color are more likely to
experience R/S in school settings (U.S. Department of Education Office for Civil Rights, 2014). While the rules and regulations that govern R/S in schools are different from those that govern R/S in psychiatric hospital settings, we may be able to glean important
information from this body of literature as it evolves. A full review of race/ethnicity’s effects on child mental health is beyond the scope of the current paper; however, it is imperative that the insidious bias that pervades the systems in our culture, not be allowed to permeate children’s mental health treatment within the highly controlled inpatient environment. Thus further, more specific work to address this question is required.
Residential Programs and R/S. The current study found that children who were transferred from a residential program to the inpatient unit demonstrated significantly
higher rates of R/S. Specifically, in the final models, children from residential programs experienced rates of Holds that were 2-times higher, Escorts that were 7-times higher, Seclusion Time that was 11-times longer, and Mechanical Restraint that was 21-times higher. Children coming from a residential program are at significant risk for R/S while inpatient, even after controlling for other demographic, psychiatric and cognitive variables.
Residential programs provide intensive supports for children and adolescents with serious emotional and behavioral problems. Children are often enrolled in these programs when they are not deemed safe to live at home, but do not require the acuity of inpatient hospitalization. Children in residential programs frequently fall into three categories: children with multiple severe mental and/or physical health problems, children with no caregivers, and children with significant maltreatment histories (Yampolskaya, Mowery, & Dollard, 2013). Thus, these children are likely to have more severe mental health problems, as well as carry multiple significant risk factors such as an abuse history or lacking a stable home environment. In some ways, residential treatment is an index of severe family dysfunction, which may predispose children to higher rates of
dysregulation. Children, especially those without identified caregivers, are also likely to be discharged from the inpatient setting to a residential program. While on the inpatient unit, children are aware that if they successfully engage in behavior regulation, and avoid R/S, they are more likely to go home more quickly. However, if a child knows that he/she is not going “home,” this may not be a motivating factor for them.
R/S is also used within many residential programs, without the same oversight as within hospitals. It is possible that children experience R/S within their residential
program prior to inpatient admission, and habituate to the experience. Future work should examine the longitudinal course of children who live in residential programs and are admitted to inpatient unit, in order to delineate this relationship more thoroughly. Clinical Implications
Based on the current study, there are several populations of children at increased risk for R/S. Specifically younger children, children of color, children with experience in residential programs, and children with a prior history of aggression. The current study mirrors the results of previous work, lending added weight to the current findings and suggesting that working with these populations may require additional attention and training.
Several programs have demonstrated effectiveness at reducing R/S in children’s inpatient units. A manualized treatment, Collaborative Problem Solving, “provides a framework to understand children’s aggressive behavior as stemming from impairments in one of five non–mutually exclusive pathways” (EF, language processing, emotion regulation, cognitive flexibility, and social skills; Martin et al., 2008, pg. 1407). The treatment, focuses on using cognitive behavioral strategies to address the specific child’s social and/or cognitive “pathway impairments,” and ultimately reduce aggression. Another effective program, based on Positive Parenting Program, highlights staff training, individualized patient management plans, and using standardized behavior management strategies (Dean, Duke, George, & Scott, 2007). Based on the results of the current study, individualized behavior management plans that identify the child’s goals and motivators would be extremely important, as well as training in cultural competence and identifying the individual child’s triggers. Programs should take a highly data driven
approach to behavior management; this is made significantly easier because the units are already mandated to collect data on R/S. Data collection would allow staff to identify common triggers, as well as any problematic patient-staff interactions, and formally test the utility of behavior plans.
It would also be extremely important to pay close attention to supporting staff. There is significant literature on caregiver stress, and how it negatively impacts parents’ relationships with children (Hayes & Watson, 2013). However, no work has examined the amount of stress inpatient staff experience, and how that may negatively impact staff mental health and staff-child interactions. Literature on parent stress and efficacy
suggests that increasing understanding and empathy can improve parent-child
interactions. Therefore, staff training may benefit from emphasizing how multiply at-risk children develop maladaptive coping strategies, and likely lack the ability to regulate their behavior appropriately. This may include more comprehensive trauma training (National Center for Traumatic Stress, 2012).
Limitations
The current study does have several limitations that should be noted. First regarding the sample, the study was conducted in a single hospital in a single inpatient unit, which necessarily limits the results’ generalizability. As described above, there are national guidelines that govern the provision of R/S within inpatient settings, which lends some degree of stability across sites; however, there is significant variability in
populations served, staff training and even workplace culture. The majority of studies on R/S have examined single inpatient units (De Hert et al., 2011; Martin et al., 2008; Tompsett et al., 2011) or multiple units within the same hospital (Delaney & Fogg,
2005); therefore future work may benefit from examining hospitals within a particular state or region. The current study additionally focused entirely on variables related to the child, and did not account for staff or hospital level variables that may influence R/S. Although previous work examined the time of day and when in a child’s LOS R/S most frequently occur (Delaney & Fogg, 2005), no study to date has thoroughly examined precipitating events or staff characteristics/behaviors related to decreased incidence of R/S.
Related to assessment and measurement, the current study relied on retrospective chart review. Many of the demographic and psychiatric variables were identified in the child’s admission evaluation; although the content is generally standardized, there is inherent variability within these documents which led to some missing data. Additionally, not every child received a neuropsychological assessment. Although I examined the differences between NP and No-NP groups, it is possible that these groups systematically differ in neuropsychological profile. I also did not examine medication as part of the current study. The majority of children were on some form of medication during their inpatient stay, and these medications may have had an effect on the child’s
neuropsychological profile, and may explain some of the null findings. For example, performance on the CPT may be improved by stimulant medications to treat ADHD (Swanson, Baler, & Volkow, 2011). Future work should account for these potential confounds. Finally, the current study did not include any behavior rating scales of EF (e.g. BRIEF-2). The addition of behavior rating scales would help to clarify the relationship between measurement, neurocognitive profile and behavior. Future Directions
Future studies assessing the relationship between behavior dysregulation and EF tests should use multiple EF measures examining the same latent constructs (e.g.
inhibition, working memory, cognitive flexibility) in order to decrease the influence of random measurement errors, or systematic errors inherent in a specific task. Additionally future work should utilize different types of EF measures including
parent/teacher/provider report questionnaires, and tasks with greater ecological validity (Anderson, 2002). Based on Nigg’s recent review and call-to-action, future work
examining the relationships between EF and behavior regulation should work to operate within the same framework and use the same terms (i.e. EF vs. effortful control).
Future studies focused on decreasing R/S within inpatient settings should examine multiple inpatient hospitals within the same state or region in order to increase
generalizability. Additionally, it will be important to examine the interactions between staff and patients. Research should follow children longitudinally to assess how early experiences may have cascading effects that lead to increased behavior dysregulation over time.
Conclusion
This study examined the relationship between children’s observable behavior dysregulation and performance on formal measures of EF within a psychiatric inpatient population. Performance on a task of inhibitory control was inversely predictive of increased holds, escorts and mechanical restraints; while counter to my hypothesis, a task of cognitive flexibility was positively predictive of holds, escorts, seclusion time and mechanical restraints. This study additionally examined demographic and psychiatric factors that predicted R/S. The child’s age, race/ethnicity, history of an out-of-home
placement and history of aggression predicted R/S above and beyond EF skills. Therefore, although EF skills may contribute to behavior dysregulation, we must be careful when making predictions based on performance-based measures; it is additionally imperative to consider a child’s specific context.
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