Home > Public Resources > Trauma Blog > 2022 - March > Trauma Begets Retraumatization through Physical Restraint in Youth Residents Trauma Begets Retraumatization through Physical Restraint in Youth Residents Brown, Edelman, Phillips, Stankus, Amoscato, & Schwartz March 1, 2022 When children and adolescents experience serious psychiatric, emotional, or behavioral problems not appropriate for outpatient treatment, they may be referred to a psychiatric residential treatment facility (PRTF). Once admitted, youth stay exclusively in these highly structured facilities to receive active treatment until they are discharged, a period ranging from a few weeks to several months. PRTFs generally represent the final, least restrictive treatment option for youth before hospitalization. From a societal perspective, PRTFs provide a valuable service within a stepped-care approach to the treatment of youth with severe mental health concerns. From a child’s perspective, an extended stay at a PRTF may be a harrowing experience. Unsurprisingly, 92% of youth referred to PRTFs report a history of chronic traumatization, underscoring both the severe functional impairment experienced by this population and the nationwide movement to implement trauma-informed care in these settings (Briggs et al., 2012). Once admitted to a PRTF, these youth find themselves away from home, isolated from family and friends in an unfamiliar environment surrounded by same-aged peers with a myriad of emotional and behavioral difficulties. Establishing a safe, therapeutic environment for youth within these facilities is a paramount challenge, indeed. Yet, a recent meta-analysis indicates that most studies of the effectiveness of interventions within PRTFs generally report positive youth outcomes (Lanier et al., 2020). However, some behavioral interventions utilized within PRTFs, such as physical restraint, are considered controversial and potentially iatrogenic. Physical restraints are commonly applied within PRTFs when a resident is considered to be an immediate danger to themselves or others; the purpose of such is to maintain safety within the unit. Most restraint incidents involve several staff members applying physical holds to immobilize or restrict the bodily movements or residents. Physical restraints can be quite violent, as most necessitate forceful physical contact to subdue a resident. Despite the intent to mitigate danger, physical restraint is associated with physical injury to both staff and patients, psychological harm, and, in some instances, death (Hollins & Stubbs, 2011; Nielson et al., 2020; Barnett et al., 2012). Now, imagine the experience of a physical restraint from the perspective of a youth with a history of chronic traumatization, including physical and sexual abuse: multiple adults physically forcing you to the ground against your will and restricting your movement, rendering you completely powerless. A multitude of characteristics from each physical restraint incident may resemble those of the youth’s past traumatic experiences, unintentionally resulting in subsequent retraumatization (Stoddard, 2014; Villalta et al., 2018). Additionally, physical restraint incidents may intensify existing feelings of disempowerment and compromise the youth’s perception that they are safe within the residential milieu. Unfortunately, our research observed that the intensity of traumatic stress symptoms reported by youth at admission to a PRTF is a significant indicator of the future frequency of physical restraint incidents. That is, youth who experience the highest levels of severe posttraumatic stress symptoms are most likely to experience frequent physical restraints. There are several possible explanations for this observation: Severe traumatic stress symptoms may be more visible to residential staff and more disruptive to the residential milieu, increasing the risk for physical restraint. These youth may experience more severe trauma-related psychopathology and functional impairment (i.e., self-harm, suicidality, violating the rights of or harming others) that jeopardizes their safety and that of others. The reason for referral or placement; children who are abused or neglected exhibit a higher likelihood of frequent restraint (Leidy et al., 2006; Matte-Landry et al. 2020). Given the potential contraindications of physical restraint among youth with chronic traumatization, the continued utilization of physical restraint within the therapeutic milieu of PRTFs is untenable, particularly with consideration of the emergence of alternative interventions. The clinical implications of our findings include the following: Education of staff and stakeholders within PRTFs about the impacts of trauma exposure on the populations they serve. Incorporation of comprehensive, evidence-based assessment of lifetime trauma history and current traumatic stress symptoms at admission to PRTFs. Early identification of residents at increased risk for restraint and the subsequent formulation of individualized treatment plans that aim to reduce this risk. The continued reformation of physical restraint practices is required to ensure the quality of treatment of youth with chronic trauma histories in PRTFs. Given the near ubiquitous nature of traumatization in youth referred to PRTFs, intervention utilization must be principally guided by the establishment and maintenance of safety and restorative practices. Target Article Brown, W. J., Nedelman, A. J., Phillips, W. G., Stankus, J. S., Amoscato, L. E., & Schwartz, E. (2022). Traumatic stress symptoms predict restraint incidents in children and adolescents in psychiatric residential treatment. Journal of Traumatic Stress, 1-12. https://doi.org/10.1002/jts.22787 Discussion Questions In our study, some residents with severe traumatic stress symptoms at admission never experienced a physical restraint during their care. What factors might explain this pattern that defies the observed trend? How might PRTFs craft their employment requirements for residential staff with the intention to reduce the utilization of physical restraint? What interventions should be considered as an alternative to physical restraint to reduce the likelihood of retraumatization in PRTFs? About the Authors Wilson J. Brown, PhD, is Assistant Professor of Clinical Psychology and Program Coordinator of the Applied Clinical Psychology (ACPSY) Master’s Degree program at Penn State Behrend. His current research interests include the utilization of translational research to understand emotion regulation in traumatized populations and the optimization of evidence-based treatments for trauma. Dr. Brown can be reached at [email protected]. Anthony J. Nedelman, PhD, is a licensed clinical psychologist in Ohio. His clinical interest includes treating mental health issues across the lifespan. He is a contributing expert to Psychology Today’s online platform and primarily writes about men’s psychological and spiritual wellness. He is the Chair of the Ohio Psychological Association’s Science and Research Committee and is working toward streamlining communication and knowledge between researcher and clinician. Dr. Nedelman can be reached at [email protected] or via Facebook and LinkedIn. William Phillips, PhD, HSPP, earned his PhD in school psychology from Ball State University. He is a licensed pediatric psychologist working in Evansville, Indiana where he specializes in working with children, adolescents, and families. His research interests include childhood food insecurity, TTRPGs as an evidence-based strategy for the treatment of trauma-related disorders, and the impact of school-based early intervention. Dr. Phillips can be contacted at [email protected]. Jaclynn Stankus, PhD, NCSP, earned her PhD in school psychology from Duquesne University. She is a licensed psychologist and a Nationally Certified School Psychologist in Savannah, Georgia where she specializes in developmental assessment and is the director of the Parent-Child Interaction Therapy (PCIT) program at Joye Psychology and Wellness, LLC. She is in the process of pursuing her PCIT Within Agency (Level 1) Trainer certification. Her research interests include community implementation of evidenced-based interventions, specifically the implementation of PCIT and its adaptation with teachers (Teacher-Child Interaction Training). Dr. Stankus can be contacted at [email protected]. Laura Amoscato, PhD, received her PhD from the University of Texas at Austin. She previously worked at Sarah Reed Children's Center in Erie, Pennsylvania as the Director of Quality Assurance and Quality Improvement where she managed and analyzed restraint data and other quality metrics. At times, Dr. Amoscato also served as both the Director and Assistant Director of the APA accredited psychology internship program at SARCC. She is currently the Lead Psychologist at Austin Child Guidance Center in Austin, Texas. Dr. Amoscato can be contacted at [email protected]. Eric Schwartz, PsyD, ABPP, is a licensed psychologist in Pennsylvania and Connecticut and is also Board Certified in Clinical Child and Adolescent Psychology. He received his doctorate at the University of Denver, Graduate School of Professional Psychology. Dr. Schwartz has dedicated most of his career working with children, adolescents, and families in the public mental health system including twenty-two years as Vice President of Clinical Services and Director of Psychology Internship Training at the Sarah Reed Children’s Center. In addition to the referenced article, Dr. Schwartz has recently co-authored a book chapter (soon to be published) on Partial Hospitalization and Day Treatment programs for children and adolescents. Dr. Schwartz now lives and works in Connecticut. Dr. Schwartz can be reached at [email protected]. References Cited Barnett, R., Stirling, C., & Pandyan, A. D. (2012). A review of the scientific literature related to the adverse impact of physical restraint: gaining a clearer understanding of the physiological factors involved in cases of restraint-related death. Medicine, Science and the Law, 52, 137-142. https://doi.org/10.1258/msl.2011.011101 Briggs, E. C., Greeson, J. K., Layne, C. M., Fairbank, J. A., Knoverek, A. M., & Pynoos, R. S. (2012). Trauma exposure, psychosocial functioning, and treatment needs of youth in residential care: Preliminary findings from the NCTSN Core Data Set. Journal of Child & Adolescent Trauma, 5(1), 1-15. https://doi.org/10.1080/19361521.2012.646413 Hollins, L. P., & Stubbs, B. (2011). The shoulder: Taking the strain during restraint. Journal of psychiatric and mental health nursing, 18, 177-184. https://doi.org/10.1111/j.1365-2850.2010.01670.x Lanier, P., Jensen, T., Bryant, K., Chung, G., Rose, R., Smith, Q., & Lackmann, L. (2020). A systematic review of the effectiveness of children’s behavioral health interventions in psychiatric residential treatment facilities. Children and Youth Services Review, 113, 104951. https://doi.org/10.1016/j.childyouth.2020.104951 Leidy, B. D., Haugaard, J. J., Nunno, M. A., & Kwartner, J. K. (2006). Review of restraint data in a residential treatment center for adolescent females. In Child and Youth Care Forum (Vol. 35, No. 5, pp. 339-352). Kluwer Academic Publishers-Plenum Publishers. Matte-Landry, A., & Collin-Vézina, D. (2020). Restraint, seclusion and time-out among children and youth in group homes and residential treatment centers: a latent profile analysis. Child Abuse & Neglect, 109, 104702. https://doi.org/10.1016/j.chiabu.2020.104702 Nielson, S., Bray, L., Carter, B., & Kiernan, J. (2020). Physical restraint of children and adolescents in mental health inpatient services: A systematic review and narrative synthesis. Journal of Child Health Care, 1367493520937152. https://doi.org/10.1177/1367493520937152 Stoddard, F. J. (2014). Outcomes of traumatic exposure. Child and Adolescent Psychiatric Clinics, 23(2), 243-256. https://doi.org/10.1016/j.chc.2014.01.004 Villalta, L., Smith, P., Hickin, N., & Stringaris, A. (2018). Emotion regulation difficulties in traumatized youth: A meta-analysis and conceptual review. European Child & Adolescent Psychiatry, 27(4), 527-544. https://doi.org/10.1007/s00787-018-1105-4