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Identification and Analysis of Factors Contributing to the Reduction in Seclusion and Restraint for a Population with Intellectual Disability

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Title: Identification and Analysis of Factors Contributing to the Reduction in Seclusion and Restraint for a Population with Intellectual Disability
Language: English
Authors: Larue, Caroline, Goulet, Marie-Hélène, Prevost, Marie-Josée, Dumais, Alexandre, Bellavance, Jacques
Source: Journal of Applied Research in Intellectual Disabilities. Mar 2018 31(2):e212-e222.
Availability: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA
Peer Reviewed: Y
Page Count: 11
Publication Date: 2018
Document Type: Journal Articles
Reports - Research
Descriptors: Severe Intellectual Disability, Patients, Clinical Diagnosis, Behavior Problems, Psychiatric Hospitals, Foreign Countries, Inclusion, Case Studies, Focus Groups, Caregivers, Family Involvement, Intervention
Geographic Terms: Canada
DOI: 10.1111/jar.12309
ISSN: 1360-2322
Abstract: Background: A cohort of 11 patients with an intellectual disability and a psychiatric diagnosis present severe behavioural disorders in psychiatric hospital of Quebec in 2009. Control-measure use for this clientele has now been reduced. How do management personnel, families and care teams explain the changes? What clinical interventions did management and care providers implement that contributed to the reduction? Method: A retrospective case study was conducted. Five focus groups were held with people involved in their care, and the patient files were examined. Results: The factors contributing to this change were the cohesion of the care providers, the involvement of the families and the efforts to determine the function of the behaviour. Implications: This study may inspire other care teams to try new approaches in dealing with patients with severe behavioural disorders. Also, the model of factors and interventions supporting a reduction in seclusion and restraint measures may inspire future studies.
Abstractor: As Provided
Entry Date: 2018
Accession Number: EJ1168775
Database: ERIC
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  Value: <anid>AN0127932484;e0301mar.18;2018Feb12.12:35;v2.2.500</anid> <title id="AN0127932484-1">Identification and Analysis of Factors Contributing to the Reduction in Seclusion and Restraint for a Population with Intellectual Disability </title> <p>Background: A cohort of 11 patients with an intellectual disability and a psychiatric diagnosis present severe behavioural disorders in psychiatric hospital of Quebec in 2009. Control‐measure use for this clientele has now been reduced. How do management personnel, families and care teams explain the changes? What clinical interventions did management and care providers implement that contributed to the reduction? Method: A retrospective case study was conducted. Five focus groups were held with people involved in their care, and the patient files were examined. Results: The factors contributing to this change were the cohesion of the care providers, the involvement of the families and the efforts to determine the function of the behaviour. Implications: This study may inspire other care teams to try new approaches in dealing with patients with severe behavioural disorders. Also, the model of factors and interventions supporting a reduction in seclusion and restraint measures may inspire future studies.</p> <p>case study; intellectual disability; seclusion and restraint; severe behavioural disorders</p> <hd id="AN0127932484-2">Introduction</hd> <p>Intellectual disability (ID) is a condition characterized ‘by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills. This disability originates before age 18’ (Schalock et al. [<reflink idref="bib49" id="ref1">49</reflink>] , p. 5). If all diagnostic criteria are taken into account, the prevalence of intellectual disability is estimated at 1% (American Psychiatric Association [<reflink idref="bib1" id="ref2">1</reflink>] ; Tassé & Morin [<reflink idref="bib53" id="ref3">53</reflink>] ; Maulik et al. [<reflink idref="bib37" id="ref4">37</reflink>] ). In a population study (n = 1023), Cooper et al. ([<reflink idref="bib8" id="ref5">8</reflink>] ) found that behavioural disorders are the mental problems most commonly associated with intellectual disability. Such disorders present as verbal and/or motor behaviour directed at oneself, the environment or others that results in injury or harm to the physical or psychological integrity of a person and/or damage to the environment (L'Abbé & Morin [<reflink idref="bib31" id="ref6">31</reflink>] ). Lowe et al. ([<reflink idref="bib33" id="ref7">33</reflink>] ) more recently defined the categories of this problematic behaviour as aggression towards others, self‐injury, destruction, and other difficult or disruptive behaviour. According to Mainville ([<reflink idref="bib34" id="ref8">34</reflink>] ), these sorts of behaviour may decline, remain unchanged or intensify in adulthood and are influenced by biopsychosocial factors.</p> <p>Moreover, intellectual disability associated with a mental‐health diagnosis is correlated with a high aggression score (Crocker et al. [<reflink idref="bib12" id="ref9">12</reflink>] ). In a Quebec population of 3246 adults with intellectual disability, researchers found the 12‐month prevalence of hetero‐ and autoaggressive behaviour to be 52% (Crocker et al. [<reflink idref="bib11" id="ref10">11</reflink>] ). In individuals with intellectual disability associated with an autism spectrum disorder, communication and social skill deficits (McClintock et al. [<reflink idref="bib38" id="ref11">38</reflink>] ; Murphy et al. [<reflink idref="bib42" id="ref12">42</reflink>] ; Matson et al. [<reflink idref="bib36" id="ref13">36</reflink>] ), sleep disorders (Polimeni et al. [<reflink idref="bib44" id="ref14">44</reflink>] ; Cortesi et al. [<reflink idref="bib9" id="ref15">9</reflink>] ; Rzepecka et al. [<reflink idref="bib47" id="ref16">47</reflink>] ), sensory disorders (Crane et al. [<reflink idref="bib10" id="ref17">10</reflink>] ), and deficits in adaptive behaviour and the management of unpredictability (Matson et al. [<reflink idref="bib35" id="ref18">35</reflink>] ) cause stress (Attwood [<reflink idref="bib2" id="ref19">2</reflink>] ). These problems also heighten dependency and the need for support in the activities of daily life, resulting in increased opportunities for frustration such as over response time, refusal, physical proximity and frequent physical contact (Mainville [<reflink idref="bib34" id="ref20">34</reflink>] ). For care providers, dealing with such frustration may result in increased fear of attack and even in having to go on leave for burnout (Mills & Rose [<reflink idref="bib40" id="ref21">40</reflink>] ). Problematic behaviour by intellectual disability patients challenges care providers; and, faced with the limits of their abilities and resources to cope with it, they may sometimes resort to using seclusion and/or restraint (SR).</p> <p>Quebec's Ministry of Health defines restraint as ‘preventing or restricting a person's freedom of movement by the application of human strength or mechanical means or by depriving the person of an instrument [he or she] uses to compensate for a handicap’; seclusion is defined as ‘confining a person to a location which [he or she] may not freely leave for a specified time’ (Ministère de la Santé et des Services sociaux (MSSS) [<reflink idref="bib41" id="ref22">41</reflink>] , p. 5 [Translated from French]). Studies reveal that the prevalence of SR measures for individuals with intellectual disability varies widely: it ranges from 1% (Emerson [<reflink idref="bib17" id="ref23">17</reflink>] ) to 22% (Pilling et al. [<reflink idref="bib43" id="ref24">43</reflink>] ) for mechanical restraint; from 3% (Kiernan & Kiernan [<reflink idref="bib28" id="ref25">28</reflink>] ) to 100% (Jacobson & Ackerman [<reflink idref="bib25" id="ref26">25</reflink>] ) for physical restraint; and from 6% (Kiernan & Kiernan [<reflink idref="bib28" id="ref27">28</reflink>] ) to 68% (Emerson [<reflink idref="bib17" id="ref28">17</reflink>] ) for seclusion. The differences in prevalence may be explained by differences in the definition of SR as well as in the type of establishment and consequently of the clientele involved. A recent Quebec study (Mérineau‐Côté & Morin [<reflink idref="bib39" id="ref29">39</reflink>] ) of 81 individuals with intellectual disability associated with aggressive behaviour who live mainly in community services showed that 63% had experienced at least one control measure in the 3 months preceding the investigation. At the tertiary psychiatric facility where this study took place, examination of the SR database revealed that nine of the patients who were frequently placed in seclusion from 2007 to 2009 accounted for 54% of all the hours of seclusion of the entire inpatient population. The nine patients were characterized by intellectual disability, self‐harming behaviours and almost daily periods of seclusion (Dumais et al. [<reflink idref="bib16" id="ref30">16</reflink>] ). These patients were subjects in the study described in this article.</p> <p>Legal initiatives in Quebec (Canada), as in many other jurisdictions internationally, call into question – and promote reduced reliance on – practices that impinge on an individual's fundamental right to move about freely. It is in this context that eleven patients with an intellectual disability associated with severe behavioural disorders were admitted to a hospital intellectual disability Psychiatry Programme in June 2008. The patients had a serious record of aggressive behaviour towards themselves or others that resulted in the application of control measures. From 2008 to 2012, the programme's care teams and managers observed a decline in the use SR measures for most the eleven patients. However, the lack of rigorous, systematic documentation of the interventions or of factors affecting patient care limits whatever lessons might be learned from the experience.</p> <hd id="AN0127932484-3">Aim and objectives</hd> <p>This study thus aims to identify the factors contributing to reduce SR use for patients with an intellectual disability, mental illness and severe behavioural disorders. It thus seeks to answer the following questions: (i) Has the application of SR to these patients actually been reduced? (ii) If it has, how do the families and care teams explain the changes? (iii) What clinical interventions did management and care providers implement that helped bring about the reduction?</p> <hd id="AN0127932484-4">Methods</hd> <p>A descriptive, retrospective study (Stake [<reflink idref="bib51" id="ref31">51</reflink>] ; Yin [<reflink idref="bib56" id="ref32">56</reflink>] ) was conducted between 26 June 2008 (when the patients were admitted to the intellectual disability Psychiatry Programme) and 5 September 2012 (when the first patient in this cohort left for a facility in the community). Two types of samples were used to answer the research questions: the first was comprised of the files of the 11 patients (cases) in the Intellectual Disability Psychiatry Programme of the Institut Universitaire de Santé Mentale de Montréal (IUSMM) and the second comprised focus‐group meetings with management staff (n = 4), care providers in ongoing contact with the patients (n = 12), patients' family members (n = 7), professional staff (n = 6) and physicians (n = 2). The purpose of these homogeneous group meetings was to capture a variety of perspectives to explain the reduction in SR use. The criteria for inclusion for family members were relationship to a patient in the study and involvement in his care during the study. To be included in the other focus groups, an individual had to hold or to have held a full‐time or part‐time position or worked as a replacement for at least 6 months in the care units concerned during the period of the study and to have been involved in the care, treatment or management of at least one of the eleven patients. The project was presented to day‐ and evening‐shift care teams and to the families.</p> <p>Two data‐gathering tools were selected to find answers to the study questions. The first was a grid validated by the research team and the management staff, used to organize the relevant, retrospective data gleaned from the patient records. The grid is divided into four sections: (i) sociodemographic information about the patient; (ii) SR hours by 28 days from June 2008 to September 2012; (iii) information about medical prescriptions; and (iv) information about clinical interventions. The research began with an examination of each patient's file to extract data on the duration of SR/month in order to find sustained periods of reduced SR (more than 2 months) and select the periods in the file (the preceding month) for closer analysis. Information in the observation grid drawn from each patient's file for each period was used to compute the number of interventions/year and compile pharmacological data. Descriptive statistics were performed on SR data.</p> <p>The second tool was a common interview plan for the different focus groups to elicit discussion of processes and factors that contributed to a perceived or real reduction in SR measures. The discussions of the focus groups were transcribed. A summary of each group's discussions was submitted to the participants by email for validation. Qualitative data from the files were grouped under categories of factors that, in accordance with Stetler et al.'s model (Stetler et al. [<reflink idref="bib52" id="ref33">52</reflink>] ), contribute to changes of practice: characteristics of the leadership, the organization and the interventions. The interventions were grouped into subcategories derived from SR reduction programme models (Huckshorn [<reflink idref="bib23" id="ref34">23</reflink>] ; Fluttert et al. [<reflink idref="bib19" id="ref35">19</reflink>] ; Scalan [<reflink idref="bib48" id="ref36">48</reflink>] ; Kontio et al. [<reflink idref="bib30" id="ref37">30</reflink>] ): family involvement, patient education, tools to support clinical judgement and improvement of the therapeutic environment. Two researchers performed a blind coding of 20% of the material. After discussion and adjustment of the emerging categories, interjudge agreement for coding was 85%. Finally, an exploratory intercase analysis was conducted to determine whether qualitative changes common to all the patients in the cohort had taken place.</p> <p>The project was approved by the IUSMM Research Ethics Committee (#2013‐017) and meets the requirements set in the Tri‐Council Policy Statement (2010).</p> <hd id="AN0127932484-5">Results</hd> <hd id="AN0127932484-6">Description of the sample</hd> <p>As Table  shows, the patients had a mean age of 41 years in 2008. Their psychiatric diagnoses varied; they had autism spectrum disorders associated with mild‐to‐severe intellectual disability concomitant with another psychiatric diagnosis, such as a bipolar disorder, a psychotic disorder, an anxiety disorder or a behavioural disorder. Different manifestations of severe behavioural disorders were recorded in the patients' files: severe self‐injury (e.g. tearing out his toenails or teeth), aggression towards objects (e.g. tearing his clothes), aggression towards people (e.g. hitting or spitting) and inappropriate behaviour (e.g. undressing in public).[<reflink idref="bib1" id="ref38">1</reflink>]</p> <p>Years old, patient diagnosis and manifestations of severe behavioural disorder</p> <ct id="AN0127932484-7"></ct> <p> <ephtml> <table border="1" cellpadding="4"><tr><th /><th>Years old</th><th>Diagnosis</th><th>Autoaggressive and heteroaggressive manifestations of severe behavioural disorder</th></tr><tr><td>Éric</td><td>40</td><td>Bipolar disorder, borderline personality, moderate intellectual disability</td><td>Hits, shoves, breaks equipment, harms self</td></tr><tr><td>Paul</td><td>55</td><td>Autistic disorder, schizophrenia spectrum, conduct disorder, unspecified adaptation disorder, moderate intellectual disability</td><td>Severe self‐injury</td></tr><tr><td>Julien</td><td>30</td><td>Autistic disorder, obsessive–compulsive disorder, attention‐deficit hyperactivity disorder, mild‐to‐moderate intellectual disability</td><td>Hits others, throws things, breaks things, provokes fights between others, spits at others, threatens others with violence</td></tr><tr><td>Maurice</td><td>49</td><td>Conduct disorder, bipolar disorder, aggressive behaviour and paraphilia, mild intellectual disability</td><td>Spits, bites, makes verbal threats, uses fists and feet to push staff members or other patients, throws and breaks things when angry. Impulsive and unpredictable</td></tr><tr><td>Jacques</td><td>41</td><td>Autistic disorder, anxiety disorder, conduct disorder, post‐traumatic stress disorder, mild intellectual disability</td><td>Harms self (hits self on head), bites, breaks things, slaps, trips, touches people inappropriately, makes verbal threats</td></tr><tr><td>Guy</td><td>55</td><td>Autistic disorder, coffee–tobacco addiction, stereotypies with self‐harm, moderate intellectual disability</td><td>Screams when touched, does not stay seated without an intervention, moves constantly, tears cloth or paper, lowers his trousers and lifts up his sweater in public places</td></tr><tr><td>Antoine</td><td>40</td><td>Obsessive–compulsive disorder, behaviour disorder, conduct disorder, moderate intellectual disability</td><td>Harms self (bangs head against the wall) when faced with refusal of a request or specific words being spoken</td></tr><tr><td>Bertrand</td><td>42</td><td>Obsessive–compulsive disorder, behaviour disorder, conduct disorder, moderate intellectual disability</td><td>Harms self (slaps, hits or scratches face, bites fingers). Smashes in the walls, throws objects, provokes, bullies</td></tr><tr><td>Adrien</td><td>34</td><td>Autistic disorder, conduct disorder, post‐traumatic stress disorder, behaviour disorder, psychosis, severe intellectual disability</td><td>Harms self (bangs into walls or windows). Bites, butts with head, undresses in public</td></tr><tr><td>Gilles</td><td>46</td><td>Autistic disorder, psychotic disorder, severe intellectual disability</td><td>Harms self. Impulsive (makes threats and hits care providers). Squeezes others very tightly in his arms</td></tr><tr><td>Nicolas</td><td>31</td><td>Autistic disorder, emotional disorder development, bipolar disorder, severe intellectual disability</td><td>Harms self (induces vomiting after meal) </td></tr></table> </ephtml> </p> <hd id="AN0127932484-8">Description of the decrease in SR measures</hd> <p>Graph  shows that from 2008 to 2012 the average hours of seclusion/period fell for most of the patients. Over the period of the study, one patient spent no hours in seclusion and was stable; four patients saw their average hours of seclusion fall by 3–12 h per month; and six patients saw their average time in seclusion decrease by 45 or more hours per month.</p> <p>Graph  charts the patients' average hours of restraint/period for the years 2008–2012. In comparison with their average hours of seclusion (Graph ), their hours of restraint are low. Moreover, the use of restraint measures fell for most of the cohort; nine patients experienced minor improvements with reductions of 1–3 h per month. The hours of restraint increased significantly for one patient (not included in the graph) after self‐harm resulted in severe head injuries requiring his medical hospitalization.</p> <p>In short, the care team's perceptions were confirmed; time in SR fell for nearly all patients in the study between 2008 and 2012.</p> <hd id="AN0127932484-9">Contributory factors: organization, care providers and patients working together</hd> <p>The views expressed by each of the focus groups tend to converge and are discussed below in terms of the broad categories developed by Stetler et al. ([<reflink idref="bib52" id="ref39">52</reflink>] ). A total of 104 units of meaning were thus grouped under the categories of leadership or organizational culture or of two emerging categories, characteristics of the care providers and characteristics of the patients.</p> <p>The main leadership characteristic that participants identified as having contributed to the reduction in SR was the ability to unify staff efforts. Table  presents the subcategories subsumed under the broader leadership category and illustrates them with verbatims.[<reflink idref="bib2" id="ref40">2</reflink>] All the focus groups discussed the importance of pursuing cohesion across professional boundaries and of providing support for training. Each of the groups stressed the value of the concerted efforts made to improve the patients' quality of life through the use of common tools, the formulation of detailed intervention plans and frequent team meetings. The various professionals were provided with a great deal of training, which helped enhance their expertise and bridge the divide between disciplines.</p> <p>Leadership factors contributing to reduction in SR measures</p> <ct id="AN0127932484-10"></ct> <p> <ephtml> <table border="1" cellpadding="2"><tr><td>Seeking cohesion across professional boundaries</td><td>‘We organize our services on an interdisciplinary basis (occupational therapist, psychiatrist, social workers, special‐education teachers, nurses, general practitioners, psychoeducators, psychologists, neuropsychologists, attendants, pharmacist). Everyone works together in his specific field to understand the severe behavioural disorders’. FGG</td></tr><tr><td>Offering training and providing support for it</td><td>‘We didn't have the expertise. The training came later. With all our good will, we felt that the way things were, we weren't making contact. The good will remained, but we had to adjust it to what the patients could take. We felt incompetent, but we told ourselves: ‘We'll get training. We'll get good.’ We had all the will and just had to get the expertise.' FGG</td></tr><tr><td>Preparing for change</td><td>‘We had a look at intervention plans and physical arrangements. We had physical arrangements made tailored to each one of them.… We racked our brains to minimize risk. We had detailed case presentations made. We engaged a neuropsychologist who gave a 1‐day presentation. We paired our care providers with theirs’. FGG</td></tr><tr><td>Gradual changes</td><td>‘They increasingly came round as they experienced successes too … by going about it so gradually, one small step at a time, [taking] sometimes 10 min or 15 min at a time to unlock a door’. FGG</td></tr><tr><td>Willingness to challenge beliefs and to build on successes</td><td>‘For the teams, seeing their successes gives them new hope. We could no longer say, ‘Yes, but that's just the way he is.’ So in our talks we could point out successes he's had'. FGG</td></tr></table> </ephtml> </p> <p>In terms of organizational culture, three themes emerged from the discussions of the management, care provider and family focus groups: an institutional philosophy advocating reduced SR use, its appropriation by team members and flexibility in dealing with the individual needs of the patients.</p> <p>As regards care provider characteristics, four themes emerged from the focus‐group discussions: the capacity for reflection, changing care providers, interest and flexibility. The care providers learn by trial and error; they make their adjustments on the basis of observations arrived at through a multimodal analysis. Changing care providers is a static factor that in and of itself makes it possible to bring fresh, more promising perspectives to bear.</p> <p>In considering patient characteristics, some focus‐group participants suggested that changing the environment in and of itself has a positive long‐term effect on patient attitudes and that ageing tends to make patients less aggressive.</p> <hd id="AN0127932484-11">Contributory factors: multilevel interventions</hd> <p>A total of 85 units of meaning extracted from the focus‐group discussions were grouped under the intervention category. In this section, we shall deal with both the interventions mentioned in the focus groups and those recorded in the observation grids based on the patient files. The terminology used to organize the material is derived from SR reduction programme models: family and patient involvement, improvement of the therapeutic environment and communication tools.</p> <p>The first key factor raised in the focus groups in terms of interventional change is a true involvement of families and patients. The discussions clearly demonstrate the desire of each of the groups to take advantage of the families' experiential knowledge. Over time, work with the families resulted in the development of true partnerships. The families felt they had the support of the care providers, as the following statement illustrates: ‘We feel the care providers want to know what we think. The people working with them have something to contribute. It's really great!’ (FGF). The care providers, for their part, feel they have support, too: ‘When they see that we investigate the behaviour and that we're engaged in a helping relationship in the work we do, it gives them a sense of security, and they back us up’ (FGI). We found a strong family involvement in the interventions recorded in the observation grids for nine of the 11 patients. Notes from the patient files illustrate the way families are supported and their parenting abilities are put to good account (examples: frequent telephone calls to talk about the patient's clinical progress, family interview at admission to provide a list with the role and contact information of the care providers working with the patient and to determine the desired level of involvement of families in terms of their objectives, expectations and concerns).</p> <p>The category of improvement of the therapeutic environment comprises interventions deemed to help reduce SR measures that were discussed in the focus groups and recorded in the observation grids (Table ). Interventions that are relational, personalized and directed to finding meaning entail that care providers' engage in significant, direct contact with patients and undertake efforts to discover the function of their behaviour. Contact makes it possible, first, for care providers to become acquainted with patients, ease their fears of attack and establish a positive relationship with the individuals in their care. In time, initial apprehensions give way to trust, understanding and affection. Interventions regarding physical arrangements comprise efforts to make areas that the patients use safer. Interventions regarding pharmacological treatment and physical investigations help cast light on symptoms of mental illness so that appropriate medication may gradually be reintroduced. Physical investigation entails performing medical assessments (EEG, neurological evaluation, etc.) to find out the source of certain problems.</p> <p>Features of interventions contributing to SR reduction</p> <ct id="AN0127932484-12"></ct> <p> <ephtml> <table border="1" cellpadding="2"><tr><td>Relational and personalized interventions</td><td><p>Prepare verbal or social scenario:  ‘His nurse went on maternity leave. We wrote a social scenario for him to explain that she was going to leave, have a baby and come back and that someone else would take her place. It helps reduce anxiety, anticipating the unexpected to avoid escalation’. FGI</p><p>Detailed routine and highly structured timetable:  ‘During his bath, guide him verbally through the steps as a way of helping him so he avoids contact with other patients’ ‘More sensitive when rising in the morning: do not rush him, eats alone in the lounge after the group, slower in the morning, follow his rhythm as much as possible. Do not talk in the room around his bed’.</p><p>Knowing each other:  ‘The important thing is contact with the patient because at first my colleagues and I were afraid of the patients. They scared us. They broke windows. We didn't know them… We had to get used to each other’. FGI</p></td></tr><tr><td>Interventions to discover meaning of the behaviour</td><td>‘What's the need for all this? If you don't ask yourself that question, you're doing just what you have to get by. You stay stuck doing things the way they've always been done’. FGPro</td></tr><tr><td>Pharmacological interventions</td><td>‘Medication has helped him, too. We get involved a lot on that level and talk to his doctor. We try new drugs. He's much calmer. We were able to take him out last weekend’. FGF</td></tr><tr><td>Physical arrangements</td><td>‘We installed toilets they couldn't pull out and also put in padded headboards and unbreakable windowpanes before they arrived. We installed monitors like the ones in baby beds for some of them so we'd know when they moved as well as doors with alarms for the rooms further away’. FGG</td></tr><tr><td>Adapted interventions</td><td><p>Flexibility: ○Allowed to scream without hitting himself and without being placed in seclusion; remind verbally of the appropriate place to masturbate and offer lubricant’ ○Do not interfere or confront him when he is attempting to steal or run away; never threaten him or mention security’</p><p>Staff avoids having coffee in the unit</p><p>Respecting preference for a male care provider</p></td></tr><tr><td>Alternative personalized and creative measures when escalation starts</td><td><p>Examples: social de‐escalation scenario, bath to relax, weighted blanket, clearly state instructions and consequences, encourage self‐expression, take the hand while keeping a safe distance to take the patient to his room, reassure, suggest choices visually</p><p>Withdraw upon seeing warning signs or triggers, such as trembling hands; calming conditions (music, subdued lighting, withdrawal to a secluded chair with carpeting on the wall and on the floor around it)</p></td></tr></table> </ephtml> </p> <p>All the focus groups brought up the usefulness of tools for communication and to support clinical judgement. They mentioned clinical tools such as evaluation and observation grids (e.g. evaluation and functional or multimodal intervention grids), intervention plans (e.g. plans for managing problematic behaviour) and the means of applying intervention plans (e.g. social scenarios).</p> <hd id="AN0127932484-13">Discussion</hd> <p>The profile of the study clientele is similar to that described in the meta‐analysis by McClintock et al. ([<reflink idref="bib38" id="ref41">38</reflink>] ), which demonstrated that autism‐associated intellectual disability presents a risk of self‐injury and aggression. The study by Ayanouglou ([<reflink idref="bib3" id="ref42">3</reflink>] ) of seven adults with intellectual disability who were followed for 30 years showed that the intensity of behaviour undergoes less significant changes in those individuals who are most disabled. We cannot draw direct links with the results of these studies on the basis of our patients' characteristics, though. The most likely explanation is that our diagnostic data describe evolving conditions, and the data on aggressive behaviour subsume many variants but do not indicate the dominance of a behaviour.</p> <p>In terms of patient age, a review of the literature by Davies & Oliver ([<reflink idref="bib13" id="ref43">13</reflink>] ) showed that, after the age of 40, self‐harming behaviour becomes significantly less prevalent, but there is a more moderate decline in aggressive behaviour. Our study does not provide grounds for such assertions; only three of the patients were under 40 years old, and there is no difference between them and the older ones on these measures. Still, the views expressed in the focus groups that patient ageing may explain the lower intensity of such behaviour is echoed in the literature. Totsika et al. ([<reflink idref="bib55" id="ref44">55</reflink>] ) found lower levels of behavioural disorder in subjects aged 50–90 years than in individuals under 50.</p> <p>The outcome for most of the patients in the study was positive in that they were subject to less SR. The factors found to contribute to this result accord with those identified in the literature. The importance attributed to unifying leadership supports the conclusions of Romijn & Frederiks ([<reflink idref="bib46" id="ref45">46</reflink>] ) who reviewed studies of SR reduction policies for people with intellectual disability. Strong managerial leadership and staff training head the list of common factors that helped limit SR use. In terms of organizational culture, a systematic quantitative review of the effectiveness of SR reduction programmes for people with developmental disorders found strategies that specifically target SR lead to more significant reductions than those that focus on managing agitation and aggression (Gaskin et al. [<reflink idref="bib20" id="ref46">20</reflink>] ). These findings are in line with our own results; the intellectual disability Psychiatry Programme calls for – and, indeed, has a committee dedicated to studying – clinical interventions that specifically target SR reduction.</p> <p>In terms of the characteristics of the people who work with this clientele, our research points to the role of flexibility and the capacity for reflection, among other things. In a study of 60 care providers, Boumans et al. ([<reflink idref="bib6" id="ref47">6</reflink>] ) suggest there is a relationship between a care team's reflexivity and the reduction in SR measures. None of our focus groups brought up care providers' previous experience in relation to violence. However, according to Hensel et al. ([<reflink idref="bib21" id="ref48">21</reflink>] ), the perception of the severity of aggression is correlated with emotional problems that care providers may have with violence, and it affects their interventions.</p> <p>In the course of our research, we recorded many interventions based on best practices in intellectual disability and severe behavioural disorder care that are geared to establishing and maintaining relations with patients and to finding meaning in order to identify the source of patients' behaviour through functional analysis. These interventions entailed employing objective, scientific data obtained in a systematic observation of triggers. In the care unit in our study, the functional analysis used incorporates biopsychosocio‐environmental variables and is thus of the multimodal type presented by Hunter & Wilkniss ([<reflink idref="bib24" id="ref49">24</reflink>] ). Similarly, a number of literature reviews underscore the point that interventions are most effective when assessments are carried out by a functional analysis of behaviour (Jones et al. [<reflink idref="bib27" id="ref50">27</reflink>] ; Heyvaert et al. [<reflink idref="bib22" id="ref51">22</reflink>] ; Thakker et al. [<reflink idref="bib54" id="ref52">54</reflink>] ; Davis et al. [<reflink idref="bib14" id="ref53">14</reflink>] ; Campbell et al. [<reflink idref="bib7" id="ref54">7</reflink>] ; Lloyd & Kenned [<reflink idref="bib32" id="ref55">32</reflink>] ). A study of 81 adults with intellectual disability also found that the use of functional analysis is one of the factors that predicts to decreased resort to SR (Mérineau‐Côté & Morin [<reflink idref="bib39" id="ref56">39</reflink>] ). Another study with 41 care providers (Snow et al. [<reflink idref="bib50" id="ref57">50</reflink>] ) concluded that functional analysis is protective against burnout. Indeed, care providers who had few explanations for their patients' behaviour or did not attempt to make a stable attribution for it displayed a higher degree of burnout. We found that care providers develop a positive attitude to patients through direct, meaningful contact in the patients' activities of daily life. The importance of a positive attitude is evidenced by a multilevel study of 121 people working with an intellectual disability clientele which demonstrated that a negative attitude on the part of the care team is strongly correlated with the frequent application of SR (Knotter et al. [<reflink idref="bib29" id="ref58">29</reflink>] ).</p> <p>We also observed that precise, detailed, personalized interventions (e.g. social scenarios) play an important role. Similarly, a systematic review by Ball & Fazil ([<reflink idref="bib4" id="ref59">4</reflink>] ) found that following routines, performing a sequence of tasks in a precise order, structured play and multisensory activities have a positive effect with SBD.</p> <p>Focus‐group participants often voiced the need to determine whether there were any physical causes behind a patient's behaviour; this concern is reflected in notes about medical assessments (e.g. EEG, neurological assessment, etc.) in the patient files. Such interventions are supported by Prokic's ([<reflink idref="bib45" id="ref60">45</reflink>] ) findings in her examination of secondary data on 296 men and women with intellectual disability that individuals who also had physical or mental problems were more likely to display aggressive behaviour. Furthermore, a systematic review to determine the physical conditions associated with SBD revealed a significant relationship between disruptive behaviour, urinary incontinence, pain, chronic sleep problems and visual deficits (De Winter et al. [<reflink idref="bib15" id="ref61">15</reflink>] ). As regards pharmacological interventions, a study by Bamidele & Hall ([<reflink idref="bib5" id="ref62">5</reflink>] ) suggests that efforts to reduce inappropriate medication, which can result as additional drugs are prescribed over the years, lead to improvements in functional capacity.</p> <p>Our findings concerning the value of family involvement are in line with data from James's ([<reflink idref="bib26" id="ref63">26</reflink>] ) review of the literature on individuals with intellectual disability and SBD, in which he stresses the value of constant communication between families and the staff working with their relative.</p> <p>Compared to the literature, our research casts little light on teaching activities for patients. A study to evaluate the effectiveness of an anger‐management intervention for adults with mild‐to‐moderate intellectual disability found that the lower cost of managing aggressive behaviour compensated for the costs incurred in developing the intervention (Felce et al. [<reflink idref="bib18" id="ref64">18</reflink>] ). The difficulty of verbal communication may well account for our meagre results on this score. However, it is plausible that many learning opportunities based on the use of social scenarios were simply not noted in the patient files.</p> <p>To sum up, the decrease in the application of SR observed in the intellectual disability Psychiatry Programme is apparently due to a combination of factors, including organizational culture, clinical leadership, care‐provider characteristics and evidence‐based interventions.</p> <hd id="AN0127932484-14">Limitations</hd> <p>Given potential biases, the results of our research have been considered with caution. As the study involved only two care units in the intellectual disability Psychiatry Programme of a single psychiatric hospital, the findings cannot be generalized. As for the data from patient files, there are probably inaccuracies in the care providers' notes, and some interventions may well have been omitted entirely. In the focus groups, the participants' statements may have been affected by social desirability bias. Lastly, the difficulty of communication meant that we could not elicit the patients' direct perceptions of their care.</p> <hd id="AN0127932484-15">Clinical Implications and Conclusion</hd> <p>This study casts light on the accomplishments of clinicians who seldom have the distance or the expertise to carry out a systematic examination of changes that may have occurred in their practice. The results show that SR measures, which are commonly applied to intellectual disability patients with severe behavioural disorders or who are heteroaggressive, may be reduced through an evidence‐based, multifactor approach. The characteristics of an organization's culture; the leadership of its management; the characteristics of the patients and their care providers; the exploration of interventions that target the physical environment; the establishment of a relationship that personalizes and individualizes treatment plans and care, including their pharmacological and physical aspects; the use of tools to support clinical judgement; patient teaching; and family involvement are all elements of best practice in an SR reduction programme. Such an approach must be constantly updated and reinforced.</p> <p>This study provides similar care units and teams working with populations displaying aggressive behaviour with matter for reflection. Eliciting the meaning of such behaviour by examining it and its biopsychosocial dimensions in a systematic manner; having care providers spend more time in contact with patients; and increasing family involvement are all relevant to other settings in which there is a desire to reduce SR use. Further research is needed to expand our understanding of the factors involved, including, for example, the severity of patients' hetero‐ and autoaggressive behaviour and their SR profile; care providers' perceptions of their previous experience as it relates to violence; and patients' perceptions of their care.</p> <hd id="AN0127932484-16">Acknowledgments</hd> <p>We wish to express our deep appreciation to the entire team of the IUSMM Intellectual Disability Psychiatry Programme, the individuals with intellectual disability and their families. We especially wish to thank Ms Céline Pommier, Ms Noémie Noiseux‐Lescop and Ms Kate Villeneuve for their collaboration and their thought‐provoking comments; and our research assistants, Farida Saadi and Alvine Claire Tsague, for their invaluable contribution.</p> <hd id="AN0127932484-17">Conflict of Interest</hd> <p>The authors have declared no conflict of interest.</p> <hd id="AN0127932484-18">Funding</hd> <p>The study received funding from de Institut universitaire en santé mentale de Montréal Foundation.</p> <ref id="AN0127932484-19"> <title>Notes</title> <blist> <bibl id="bib1" idref="ref2" type="bt">1</bibl> <bibtext>The patients's names have been changed to protect their identity. </bibtext> </blist> <blist> <bibl id="bib2" idref="ref19" type="bt">2</bibl> <bibtext>All verbatims in the text and in the tables have been translated from French. </bibtext> </blist> </ref> <ref id="AN0127932484-20"> <title>References</title> <blist> <bibtext>American Psychiatric Association. 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Sage, Thousand Oaks, CA. </bibtext> </blist> </ref> <p>PHOTO (COLOR): Mean hours of seclusion/period, 2008–2012</p> <p>PHOTO (COLOR): Mean hours of restraint/period, 2008–2012</p> <aug> <p>By Caroline Larue; Marie‐Hélène Goulet; Marie‐Josée Prevost; Alexandre Dumais and Jacques Bellavance</p> </aug>
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  Data: <searchLink fieldCode="AR" term="%22Larue%2C+Caroline%22">Larue, Caroline</searchLink><br /><searchLink fieldCode="AR" term="%22Goulet%2C+Marie-Hélène%22">Goulet, Marie-Hélène</searchLink><br /><searchLink fieldCode="AR" term="%22Prevost%2C+Marie-Josée%22">Prevost, Marie-Josée</searchLink><br /><searchLink fieldCode="AR" term="%22Dumais%2C+Alexandre%22">Dumais, Alexandre</searchLink><br /><searchLink fieldCode="AR" term="%22Bellavance%2C+Jacques%22">Bellavance, Jacques</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Journal+of+Applied+Research+in+Intellectual+Disabilities%22"><i>Journal of Applied Research in Intellectual Disabilities</i></searchLink>. Mar 2018 31(2):e212-e222.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 11
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2018
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Severe+Intellectual+Disability%22">Severe Intellectual Disability</searchLink><br /><searchLink fieldCode="DE" term="%22Patients%22">Patients</searchLink><br /><searchLink fieldCode="DE" term="%22Clinical+Diagnosis%22">Clinical Diagnosis</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Problems%22">Behavior Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Psychiatric+Hospitals%22">Psychiatric Hospitals</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Inclusion%22">Inclusion</searchLink><br /><searchLink fieldCode="DE" term="%22Case+Studies%22">Case Studies</searchLink><br /><searchLink fieldCode="DE" term="%22Focus+Groups%22">Focus Groups</searchLink><br /><searchLink fieldCode="DE" term="%22Caregivers%22">Caregivers</searchLink><br /><searchLink fieldCode="DE" term="%22Family+Involvement%22">Family Involvement</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Canada%22">Canada</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1111/jar.12309
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1360-2322
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: A cohort of 11 patients with an intellectual disability and a psychiatric diagnosis present severe behavioural disorders in psychiatric hospital of Quebec in 2009. Control-measure use for this clientele has now been reduced. How do management personnel, families and care teams explain the changes? What clinical interventions did management and care providers implement that contributed to the reduction? Method: A retrospective case study was conducted. Five focus groups were held with people involved in their care, and the patient files were examined. Results: The factors contributing to this change were the cohesion of the care providers, the involvement of the families and the efforts to determine the function of the behaviour. Implications: This study may inspire other care teams to try new approaches in dealing with patients with severe behavioural disorders. Also, the model of factors and interventions supporting a reduction in seclusion and restraint measures may inspire future studies.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2018
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1168775
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1168775
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      – Type: doi
        Value: 10.1111/jar.12309
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 11
        StartPage: e212
    Subjects:
      – SubjectFull: Severe Intellectual Disability
        Type: general
      – SubjectFull: Patients
        Type: general
      – SubjectFull: Clinical Diagnosis
        Type: general
      – SubjectFull: Behavior Problems
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      – SubjectFull: Psychiatric Hospitals
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      – SubjectFull: Foreign Countries
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      – SubjectFull: Inclusion
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      – SubjectFull: Case Studies
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      – SubjectFull: Focus Groups
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      – SubjectFull: Caregivers
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      – SubjectFull: Family Involvement
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      – SubjectFull: Intervention
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      – SubjectFull: Canada
        Type: general
    Titles:
      – TitleFull: Identification and Analysis of Factors Contributing to the Reduction in Seclusion and Restraint for a Population with Intellectual Disability
        Type: main
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            – TitleFull: Journal of Applied Research in Intellectual Disabilities
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