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Abstract

Background: Seclusion and restraint are interventions used in the treatment and management of disruptive and violent behaviours in psychiatry. The use of seclusion varies widely across institutions. The literature does offer numerous suggestions for interventions to reduce or prevent aggression.

Objectives: 1. To estimate the effects of seclusion and restraint compared to the alternatives for those with serious mental illnesses. 2. To estimate the effects of strategies to prevent seclusion and restraint in those with serious mental illnesses.

Search strategy: Electronic searches of The Cochrane Controlled Trials Register (Issue 1, 1999) and The Cochrane Schizophrenia Group's Register (January 1999) were supplemented with additional searches of Biological Abstracts (1989-1999), CINAHL (1982-1999), EMbase (1980-1999), MEDLINE (1966-1999), MEDIC (1979-1999), PsycLIT (1974-1999), Sociofile (1974-1999), SPRI & SWEMED (1982-1999), Social Sciences Citation Index (1996-1999), and WILP (1983-1999). In addition, trials were sought by hand searching the reference lists of all identified studies and conference abstracts and contacting the first author of each relevant study.

Selection criteria: Randomised controlled trials were included if they focused on the use (i) of restraint or seclusion; or (ii) of strategies designed to reduce the need for restraint or seclusion in the treatment of serious mental illness.

Data collection and analysis: Studies were reliably selected, quality rated and data extracted. For dichotomous data relative risks (RR) with 95% confidence intervals (CI) were estimated. Normal continuous data were summated using the weighted mean difference (WMD).

Main results: 1. Effect of seclusion and restraint The search strategy yielded 2155 citations. Of these, the full articles for 35 studies were obtained. No studies met minimum inclusion criteria and no data were synthesised. Most of the 24 excluded studies focused upon the restraint of elderly, confused people and preventing them from wandering or falling. 2. Prevention of seclusion and restraint Work ongoing.

Reviewer's conclusions: No controlled studies exist that evaluate the value of seclusion or restraint in those with serious mental illness. There are reports of serious adverse effects for these techniques in qualitative reviews. Alternative ways of dealing with unwanted or harmful behaviours need to be developed. Continuing use of seclusion or restraint must therefore be questioned from within well-designed and reported randomised trials that are generalisable to routine practice.

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Conflict of interest statement

The reviewers believe that seclusion and restraint can be used to excess and that the least restrictive principle is often not sought.

Cited by

Factors relating to the use of physical restraints in psychogeriatric care: a paradigm for elder abuse.

Bredthauer D, Becker C, Eichner B, Koczy P, Nikolaus T. Bredthauer D, et al. Z Gerontol Geriatr. 2005 Feb;38(1):10-8. doi: 10.1007/s00391-005-0285-y. Z Gerontol Geriatr. 2005. PMID: 15756482

The methodical work approach and the reduction in the use of seclusion: how did it work?

Boumans CE, Walvoort SJ, Egger JI, Hutschemaekers GJ. Boumans CE, et al. Psychiatr Q. 2015 Mar;86(1):1-17. doi: 10.1007/s11126-014-9321-7. Psychiatr Q. 2015. PMID: 25270895

References

References to studies excluded from this review

Evans 1997 {published data only}

References to studies awaiting assessment

ISRCTN49454276 {published data only}

ISRCTN49454276. Trec‐save: A trial for aggressive or violent seriously mentally ill people. http://www.controlled‐trials.com 2011. - PMC - PubMed

Additional references

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national center for biotechnology information

# data[].attributes.attachment_link.title
Seclusion and restraint for people with serious mental illnesses - PubMed

# data[].attributes.attachment_link.description
No controlled studies exist that evaluate the value of seclusion or restraint in those with serious mental illness. There are reports of serious adverse effects for these techniques in qualitative reviews. Alternative ways of dealing with unwanted or harmful behaviours need to be developed. Continui ...

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Protocols to reduce seclusion in inpatient mental health units - PubMed

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The use of seclusion to manage conflict behaviours in psychiatric inpatient settings is increasingly viewed as an intervention of last resort. Many protocols have, thus, been developed to reduce the practice. We conducted a systematic review to determine the effectiveness of protocols to reduce secl …

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Development and evaluation of a de-escalation training intervention in adult acute and forensic units: the EDITION systematic review and feasibility trial - PubMed

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Conflict (a term used to describe a range of potentially unsafe events including violence, self-harm, rule-breaking, medication refusal, illicit drug and alcohol use and absconding) in mental health settings causes serious physical and psychological harm. Containment interventions which are intended …

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Effectiveness of Music Therapy for Autism Spectrum Disorder, Dementia, Depression, Insomnia and Schizophrenia - Repository of AIHTA GmbH

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Effectiveness of music therapy in children with autism spectrum disorder: A systematic review and meta-analysis - PubMed

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MT can improve social skills in children with ASD; however, there does not seem to be a consensus on the persistence of its effects. These findings can inform clinical practice. Promoting the use of MT in children with ASD and improving its symptoms are the ultimate goals.

# data[].attributes.attachment_link.readable_text
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Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure.
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Affiliations

¹ GAMUT-The Grieg Academy Music Therapy Research Centre, Uni Research Health, Uni Research, Bergen, Norway.

² Melbourne Conservatorium of Music, University of Melbourne, Melbourne, Australia.

³ Department of Communication and Psychology, Aalborg University, Aalborg, Denmark.

⁴ Postgraduate Program in Child and Adolescent Health, Faculty of Medicine, Rio Grande do Sul Federal University, Porto Alegre, Brazil.

⁵ School for Creative Arts Therapies, University of Haifa, Haifa, Israel.

⁶ Music Therapy Program, David-Yelin College, Jerusalem, Israel.

⁷ IRCCS Stella Maris Foundation, Pisa, Italy.

⁸ Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.

⁹ Jeonju University, Jeonju, South Korea.

¹⁰ Centre for Psychiatry, Imperial College London, London, United Kingdom.

¹¹ Anglia Ruskin University, Cambridge, United Kingdom.

¹² Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom.

¹³ Rebecca Center for Music Therapy at Molloy College, Rockville Centre, New York.

¹⁴ Personal Social Services Research Unit, LSE Health and Social Care, The London School of Economics and Political Science, London, United Kingdom.

¹⁵ Villa Santa Maria Institute, Tavernerio, Italy.

Randomized Controlled Trial

Affiliations

¹ GAMUT-The Grieg Academy Music Therapy Research Centre, Uni Research Health, Uni Research, Bergen, Norway.

² Melbourne Conservatorium of Music, University of Melbourne, Melbourne, Australia.

³ Department of Communication and Psychology, Aalborg University, Aalborg, Denmark.

⁴ Postgraduate Program in Child and Adolescent Health, Faculty of Medicine, Rio Grande do Sul Federal University, Porto Alegre, Brazil.

⁵ School for Creative Arts Therapies, University of Haifa, Haifa, Israel.

⁶ Music Therapy Program, David-Yelin College, Jerusalem, Israel.

⁷ IRCCS Stella Maris Foundation, Pisa, Italy.

⁸ Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.

⁹ Jeonju University, Jeonju, South Korea.

¹⁰ Centre for Psychiatry, Imperial College London, London, United Kingdom.

¹¹ Anglia Ruskin University, Cambridge, United Kingdom.

¹² Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom.

¹³ Rebecca Center for Music Therapy at Molloy College, Rockville Centre, New York.

¹⁴ Personal Social Services Research Unit, LSE Health and Social Care, The London School of Economics and Political Science, London, United Kingdom.

¹⁵ Villa Santa Maria Institute, Tavernerio, Italy.

Abstract

Importance: Music therapy may facilitate skills in areas affected by autism spectrum disorder (ASD), such as social interaction and communication.

Objective: To evaluate effects of improvisational music therapy on generalized social communication skills of children with ASD.

Design, setting, and participants: Assessor-blinded, randomized clinical trial, conducted in 9 countries and enrolling children aged 4 to 7 years with ASD. Children were recruited from November 2011 to November 2015, with follow-up between January 2012 and November 2016.

Interventions: Enhanced standard care (n = 182) vs enhanced standard care plus improvisational music therapy (n = 182), allocated in a 1:1 ratio. Enhanced standard care consisted of usual care as locally available plus parent counseling to discuss parents' concerns and provide information about ASD. In improvisational music therapy, trained music therapists sang or played music with each child, attuned and adapted to the child's focus of attention, to help children develop affect sharing and joint attention.

Main outcomes and measures: The primary outcome was symptom severity over 5 months, based on the Autism Diagnostic Observation Schedule (ADOS), social affect domain (range, 0-27; higher scores indicate greater severity; minimal clinically important difference, 1). Prespecified secondary outcomes included parent-rated social responsiveness. All outcomes were also assessed at 2 and 12 months.

Results: Among 364 participants randomized (mean age, 5.4 years; 83% boys), 314 (86%) completed the primary end point and 290 (80%) completed the last end point. Over 5 months, participants assigned to music therapy received a median of 19 music therapy, 3 parent counseling, and 36 other therapy sessions, compared with 3 parent counseling and 45 other therapy sessions for those assigned to enhanced standard care. From baseline to 5 months, mean ADOS social affect scores estimated by linear mixed-effects models decreased from 14.08 to 13.23 in the music therapy group and from 13.49 to 12.58 in the standard care group (mean difference, 0.06 [95% CI, -0.70 to 0.81]; P = .88), with no significant difference in improvement. Of 20 exploratory secondary outcomes, 17 showed no significant difference.

Conclusions and relevance: Among children with autism spectrum disorder, improvisational music therapy, compared with enhanced standard care, resulted in no significant difference in symptom severity based on the ADOS social affect domain over 5 months. These findings do not support the use of improvisational music therapy for symptom reduction in children with autism spectrum disorder.

Trial registration: isrctn.org Identifier: ISRCTN78923965.

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Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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national center for biotechnology information

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Effects of Improvisational Music Therapy vs Enhanced Standard Care on Symptom Severity Among Children With Autism Spectrum Disorder: The TIME-A Randomized Clinical Trial - PubMed