If you feel angry, sit on your hands and think about pizza." This is not something you would necessarily expect a child psychiatrist to say to a patient, but Kim Masters, M.D., has found that it works in children with aggressive behavior.

Masters, medical director of a private psychiatric hospital 75 miles south of Savannah, Ga., on St. Simons Island, explained to Psychiatric News, "When children are sitting on their hands, they can’t throw things or get into a fight. If they are thinking about pizza, they are distracted from whatever is making them angry."

Masters and child psychiatrist Christopher Bellonci, M.D., describe several practical techniques like this from anger management and crisis de-escalation programs in the United States in a new practice "parameter" from the American Academy of Child and Adolescent Psychiatry (AACAP).

The practice parameter emphasizes that teaching children these techniques can prevent the aggressive behaviors that can lead to the need to use seclusion and restraint in psychiatric institutions, including hospitals and residential treatment centers.

The practice parameter discusses behavioral strategies that are nonrestrictive, restrictive, and highly restrictive. The last category includes seclusion and different types of restraint. Also covered is how to use incidents in which seclusion or restraint was used to promote alternative strategies.

Preventing aggressive behavior in children begins with diagnosing and treating the underlying psychiatric illness, according to the practice parameter. "The evaluation of a patient should include a review of aggressive behavior including triggers, warning signs, repetitive behaviors, response to treatment, and prior seclusion and restraint events associated with aggressive acts. [MS]"

MS stands for "minimal standard," which means there is substantial empirical evidence for the recommendation, and it should be applied in all cases unless there is a compelling reason not to follow the standard. All recommendations and techniques in the practice parameter are rated. Other ratings are "CG," which stands for "clinical guidelines" and recommendations based on empirical evidence; "OP," which stands for "options" and refers to practices that are acceptable but not required; and "NE," which stands for "not endorsed."

Treatment planning should include strategies to prevent aggressive behavior, de-escalate negative behavior before it becomes necessary to use restrictive interventions, and psychological and pharmacological treatments for the underlying illness.

"We teach children how to recognize the triggers of aggressive behaviors with the acronym HALTS, which stands for Hungry, Angry, Lonely, Tired, and (keeping) Secrets," said Masters in an interview.

Masters explained that "keepers of secrets become somewhat paranoid in dealing with others and so are irritable and more prone to get angry."

"We encourage children, when one or more of these factors is present, to let the staff know that so they can help monitor [the children’s] behavior and prevent them from blowing up," said Masters.

Training staff how to manage children’s aggressive behaviors is another important component of prevention, said Masters. "Staff work with children on these techniques through role playing and repeated practice. If children need a timeout in a seclusion room, we use that as an opportunity to review the anger management techniques to prevent further escalations."

The practice parameter encourages hospital staff and the admitting physician to communicate the concepts of self-responsibility and self-control to patients before they are admitted and to enlist the parents’ support.

The emphasis should always be on prevention from the first contact with the patient to discharge, said Masters. This approach has resulted in eliminating the use of restraint in the last year and a half that he has been medical director of the Georgia psychiatric hospital.

"We use seclusion about once every other month, compared with seven or eight times a month when I arrived," said Masters. The psychiatric hospital he directs treats an average of 10 children and adolescents at a time.

However, many psychiatric inpatient facilities including residential treatment centers for children "do not hire enough qualified staff to run a program and engage in prevention work with aggressive children at the same time. So crises escalate into seclusions or restraints to keep order," said Masters.

He recommends having a nursing staff-to-patient ratio of 1-to-6. "Each unit should have a registered nurse [R.N.] as the head of the nursing staff, and there should be an R.N. and at least one other nurse on each unit," he said. In addition, the staffing ratio should be flexible enough to allow for one-on-one monitoring of patients when the need arises.

The practice parameter mentions the need for staff training and describes how to involve staff in the prevention and management of aggressive behaviors and seclusion and restraint, as well as when and when not to use the restrictive procedures.

The practice parameter also describes relevant sections of the interim final rule on seclusion and restraint from the Department of Health and Human Services and seclusion and restraint standards from the Joint Commission on Accreditation of Healthcare Organizations.

AACAP members may download "Prevention and Management of Aggressive Behavior With Special Reference to Seclusion and Restraint" at no charge by going to the "Members Only" section of the AACAP Web site at www.aacap.org. Nonmembers have to pay $15; more information is available online at www.aacap.org/publications/pubcat/guideline.htm or by phone at (202) 966-7300. Masters can be reached by e-mail at KMASTER105@earthlink.net. ▪