Monday, August 12, 2019

Behavior Modification Found to Be Effective for Managing Pediatric Aggression

A behavior modification program that features positive and negative incentives reduced the use of psychotropic medications and/or physical interventions to manage agitated outbursts in children hospitalized for aggression, compared with a program that relied on verbal de-escalation techniques. The findings were published online by the Journal of the American Academy of Child & Adolescent Psychiatry.

“[O]ur data support the effectiveness of the [behavior modification program] and suggest that verbal attempts to calm the raging child can be counterproductive,” wrote Gabrielle Carlson, M.D., of the Renaissance School of Medicine at Stony Brook University and colleagues.

Carlson and colleagues assessed research and medical records of five cohorts of children admitted to Stony Brook’s 10-bed children’s psychiatric inpatient unit for aggressive behavior between 2008 and 2018. During this time, the facility transitioned away from a behavior modification program (BMP)—which involved collaborative problem-solving therapy coupled with positive rewards for good behavior and “time outs” for bad behavior—to reduce aggression. The unit switched to a program that used verbal de-escalation or distraction to talk children down from what the authors described as “intensely emotional situations.” Carlson and colleagues noted the switch was due to a perceived inability to provide enough incentives for good behavior as well as a belief that “time outs” were a form of physical restraint.

The final analysis included 347 children admitted during BMP use and 163 admitted during de-escalation use. The researchers found that the use of medications like sedatives or antipsychotics to reduce agitation was significantly lower when BMP was in use. “As needed” medical sedation was used 163 times per 1,000 patient-days when BMP was used compared with 483 times per 1,000 patient-days when de-escalation was used. The need for seclusion or physical restraint also was lower with BMP than with de-escalation (17 times versus 65 times, respectively, per 1,000 patient-days).

“Perhaps the increased attention given to the agitated child by continually talking to him/her, encouraging skill use, and sometimes giving children what they wanted to limit frustration inadvertently reinforced the unwanted behaviors,” wrote Carlson and colleagues as a possible explanation for why verbal de-escalation strategies increased the use of medication and/or restraint. They also suggested that under the de-escalation strategy children may have learned that aggression was a good way to avoid doing an unpleasant task, since staff sometimes let children get their way to calm them. However, the authors also noted the differences seen in outcomes between the two approaches may have been the result of the staff being less familiar with the technique. “It is possible that staff wasn’t adequately trained to execute de-escalation interventions correctly, biasing findings in favor of [BMP],” they wrote.

To read more about this topic, see the American Journal of Psychiatry article “Brain Mechanisms of Attention Orienting Following Frustration: Associations With Irritability and Age in Youths.”

(Image: iStock/KatarzynaBialasiewicz)


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