The Effects of Child-adult Relationship Enhancement (Care) Training in Reducing Restraints and Staff Injuries

Date of Submission


Degree Type


Degree Name

Doctor of Psychology (PsyD)



Department Chair

Stephanie H. Felgoise, PhD, ABPP

First Advisor

Susan Panichelli-Mindel, PhD

Second Advisor

Michelle Lent, PhD

Third Advisor

Julia Vahlsing, PsyD


Inpatient hospitalization provides a way to treat and stabilize children and adolescents with mental health issues, including externalizing behavioral problems. However, little research exists concerning effective evidence-based approaches to treating externalizing behaviors in inpatient psychiatric settings. Physical restraints, chemical restraints, and seclusion are often used to calm violent outbursts by patients, despite evidence indicating such measures cause psychological and physical trauma to patients and employees. The Child–Adult Relationship Enhancement (CARE) program is an alternative approach designed to reduce externalizing behaviors by fostering better relationships between patients and staff. CARE is based on the premise that when adults create positive interactions while working with children, the children's problematic behaviors diminish. CARE skills are designed for use with children between two and 18 years of age; these skills include identifying disruptive coercive cycles, improving adult-child relationships, and providing effective alternatives to physical discipline. This program evaluation examined whether use of restraints and staff injuries decreased after employees at inpatient behavioral health facilities adopted the CARE model. In addition, the program evaluation analyzed staff members’ perceptions concerning the intervention. If proven an effective intervention, CARE has the potential to benefit employee-patient relationships, reducing the need for restraints and decreasing staff injuries.

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