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This article identifies community-based alternatives to secure care being utilised in The Netherlands, Canada, Hawaii and Scotland. These countries offer ways to not only reduce or eliminate the need to deprive children and young people of their liberty in secure care but also reduce rates of child removal and alternative care placements. Secure care is the containment of children and young people, often subject to child protection interventions and residing in residential care, in a locked facility when they pose a significant risk of harm to the community and themselves. An admission to secure care exposes children to restrictive practices, such as seclusion, use of force and restraint. Jurisdictions have an ethical imperative, and often legislative obligation, to ensure there are less intrusive community-based supports available, which could be utilised instead of a secure care admission where possible. However, there is little research on what alternatives effectively divert secure care admissions. Hawaii, Canada, The Netherlands and Scotland demonstrate how countries can reduce the number of vulnerable children deprived of their liberty and exposed to restrictive practices by enhancing research linkages, responding to the voice of lived experience, and positioning secure care and alternatives within system-wide reform. [ABSTRACT FROM AUTHOR]

Trial Design: We present a study protocol for a multi-centre, randomised, double-blind, parallel-group, placebo-controlled trial that seeks to test the feasibility, acceptability and effectiveness of a 52-week period of treatment with the first-in-class co-stimulatory blocker abatacept for preventing or delaying the onset of inflammatory arthritis.Methods: The study aimed to recruit 206 male or female subjects from the secondary care hospital setting across the UK and the Netherlands. Participants who were at least 18 years old, who reported inflammatory sounding joint pain (clinically suspicious arthralgia) and who were found to be positive for serum autoantibodies associated with rheumatoid arthritis (RA) were eligible for enrolment. All study subjects were randomly assigned to receive weekly injections of investigational medicinal product, either abatacept or placebo treatment over the course of a 52-week period. Participants were followed up for a further 52 weeks. The primary endpoint was defined as the time to development of at least three swollen joints or to the fulfilment of the 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria for RA using swollen but not tender joints, whichever endpoint was met first. In either case, swollen joints were confirmed by ultrasonography. Participants, care givers, and those assessing the outcomes were all blinded to group assignment. Clinical assessors and ultrasonographers were also blinded to each other's assessments for the duration of the study.Conclusions: There is limited experience of the design and implementation of trials for the prevention of inflammatory joint diseases. We discuss the rationale behind choice and duration of treatment and the challenges associated with defining the "at risk" state and offer pragmatic solutions in the protocol to enrolling subjects at risk of RA.Trial Registration: Current Controlled Trials, ID: ISRCTN46017566 . Registered on 4 July 2014. [ABSTRACT FROM AUTHOR]