Restraint and seclusion use in U.S. school settings: recommendations from allied treatment disciplines.

Restraint and seclusion (R&S) are high risk, emergency procedures that are used in response to perceived violent, dangerous situations. They have been employed for years in a variety of settings that serve children, such as psychiatric hospitals and residential treatment facilities, but are now being recognized as used in the public schools. The field of education has begun to examine these practices in response to national scrutiny and a Congressional investigation. The fields of mental health and child welfare were similarly scrutinized 10 years ago following national media attention and have advanced R&S practice through the adoption of a prevention framework and core strategies to prevent and reduce use. A review of the evolution of the national R&S movement, the adverse effects of these procedures, and a comprehensive approach to prevent their use with specific core strategies such as leadership, workforce development, and youth and family involvement in order to facilitate organizational culture and practice change are discussed. Proposed guidelines for R&S use in schools and systemic recommendations to promote R&S practice alignment between the child-serving service sectors are also offered.

Restraints and the code of ethics: An uneasy fit.

This article examines the use of physical restraints through the four broad principles of ethics common to all helping professions. It asks whether the continued use of physical restraints is consistent with ethical practice through the lens of those principles. It also examines where the necessity to use restraints in the absence of empirically supported alternatives leaves professionals in terms of conflicts between ethical principles and makes recommendations for changes in education and clinical practice. It concludes that an analysis through a bioethics lens demonstrates that the use of restraints as a tool in psychiatric settings is a complex and multifaceted problem. Principles of ethics may often be in conflict with each other in instances where patients must be physically restrained.

Tied up and isolated in the schoolhouse.

In 1999, the United States General Accountability Office (USGAO) investigated restraints and seclusion use in mental health settings and found patterns of misuse and abuse. A decade later, it found the same misuse and abuse in schools. Restraints and seclusion are traumatizing and dangerous procedures that have caused injury and death. In the past decade, restraints and seclusion have gone from being considered an essential part of the psychiatric mental health toolkit to being viewed as a symptom of treatment failure. In most mental health settings, the use of restraints and seclusion has plummeted due to federal regulations, staff education, and concerted effort of psychiatric national and local leadership. The purpose of this article is to provide a background to and an overview of the present imbroglio over restraints and seclusion in public and private schools, articulate their dangers, dispel myths and misinformation about them, and suggest a leadership role for school nurses in reducing the use of these procedures.

Still shackled in the land of liberty: denying children the right to be safe from abusive "treatment".

The troubled-teen industry has come under federal scrutiny after over a decade of reported abuses and the reported deaths of at least 10 children. This article provides a brief overview of the development of the troubled-teen industry, addresses the thorny issue of parents' right to send their children to these facilities vis-a-vis the rights of their children, and argues that nurses and other health professionals have a collective obligation to speak out against them in the strongest possible terms. Suggestions for action by nurses are proposed that could protect vulnerable children against this continuous cycle of institutionalized child abuse masquerading as therapy.

Beyond point and level systems: moving toward child-centered programming.

Many residential treatment facilities and child inpatient units in the United States have been structured by way of motivational programming such as the point and/or level systems. On the surface, they appear to be a straightforward contingency management tool that is based on social learning theory and operant principles. In this article, the authors argue that the assumptions upon which point and level systems are based do not hold up to close empirical scrutiny or theoretical validity, and that point and level system programming is actually counterproductive with some children, and at times can precipitate dangerous clinical situations, such as seclusion and restraint. In this article, the authors critique point and level system programming and assert that continuing such programming is antithetical to individualized, culturally, and developmentally appropriate treatment, and the authors explore the resistance and barriers to changing traditional ways of "doing things." Finally, the authors describe a different approach to providing treatment that is based on a collaborative problem-solving approach and upon which other successful models of treatment have been based.

Spiritual issues in psychiatric care.

This article differentiates between the concepts of spirituality and religion and analyzes the strengths and weaknesses of the research findings related to spirituality, religion, and mental health. To discuss the importance of clarifying values and becoming self-aware in relation to implementing spiritual and religious interventions. The components of spiritual assessment are presented as well as spiritual coping practices and interventions the nurse might use when working with clients. Review of literature from MEDLINE, CINAHL, and current texts. Spirituality and religion are too often neglected foci of psychiatric mental health assessment and intervention. In order to maximize therapeutic effectiveness, nurses should be aware that for many patients spirituality is a critical life factor. Accordingly, they should screen patients and strive to meet patient needs for spiritual expression, while recognizing that there are important boundary and ethical issues in psychiatric mental health settings.

Level systems: inpatient programming whose time has passed.

TOPIC: Structuring of inpatient behavioral programming in child-adolescent psychiatric, residential treatment, and juvenile justice settings. PURPOSE: To review the underlying theory underpinning current practices and recommend remedies to the uncovered problems. SOURCES: A review of the literature from 1965 to 2001 from selected nursing and medical psychiatric and mental health publications. CONCLUSIONS: Intensive professional and staff education and greater precision in communication about patients' behaviors are needed in many settings. There is also a need to move away from generic treatment approaches and return to individual treatment planning based on individual assessments and the unique needs of an increasingly volatile and complex in-patient population.

Surfacing the life phases of a mental health support group.

Support groups have increased rapidly in number and become a viable alternative to formal treatment in the United States. However, little is known regarding how mental health advocacy or support groups start and develop, or about challenges that can threaten their survival. In this 2 1/2-year ethnography, the author studied the culture of a developing family support program associated with a system of care. Several phases emerged, reflecting an organizational dynamic. The group dynamics and response to challenges have implications for organizers and parent organizations about the need for technical assistance necessary for survival of the group. Participant observation and immersion in the culture of such groups can provide a deeper understanding of the ideologies and values around which they organize and the kinds of tensions that members can experience during the group's cycle.

Discarding ideology: the nature/nurture endgame.

TOPIC: The concepts and research that underpin our understanding of how the brain is the organ of the mind. PURPOSE: To describe the dynamic nature of nervous system functioning and development; to discuss how the nervous system changes anatomically throughout the lifespan; to examine the vital role and interaction of genetics and environment; and to discuss the relationship among the brain, neurotransmission, genes, and psychiatric illness. SOURCES: Published literature. CONCLUSIONS: The latest research from the neurosciences lays to rest any suggestion that psychiatric illnesses are psychologically induced.

The substance of a support group.

This ethnographic research constitutes a study of the culture of a family-run advocacy organization for families of children and youth with mental health needs. Data collection includes 703 pages of interview transcripts, observations, field notes, and archival material collected by the principle investigator during 2.5 years of participant observation with this support group. This article provides the context for the study and describes the support group's cultural ideologies and cultural forms that are a concrete expression of those ideologies: There are four major categories of cultural forms as follows: symbols, language, narratives or stories, and practices. Manifestations of each form are discussed and described. The proliferation of support and advocacy groups in the mental health arena promises a rich source of understanding of the needs of families in distress as well as inspiration for new and practical interventions.

Adverse effects associated with physical restraint.

OBJECTIVE: Restraint use is not monitored in the US, and only institutions that choose to do so collect statistics. In 1999, investigative journalists reported lethal consequences proximal to restraint use, making it a life-and-death matter that demands attention from professionals. This paper reviews the literature concerning actual and potential causes of deaths proximal to the use of physical restraint. METHOD: Searching the electronic databases Medline, Cinahl, and PsycINFO, we reviewed the areas of forensics and pathology, nursing, cardiology, immunology, psychology, neurosciences, psychiatry, emergency medicine, and sports medicine. CONCLUSIONS: Research is needed to provide clinicians with data on the risk factors and adverse effects associated with restraint use, as well as data on procedures that will lead to reduced use. Research is needed to determine what individual risk factors and combinations thereof contribute to injury and death.

The Dawn Project: a model for responding to the needs of children with emotional and behavioral challenges and their families.

Systems of care represent a fundamental departure from traditional service provision by espousing genuine family-centered, culturally competent philosophies and blending the funding streams of multiple payers (e.g., education, mental health, child welfare). In Marion County, Indiana, local leaders created a system of care based on these principles called the Dawn Project. Currently, a comprehensive, multidisciplinary evaluation is being implemented to evaluate the program. Preliminary findings from initial evaluation efforts suggest that for youth in the project, there is significant clinical improvement during the first year of receiving services, a reduction in the use of more restrictive settings, and a decrease in recidivism among those who successfully complete the program.

Reconsidering punitive and harsh discipline.

Corporal punishment and other harsh interventions continue to be widespread despite the fact that the leading theories or models of behavioral management do not support their effectiveness. There is overwhelming evidence that harsh interventions are damaging to children, both emotionally and physically. The effects of such trauma may be compounded when a child has preexisting learning difficulties. When schools respond to these challenges using harsh methods, children can be further traumatized. The authors review principles of childhood neurodevelopment, describe a model to understand children in context, and discuss how exposure to certain noxious sensory experiences can affect children's responses to threat or perceived threat. They also describe implications for school nurses.