Kim J. Masters, M.D. and
Joseph V. Penn, M.D.

I am very fortunate to share the writing of this column with Joseph V. Penn, M.D., CCHP, the AACAP representative to the National Commission on Correctional Health Care (NCCHC). Dr. Penn is Clinical Assistant Professor at Brown University Medical School and Director of Child and Adolescent Forensic Psychiatry at Rhode Island Hospital. I also thank AACAP member Louis J. Kraus, M.D., Woman’s Board Professor of Child and Adolescent Psychiatry and Chief, Section of Child and Adolescent Psychiatry at Rush University Medical Center, for his suggestions and review of this article.

Kim J. Masters, M.D.

Youth with mental illness present a special challenge to the juvenile justice system. While epidemiological studies on the prevalence of mental and substance-related disorders among youth in the juvenile justice system are limited, research suggests that these problems are significantly more common among youthful offenders than in other youth (Cocozza, 1992; Atkins et al., 1999; Garland et al., 2001). While as many as 65%-75% of youthful offenders have one or more diagnosable psychiatric disorders (Teplin et al., 2002; Wasserman et al., 2003), most juvenile detention facilities do not have the capacity to serve them. This situation is aggravated by multiple problems, including overcrowding, dilapidated institutions, inadequate funding for services and programs, and inadequately trained custodial and mental health staff. These factors are associated with an increased risk of suicide, physical assaults, and accidental injuries (National Juvenile Detention Association, 2000).

In 1990, Jeffrey Mitchell, M.D. and Christopher Varley, M.D., two child psychiatrists, studied isolation and restraint in juvenile correctional facilities. They noted in summary: “Until more accurate observations are made, the authors tentatively conclude that juvenile correctional facilities use a wider range of interventions than psychiatric facilities, with abusive isolation and restraint practices at one end of the spectrum (Mitchell and Varley, 1990). The reasons for this included the remote location of some facilities that put them out of range for professional consultations, the lack of procedure manuals, and for many, lack of accreditation by the National Commission on Correctional Health Care (NCCHC).”

According to Judith Stanley, MS, CCHP-A, Director of Accreditation at the NCCHC, 63 out of an estimated 1,800 juvenile correctional-type facilities in the United States and Puerto Rico (including boot camps, training schools, county and state detention and confinement places), are accredited by them. NCCHC has compliance measures for “segregated juveniles” and for mechanical restraints. Performance measures of these are currently optional.

Thus the treatment of juveniles in restraints or seclusions varies from state to state and even within states. Furthermore, how regulations are defined and applied may also vary from one facility or one jurisdiction to the next. A brief review of state juvenile correctional web sites shows the diversity of the application of restrictive interventions. If you have some free time when you are exploring the web, visit some state juvenile justice sites for a view of this situation. To encourage you to go online, I have included several web addresses below.

The care and management of children and adolescents in America’s criminal justice system is well known for its inadequacy, abusiveness, and neglect. The Amnesty International web site gives an overview of this situation (http://web.amnesty.org/ library/Index/engAMR510601998).

The use of seclusion and restraint varies from prohibition in South Dakota, which may have resulted partly from a 60 Minutes II exposé, to the use of the restraint chair in Maine and New Jersey. (The 60 Minutes II program of January 2001, detailed the lack of attention to psychiatric illness and the extensive mistreatment of Dean Honomichl through boot camp and juvenile prison in South Dakota. For more information about the 60 Minutes II exposé, go to http:// cbsnews.com/stories/2002/01/02/31/ health/main326832.shtml.) Florida also recently banned the use of abusive holds and the restraint chair. For more information about these states’ seclusion and restraint policies, visit their respective web sites at:

It appears that most of the reform is driven by horror stories of mistreatment or deaths, which then cause investigations and ultimately changes in the regulations in that facility or legal jurisdiction. It appears that state, rather than national, policy has the most influence in the way that restrictive intervention regulations about children and adolescents are written. Local jurisdictions, however, determine how they are applied.

However, there have been national demonstration projects aimed at demonstrating the effectiveness of strength based and trauma based approaches to dealing with aggression and violence in the juvenile justice system. One of these is the Sanctuary model. According to the web site that describes the model (http://www. sanctuaryweb.com/main/NCTSN. htm), up to 50% of juveniles in the system have post traumatic stress disorder (PTSD). It recommends a thorough evaluation of all children and adolescents for this. Based on its results, a treatment is developed which stresses providing a safe environment through changing the institutional culture and focusing on trauma based healing. This model has been shown to result in significant reductions in the use of restrictive interventions.

An example of a strength based initiative to reduce seclusion and restraint occurred in an intermediate care service for severely disturbed adolescents. Using information from seclusion and restraint debriefing sessions, staff modified seclusion and restraint practices, resulting in a dramatic reduction in their use. (Mohr, Petti, et al 2001). The paper has potential implications for decreasing restrictive interventions in the juvenile correctional system.

The Office of Juvenile Justice and Delinquency Prevention (OJJDP) has A A A played a prominent role in attempts to reform the system as its web site delineates (http://ojjdp.ncjrs.org). Its mission statement describes OJJDP’s role: “to provide national leadership, coordination, and resources to prevent and respond to juvenile delinquency and victimization. OJJDP supports states and communities in their efforts to develop and implement effective and coordinated prevention and intervention programs and to improve the juvenile justice system so that it protects public safety, holds offenders accountable, and provides treatment and rehabilitative services tailored to the needs of juveniles and their families.”

The use of “chemical restraints” in the juvenile justice system is particularly problematic; some states now ban this practice. Amnesty International and the Child Welfare League oppose the practice. For more information, see their respective web sites at http://www.nospank.net/ai-rpt3.htm and http:// www.cwla.org/advocacy/secres000531.htm. As I have pointed out in this column previously, if one uses the Centers for Medicare and Medicaid Services’ (CMS) definition of chemical restraint—a medication not used for a patient’s psychiatric condition, and one which is intended to immobilize the patient—then probably no child and adolescent psychiatrist uses or should use chemical restraints.

Furthermore, as Dr. Penn notes, ”it is important to distinguish between a disciplinary restraint (that we should not be involved in, should not assist with, should not order, but should make sure that nursing or other health professionals monitor youths and make sure they are not injured) and a therapeutic restraint,” (Penn 2004).

AACAP’s upcoming Practice Parameter for the Assessment and Treatment of Youth in Juvenile Detention and Correctional Facilities addresses restrictive interventions also:

“Recommendation 11. Clinicians should be knowledgeable about the facility’s policies and procedures regarding seclusion, physical restraints, and forced psychotropic medication, and in support of humane care, should advocate for the selective use of restrictive procedures only when needed to maintain safety or when less restrictive measures have failed [CG].”

By one estimate there at least 11,000 children and adolescents in the Juvenile Justice System. It is possible that restrictive interventions pose the greatest danger both physically and psychologically to them. I hope that this column will be one pathway to stimulate interest in working in this field, and to promote support and communication with Academy members who are actively involved in the care of these young people.

Dr. Masters is Chief Medical Officer of ABS New Hope Treatment Centers and Assistant Clinical Professor of Health and Behavior at the Medical College of Georgia.

References
Atkins DL, Pumariega AJ, Montgomery L, Rogers K, Nybro C, Jeffers G, Sease F. Mental health and incarcerated youth. Prevalence and Nature of Psychopathology. Journal of Child and Family Studies. 1999; 8(2):193-204.

Cocozza JJ, Ed. Responding to the mental health needs of youth in the juvenile justice system. Seattle: National Coalition for the Mentally Ill in the Criminal Justice System; 1992.

Garland AF, Hough RL, McCabe KM, Yeh M, Wood PA, Aarons GA. Prevalence of psychiatric disorders in youths across five sectors of care. J Am Child Adolesc Psychiatry. 2001; 40:409-418.

Mitchell, J, & Varley, C. Isolation and Restraint in Juvenile Correction Facilities. J.Am.Acad.Child Psychiatry. 1990; 29: 251-255.

National Juvenile Detention Association. Position statements. URL: http://www.njda.com/position.html. 2000. Accessed on 7/6/2000.

Penn, JV Use of Psychotropic Medications with Incarcerated Youth. Standards for Health Services in Juvenile Detention and Confinement Facilities National Commission on Correctional Health Care: 2004; 263-265. Penn JV, Thomas CR. AACAP Work Group on Quality Issues. Practice Parameter for the Assessment and Treatment of Youth in Juvenile Detention and Correctional Facilities (in press). 2005.

Petti, TA, Mohr, WK, Somers, JW, and Sims, L Perception of Seclusion and Restraint in an Intermediate-Term Care Facility. Journal of Child and Adolescent Psychiatric Nursing. July-September 2001.

Teplin LA, Abram KM, McClelland GM, Dulcan MK, Mericle A. Psychiatric disorders in youth in juvenile detention. Arch Gen Psychiatry. 2002; 59:1133-43.

Wasserman GA, Jensen PS, Ko SJ, et al. Mental Health Assessments in Juvenile Justice: Report on the Consensus Conference. J Am Acad Child Adolesc Psychiatry. 2003; 42:752-761.