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Isolation and Restraint in Juvenile Correctional Facilities
Isolation and Restraint in Juvenile Correctional Facilities JEFF MITCHELL , M .D., AND CHRISTOPHER VARLEY, M .D . Abstract. Although mental health and correctional programs for juveniles house similar populations, their approaches to behavioral management can be quite different. This difference is evident in the use of isolation and restraint. Both of these interventions are effective behavioral management tools but are subject to abuse if not closely monitored. The authors. drawing from their experiences as mental health consultants to juvenile correctional programs and as expert witnesses in litigation, review the wide range of isolation and restraint practices in correctional programs and make recommendations for supervision and standardization. J. Am . Acad. Child Ado lesc. Psychiat ry 1990.29, 2:251-255. Key Words: isolation. restraints, delinquents. correctional facilities.
American Psychiatric Assoc iati on, 1973) now devote four pages to these interventions (Joint Commission for the Accred itation of Hospitals, 1985), Mental he alth professionals appear to have developed a se nse, if not an explicit awareness , o f their potential dange rs , This awaren ess does not ex ist to the same de gree in the fie ld of juvenile correctio ns , Th e authors ha ve provided consu ltation to in stitutions for delinquents around the country, and one (J ,M .) has been an e xpert witness in over a dozen suits against juvenile rehabilitation programs . From the se experiences and their review of litigation , they have observed a wide range o f isol ation and re straint practices . The purpose of thi s article is to describe the se practices and propose changes that will standardize the use of iso lation and restraint w ith out threatening safety and sec urity .
The terror of a child in prison is quite limitless. [ remember once in Reading , as [ was going out to exercise, seeing in the dimly lit cell right opposite my own a small boy . . . . The child's face was like a white wedge of sheer terror. There was in his eyes the terror of a hunted animal. . . . The terror that seizes and dominates the child. as it seizes a grown man also, is of course intensified beyond power of expression by the solitary cellular system of our prisons. Every child is confined to its cell for twenty-three hours out of the twentyfour. This is the appalling thing. To shut up a child in a dimly lit cell, for twenty-three hours out of the twenty-four , is an example of the cruelty of stupidity. .. Oscar Wilde, comments on his imprisonment in Reading G ao l, 189 7 (Hart-Davis. 1963)
Def initions Isolation in thi s paper refers to the practice o f removing a youth from the living en vironment to hi s or her room , or to a spe c ially built isolation room , for purposes of behavioral control. In juven ile correctio nal facil ities, young people who are isolated for 24 hours or more are usually allo wed to be o ut of their ce lls an hour per day . Restraint is defined as mechanical re straint; i.e., it doe s not include manual re straint (e .g, holding a person) . It also does not include the use of restraining devices such as handcuffs, for subduing and transporting a potentially dan gerous individual. It refers to co nta ining an individual with me chanical de vices in order to obtain a calming effect or prevent injury. In medical and mental health fac ilities , the de vice s used are four- or fivepoint restraints . de signed to sec ure the arms and legs in a natural po sition to a bed. Th ese are often referred to as " soft " restraint s because they are made of padded leather, de signed to secure the limbs with out threatening blood circulation or nerve functioning,
Introduction Isol ation and restraint are common int ervention s in mental health facilities treat ing childre n and adults . In the past dec ade, there has been considerable se lf-scrutiny in psych iatry over the uses and abuses o f such measures (G uthe il , 1978; Mattson and Sacks, 1978; Plutchik et aI., 1978 ; Soloff and Turner, 1981 ; Phillips and Nasr , 1983; Garri son , 1984; Gutheil and Tardiff , 1984, American Psychiatric Association , 1985 ; Joshi et aI. , 1988). As a result , mental health sta ndards, whi ch at on e time paid little attention to isolation and restraint (A me rican Psychi atric Asso ciation , 1971;
Accepted April 18. 1989. At the time of this study , Dr . Mit chell \I'as Assistant Prof essor. Division ofChild Psychiatry, Unive rsity of WashingIOn School ofM edicin e, Seattle , and Director of the mental health programs fo r the King County Depa rtment of Youth Services and the Echo Glen School for Children , a state -run training school . He is currently with the Departm ent of Mental Health , Lovelace Medical Cent er , Albuquerque . Dr. Varley is Ass ociate Prof essor . Division of Child Psych iatry, Departm ent of Psychiatry , University of Washington School of Medicine . Seattle, and serves as a consultant 10 ju venile cor rectional programs in the Pacific Northwesi . Request repr ints fr om Dr . Mit chell at Lovelace Medical Center , Department of Mental Health , 5400 Gibson Bl vd ., S .E., Albuquerque , NM 87108. 0890-8567/90/2902-0251$02.0 0/0© 1990 by theAmerican Academy
Overlap in Populations There are similarities between incarcerated and psychiatrically ho sp italized juveniles , Diagnosti c studies conducted in ju venile corre ctional facilities (Le wis et aI., 1979a . Chiles et aI. , 1980 ; Kashani et aI., 1980; Miller et aI., 1982 ; Ale ssi et aI., 1984: McManus et al ., 1984 , Hyde et aI. , 1986) report high rate s of neuropsychiatric morbidity among residents . According to a study of servic es for ch ildren and ado les ce nts in the state of W ashington (T ru pin et aI. , 1988),
of Child and Adolescent Psychiatry.
251
MIT CHELL AND VARLE Y
76% of incarcerated adolescents were as se verel y emotionally disturbed as their peers in a state-run psychi atric inpatient facility. A study conducted by Lewi s and Shanock (1980) concluded that juvenile co rrectional facilitie s tended to be "psychiatric treatment centers" for adolescent males who had been in mental health facilities during their preadole scen ce and were no longer welcome in ment al health programs becau se of their behavior. Their group also discovered a tendency for black, troublesome teen ager s to be incarcerated, while Caucasian youngsters with similar behavioral problems were psychiatrically hospitalized (Lewis et aI. , 1979b; Lewi s et aI., 1980). A stud y of antisocial behavior in hospitalized , psychot ic adolescents (Inarndar et al. , 1982) found histories of assaulti ve violence in 83.3 % of the males and 42.9 % of the fem ales . It seem s reasonable to conclude from these findings that incarcerated and psychiatrically hospitali zed juveniles are not totally distinct populations with reg ard to psych opathology and certain " acting out" behaviors .
Practices in Juvenile Correctional Facilities Isolat ion Similarities in client population s, howe ver, do not necessarily correspond to similarities in institutional practice . In programs for delinquents, for instance, the authors have found a tendency for staff members to view isolation as a prolonged interv enti on , lasting days, weeks, and, in some cases, months. There also appe ars to be a lack of standardization of isolation practices , an obser vation supported by a telephone survey of directors of state servi ces for incarcerated juveniles conducted in 1984 by the Evergreen Legal Services, a Wa shington-based advocacy group. Every state and the District of Columbia was surveyed about its isolation policies and practices. Some states had clear criteria for isolation , while others had no criteria, or vague cr iteria such as "out of control " behavior. A few states had requ irements for supervision of an isolated youth (e.g., visual checks every 10 minutes , supervisory rev iew) and required a minimum of daily recreational activity . Most, however, had no such guidelines. The upper time limit of isolat ion was another important variation in practice , as illustrated in Table I . Some state s required youths to be out of isolation within a few hour s. At the other end of the spectrum , one state allow ed isolation for up to 15 days, and seven had no upper limit. Parentheticall y , the adherence of state s to their own guide lines may be questioned , since one of the states reporting a 24hour upper limit was found during litigation (Danny O. v. Bowman) to isolate residents for up to 3 month s. Reasons for isolation can be dive rse, as illust rated by one author' s (J.M .) review of the use of a maximum security isolation unit in a large training school. Five hundred and twent y-seven reports of incidents leading to isolation, involving 30 randoml y selected resident s , were revie wed and classified according to type and seriousness. The number of incidents per resident ranged from I to 98. Th e data , presented in Table 2, reveal that most (5 1.3%) of the isolations were for noncompliance or rule violations . Although
252
I . Telephone Sliney" of 50 States and the District of Columbia (/ 984 ) Regarding Isolation Practices in State-run Juvenile Correctional Facilities"
T ABLE
Time Limit Under 24 hours ' 24 hours 48 hours 72 hours Four days Five days 6- 10 days 14 days 15 days No limit
No . of States 10 9 1 9 I 8 4 I 1 7
" Unpubl ished data quoted with the permission of the Evergreen Legal Services, Washington State . b Upper time limit allowed for isolation. ' Range: I to 8 hours .
the program directors stated during litigation (Gary H. v . Hegstrom ) that they had a beh avior modification program , it was evident from the data that the principal , if not first line , intervention was isolati on . The se data represent only one institut ion' s response to a wide range of behaviors . However, in the author's experience, they exemplify programs that overrely on isolati on . There is also variation in isolation site from one institution to another. Som e facilities simpl y confine residents in their rooms. Others have special isolation rooms in living unit s, similar to the "quiet room s" on psychiatric ward s. A third kind of isolation occ urs in separate buildings designed solely for this purpose . These structures , usually referred to as "adjustment" or "security" units , often require full-time staffing, and thus constitute a drain on resourc es. The rooms in these units usually have the heavy metal doors used in adult maximum security pri sons , with small plexiglass windows and feedh oles a few feet above the ground. Isolated young people spend most of their day on the floor, looking and talking through the feedholes. As illustrated in Table 2, security unit s can become the de facto behavioral manage ment system for a facilit y . The authors have found that program s with these units are most likely to engage in prolonged isolation ; i.c.. confining a youth to a cell 23 hours a day for week s at a time. Is there any harm in this ? The literature sugge sts that a variety of mental and behavioral disturbances can be created by isolation for long periods of time . Prolonged isolation increases territorial aggression in rats (Valzelli, 1974) and dominance-related aggression in vervet monkeys (Raliegh et aI. , 1987). Impulsivity, per ceptual distortion, affective disturb ance , and paranoid ideati on have been observed in adult prisoners in maximum security isolat ion (Grassian, 1983). The authors are not aware of studi es using norm al or incarcerated adolescents. However, one rev iew (Zubeck , 1973 ) of exp erim ents on young adult volunteers studying the effects of social isolation and sensory depri vation , usually lasting I week , found that about one-third of the subjects withdrew befo re the end of the experimental per iod. Coml.Am.A cad . Child Adolesc . Psychiatry, 29 :2, March 1990
ISOLATION/RESTRAINT - JUVENILE CORRECTIONS
Incidents Involving Use of Physical Force
2. Classification of 527 Incidents, Involving 30 Juveniles, Leading to Transfer to a Maximum Security Isolation Unit of a Juvenile Correctional Facility"
TABLE
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I. Decline in incidents in general in the King County (Seattle, WA) Juvenile Detention Center (KCJDC), following the closure of its isolation unit on January I, 1988. FIG.
l.Am.Acad. Child Adolesc. Psychiatry, 29:2 .March 1990
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2. Decline in incidents involving use of physical force in the King County (Seattle, WA) Juvenile Detention Center (KCJDC), following the closure of its isolation unit on January I, 1988.
FIG.
Incidents Involving Injury to Youths
pared to subjects who completed the study, the "quitters" tended to be younger; to watch television more; to be nonreaders; to smoke; to dislike quiet, solitude, and darkness; and to score higher on psychological tests measures that are associated with aggressiveness, hyperactivity, and potential violence. The implication from these studies is that young people with these traits (e.g., juvenile delinquents) may be more vulnerable to the negative effects of isolation than a more stable population. It is the author's impression that programs relying on excessive isolation experience high rates of aversive behaviors among residents. A single case study supporting this impression comes from the authors' data on the effect of closing a maximum security unit in one of their consultee agencies, the detention center of the King County Juvenile Department of Youth Services (Seattle, Washington). This unit housed 15-25% of the detention population when it
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" Gary H. I' Hegstrom. " 27 (62.8%) of the verbal threats involved one youth. , 28 (28.6%) of the assaults involved one youth.
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FIG. 3. Decline in incidents resulting in injury to juveniles in the King County (Seattle, WA) Juvenile Detention Center (KCJDC), following the closure of its isolation unit on January I, 1988.
was in maximum use. After its closure on January I, 1988, a behavior modification program was instituted. There was resistance to this change from many staff members, who worried about the threat to safety and security. However, the data on incidents in the facility in the year before (1987) and the year after (1988) the closure indicate that their worries were unfounded. As shown in Figures 1-3, there were statistically significant declines in the rates (defined as the number of incidents in a given month, divided by the average daily population for that month) of incidents in general (means = 0.788 :±: 0.414 vs. 0.598 :±: 0.273; t-value [all t-values two-tailed] (II) = 2.56; p < .05), incidents requiring the use of physical force (means = 0.452 + 0.186 vs. 0.304 :±: 0.119; t-value (II) = 3.08; P < 0.02), and incidents resulting in injury to youths (means = 0.329 :±: O. I 15 vs. 0.232 :±: 0.060; t-value (II) = 2.67; P < 0.05) from 1987 to 1988. Restraint In juvenile correctional facilities, restraint practices are 253
MITCH ELL AND VARL EY
as diverse as isolation practices. Some facilities never use restraints, while others restra in residents on a dail y basis. Restraint time varies from hour s to , in extreme cases, days. The authors have also found that some facilitie s use the same " soft" restraints used in medical and psychiatri c settings, but many use hand cuffs. Designed for police work , handcuffs are unsuited for restraint. The y can be overtightened , thus constricting circulation and causing nerve damage. In addition , they do not adequatel y contain an individual, thereby placing the youth and staff members at risk for injury . Unusual restraint practices involving handcuffs have evolved in some ju venile correctional program s. Litigation (Costello and Jame son , 1987) has exposed programs that handcuff youth s in unnatural positions (e.g ., spreadeagle, hands above heads) and to fixed objects such as bedposts, window bars , table legs, and fences. Others have resorted to "hog-tying" ju veniles; i.e., handcuffing their wrists to their ankles behind their backs. In rarer instance s, cruel and dangerous pract ices, such as hanging a straightjacketed youngster unside down or blocking an airway of a restrained youth (D anny O. v. B owman ). have occurred . When giving expert opinio n about these practic es, psychiatri sts may be tempt ed to apply mental health standards; i.e .. rather than recommend cessation of restraint , they may recommend proper restraint. If, however, ju venile correctional programs exist that do not use restraint , why recommend them at all? In addition, the authors have found that the abilit y of ju venile corr ectional programs to properly equip themselves , tightly monitor the use of restraint , and train their staff to restrain j udiciously is limited , if not nonexistent. Thi s inability does not necessarily reflect malevolent intent. It may be deri ved from differen ces in architecture, training requirements, and staffing levels between mental health and correctional facilities. Regardless, the author s have recommended that ju venile correctional facilities avoid using restraints.
Comments and Conclusions This has been a critical assessment by mental health professionals of the use of two behavioral measures in juvenile correctional facilitie s. It should not be viewed as onesided, however. The broad lesson is that an intervention can appear as a reaction to day-to-day crises and evolve into an institutional practice with its foundation never being questioned. Mental health programs are not immune from this process (Gutheil, 1978). Also , it should be pointed out that a large number of juvenile correctional facilities have not been visited by the authors, nor have they been the subject of litigation. Generalization to these programs based on inform ation about a few facilitie s may be inaccurate or unfair. A scientific survey, perhaps conducted by the American Corr ectional Association or the National Commission on Correctional Health Care , would determine the extent of the problem . Until more accurate observation s are made , howev er , the authors tentatively conclude that ju venile correctional facilitie s use a wider range of interventions than psychi atric facilities, with abu sive isolation and restraint practices on one end of the spectrum. There may be a number of reasons
254
for this variation. Juri sdictions tend to build their co rrectional facilities in remote location s, far from resources and professional consultati on . Procedural manuals, in the authors' experience , are often none xistent, outdated , or unread . Written standards of practice in such facilities are recent developments, and their use is minim al. As of this writing, for instance , fewe r than 30 ju venile correctional facilities in the United States are accredited by the Nation al Commi ssion on Correctional Health Care (Pe rs. Commun ., Dr. J. Anno , NCCHC Secretary-Treasurer). Finally , even though profes sional orga nizations such as the American Correctional Association , National Ju venile Detenti on Association, and the National Commission on Correctional Health Care have been formed, there are little or no pressures to join them , attend their conferences, or follow their standards. However, programs that have not scrutinized their isolation and restraint practices are increasingly vulnerable to litigation (Costello et aI., 1987). The authors contend that lawsuits over these issues are avoidable . Effective and humane practi ces , posing no threat to security or safety, already exist in facil ities around the country. With this in mind , the authors make the following recommendation s to the administrators of ju ven ile correctional program s and their mental health consultants: I. Eliminate separate isolation units. They are a needle ss drain on the budget and personnel , undermine creative behavioral programs, and increase the likelihood that isolation will be overused . 2. Place a firm upper time limit on isolation . A 24-hour upper limit is more than suffic ient. One of the facilities the authors consulted found a 5-hour limit workable , and j udges who enjoin facilities from overu sing isolation tend to impose limits in the range of 2 to 5 hours (Costello et al . , 1987). 3. Eliminate restr aints. Programs have found that they do not need them. Thei r potential for abuse is great, and few, if any, juvenile correctional facilities are equipped for their proper use. 4. If a facility decides that it must use restraint , it is obligated to restrain correctly. Soft restraints should be used and attached to approp riate beds. Their use should be strictly supervised by admini strators and medical personnel. Hand cuffs should not be used for this purpose . Restraining a person in an unnatural position is forbidden . Restraining a person for more than an hour is rarely neces sary , and should require med ical approval. Med ical intervention (me ntal status evaluation , use of med ication s, tran sfer to a mental health facilit y) should occur whenever a youth requires restraint for more than 2 hour s. 5. It is essenti al for j uvenile correctional programs to provide their resident s with stimulating recreational programs, educational programs, well-administered beh avior management program s (e.g., level sys tem , token eco nomy), and team- generated , individualized serv ice plans. In some cases, judicious use of psychotropi c medications can reduce aberrant behavior in psychotic , depressed , or brain-dam aged youngsters (Mitchell, in press). For these reasons, adequate levels of ment al health consultation have the potential to improve a program ' s behavior al management repertoire . It l.Am.Acad. Child Adolesc.Psychiatry, 29:2, March 1990
ISOLA TION/RESTRAINT - JUVENILE CORRECTIONS
is disturbing to find that 29% of medium-sized (average daily population, 50 to 200) and 68% of small (average daily population fewer than 50) juvenile correctional facilities reported in a recent survey that they do not have ongoing mental health services (Anno, 1984). All of these recommendations are practical and serve to improve behavioral management. Administrators who eliminate abusive isolation and restraint practices find that they are in more control of their programs. It is presumed that their residents recognize this and behave accordingly.
References Alessi, N. E., McManus, M. Grapentine, W. L. & Brickman, A. (1984), The characterization of depressive disorders in serious juvenile offenders. J. Affect. Disord., 6:9-17. American Psychiatric Association, (1971), Standards for Psychiatric Facilities (2nd Ed.) Washington, DC: APA Press. - - (1973), Standards for Facilities Serving Children and Adolescents. (2nd Ed.) Washington, DC: APA Press. - - (1985), Seclusion and restraint (Task Force Report No. 22). Washington, DC: APA Press. Anno, J. B. (1984), The availability of health services for juvenile offenders: preliminary results of a national survey. Journal ofPrison and Jail Health, 4:77-90. Chiles, J. A., Miller, M. L. & Cox, G. B. (1980), Depression in a delinquent population. Arch. Gen. Psychiatry. 37: 1179-1184. Costello, J.C. & Jameson, E. 1. (1987), Legal and ethical duties of health care professionals to incarcerated children. J. Legal Med., 8:191-263. Danny O. v. Bowman. No. 84-1272 (D. Idaho July 12, 1985). Garrison, W. T. (1984), Aggressive behavior, seclusion, and physical restraint in an inpatient child population. J. Am. Acad. Child Psychiatry. 23:448--452. Gary H. v. Hegstrom. No. 77-1039-BU (D. Or. Dec. 17, 1984). Grassian, S. (1983), Psychopathological effects of solitary confinement. Am. J. Psychiatry. 140:1450--1454. Gutheil, T. G. (1978), Observations on the theoretical basis for seclusion of the psychiatric inpatient. Am. J. Psychiatry. 135:325328. - - & Tardiff, K. (1984), Indications and contraindications for seclusion and restraint. In: The Psychiatric Uses of Seclusion and Restraint. ed. K. Tardiff. Washington, DC: APA Press, pp. 1118. Hart-Davis, R. H. ed. (1963); The Letters of Oscar Wilde. New York: Harcourt, Brace & World, pp. 568-569. Hyde, T., Mitchell, J. & Trupin, E. (1986), Psychiatric disorders in a delinquent population. Paper presented at the annual meeting of the National Commission on Correctional Health Care, Washington, DC. Inamdar, S. c., Lewis, D. O. , Siomopoulos. G., Shanock , S. S. & Lamela, M. (1982), Violent and suicidal behavior in psychotic adolescents. Am. J. Psychiatry, 139:932-935.
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Joint Commission on the Accreditation of Hospitals. Consolidated Standards Manual!85 :for Child, Adolescent, and Adult Psychiatric. Alcoholism. and Drug Abuse Facilities and Facilities Serving the Mentally Retarded and Developmentally Disabled (1985), Chicago, Illinois, pp. 81-84. Joshi, P. T., Capozzolli, J. A. & Coyle, J. T. (1988), Use of a quiet room on an inpatient unit. J. Am. Acad. Child Adolesc. Psychiatry. 27:642-644. Kashani, J. H., Manning, G. W., McKnew, D. H., Cytryn, L., Simonds, 1.F. & Woodperson, P. C. (1980), Depression among incarcerated delinquents. Psychiatry Res .. 3:185-191. Lewis, D.O., Shanock, S. S., Pincus, J. H. & Glaser, G. H. (l978a), Violent juvenile delinquents: psychiatric neurological, psychological and abuse factors. J. Am. Acad. Child Psychiatry. 18:307-319. - - Balla, D. A. & Shanock, S. S. (l979b), Some evidence of race bias in the diagnosis and treatment of the juvenile offender. Am. J. Orthopsychiatry. 49:53-6 I. . - - & Shanock, S. S. (1980), The use of a correctional settmg for follow-up care of psychiatrically disturbed adolescents. Am. J. Psychiatrv, 137:953-955. - - Shanock, S. S., Cohen, R. J., Kligfeld, M. & Frisone, G. (1980), Race bias in the diagnosis and disposition of violent adolescents. Am. J. Psychiatry. 137:1211-1216. Mattson, M. R. & Sacks, M. H. (1978), Seclusion: uses and complications. Am. J. Psychiatry. 135:1210--1213. McManus, M.• Alessi. N. E., Grapentine, W. L. & Brickman, A. (1984), Psychiatric disturbance in juvenile delinquents. J. Am. Acad. Child Psychiatry. 23:602-615. Miller, M.' L., Chiles, 1. A. & Barnes, V. E. (1982), Suicide attempters within a delinquent population. J. Consult. Clin. Psychol .. 50:491--498. Mitchell, J. (in press). Use of psychotropic medications in juvenile correctional facilities: practical considerations. Journal of Prison and Jail Health. Phillips. P. & Nasr, S. J. (1983), Seclusion to restraint and prediction of violence. Am. J. Psychiatry. 140:229-232. Plutchik, R. Karasu, T. 'B., Conte, H. R., Siegel, B. & Jerrett, I. (1978), Toward a rationale for the seclusion process. J. Nerv. Ment. Dis., 166:571-579. Raliegh, M. J., McGuire, M. T., Brammer, G. L. & Yuwiler, ~. (1987), Social and environmental influences on blood serotomn concentrations in monkeys. Arch. Gen. Psychiatry. 41 :405-410. Soloff, P. H., & Turner, S. M. (1981), Patterns of seclusion: a prospective study, J. Nerv. Ment. Dis., 169:37--44. Trupin, E., Low, B" Forsyth-Stephens, A., Tarico, V. & Cox, G. B. (1988), Washington State children's mental health system analysis (special report to the Washington State Department of Social and Health Services). Valzelli, L. (1974), 5-hydroxytryptamine in aggressiveness. Adv. Biochem. Psychopharmacol .. 11:255-263. Zubeck, J. P. (1973), Behavioral and physiological effects of prolonged sensory and perceptual deprivation: a review. In: Man in Isolation and Confinement. ed. J. E. Rasmussen. Chicago, IL: Alpine Pub., pp. 9-83.
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American Psychiatric Assoc iati on, 1973) now devote four pages to these interventions (Joint Commission for the Accred itation of Hospitals, 1985), Mental he alth professionals appear to have developed a se nse, if not an explicit awareness , o f their potential dange rs , This awaren ess does not ex ist to the same de gree in the fie ld of juvenile correctio ns , Th e authors ha ve provided consu ltation to in stitutions for delinquents around the country, and one (J ,M .) has been an e xpert witness in over a dozen suits against juvenile rehabilitation programs . From the se experiences and their review of litigation , they have observed a wide range o f isol ation and re straint practices . The purpose of thi s article is to describe the se practices and propose changes that will standardize the use of iso lation and restraint w ith out threatening safety and sec urity .
The terror of a child in prison is quite limitless. [ remember once in Reading , as [ was going out to exercise, seeing in the dimly lit cell right opposite my own a small boy . . . . The child's face was like a white wedge of sheer terror. There was in his eyes the terror of a hunted animal. . . . The terror that seizes and dominates the child. as it seizes a grown man also, is of course intensified beyond power of expression by the solitary cellular system of our prisons. Every child is confined to its cell for twenty-three hours out of the twentyfour. This is the appalling thing. To shut up a child in a dimly lit cell, for twenty-three hours out of the twenty-four , is an example of the cruelty of stupidity. .. Oscar Wilde, comments on his imprisonment in Reading G ao l, 189 7 (Hart-Davis. 1963)
Def initions Isolation in thi s paper refers to the practice o f removing a youth from the living en vironment to hi s or her room , or to a spe c ially built isolation room , for purposes of behavioral control. In juven ile correctio nal facil ities, young people who are isolated for 24 hours or more are usually allo wed to be o ut of their ce lls an hour per day . Restraint is defined as mechanical re straint; i.e., it doe s not include manual re straint (e .g, holding a person) . It also does not include the use of restraining devices such as handcuffs, for subduing and transporting a potentially dan gerous individual. It refers to co nta ining an individual with me chanical de vices in order to obtain a calming effect or prevent injury. In medical and mental health fac ilities , the de vice s used are four- or fivepoint restraints . de signed to sec ure the arms and legs in a natural po sition to a bed. Th ese are often referred to as " soft " restraint s because they are made of padded leather, de signed to secure the limbs with out threatening blood circulation or nerve functioning,
Introduction Isol ation and restraint are common int ervention s in mental health facilities treat ing childre n and adults . In the past dec ade, there has been considerable se lf-scrutiny in psych iatry over the uses and abuses o f such measures (G uthe il , 1978; Mattson and Sacks, 1978; Plutchik et aI., 1978 ; Soloff and Turner, 1981 ; Phillips and Nasr , 1983; Garri son , 1984; Gutheil and Tardiff , 1984, American Psychiatric Association , 1985 ; Joshi et aI. , 1988). As a result , mental health sta ndards, whi ch at on e time paid little attention to isolation and restraint (A me rican Psychi atric Asso ciation , 1971;
Accepted April 18. 1989. At the time of this study , Dr . Mit chell \I'as Assistant Prof essor. Division ofChild Psychiatry, Unive rsity of WashingIOn School ofM edicin e, Seattle , and Director of the mental health programs fo r the King County Depa rtment of Youth Services and the Echo Glen School for Children , a state -run training school . He is currently with the Departm ent of Mental Health , Lovelace Medical Cent er , Albuquerque . Dr. Varley is Ass ociate Prof essor . Division of Child Psych iatry, Departm ent of Psychiatry , University of Washington School of Medicine . Seattle, and serves as a consultant 10 ju venile cor rectional programs in the Pacific Northwesi . Request repr ints fr om Dr . Mit chell at Lovelace Medical Center , Department of Mental Health , 5400 Gibson Bl vd ., S .E., Albuquerque , NM 87108. 0890-8567/90/2902-0251$02.0 0/0© 1990 by theAmerican Academy
Overlap in Populations There are similarities between incarcerated and psychiatrically ho sp italized juveniles , Diagnosti c studies conducted in ju venile corre ctional facilities (Le wis et aI., 1979a . Chiles et aI. , 1980 ; Kashani et aI., 1980; Miller et aI., 1982 ; Ale ssi et aI., 1984: McManus et al ., 1984 , Hyde et aI. , 1986) report high rate s of neuropsychiatric morbidity among residents . According to a study of servic es for ch ildren and ado les ce nts in the state of W ashington (T ru pin et aI. , 1988),
of Child and Adolescent Psychiatry.
251
MIT CHELL AND VARLE Y
76% of incarcerated adolescents were as se verel y emotionally disturbed as their peers in a state-run psychi atric inpatient facility. A study conducted by Lewi s and Shanock (1980) concluded that juvenile co rrectional facilitie s tended to be "psychiatric treatment centers" for adolescent males who had been in mental health facilities during their preadole scen ce and were no longer welcome in ment al health programs becau se of their behavior. Their group also discovered a tendency for black, troublesome teen ager s to be incarcerated, while Caucasian youngsters with similar behavioral problems were psychiatrically hospitalized (Lewis et aI. , 1979b; Lewi s et aI., 1980). A stud y of antisocial behavior in hospitalized , psychot ic adolescents (Inarndar et al. , 1982) found histories of assaulti ve violence in 83.3 % of the males and 42.9 % of the fem ales . It seem s reasonable to conclude from these findings that incarcerated and psychiatrically hospitali zed juveniles are not totally distinct populations with reg ard to psych opathology and certain " acting out" behaviors .
Practices in Juvenile Correctional Facilities Isolat ion Similarities in client population s, howe ver, do not necessarily correspond to similarities in institutional practice . In programs for delinquents, for instance, the authors have found a tendency for staff members to view isolation as a prolonged interv enti on , lasting days, weeks, and, in some cases, months. There also appe ars to be a lack of standardization of isolation practices , an obser vation supported by a telephone survey of directors of state servi ces for incarcerated juveniles conducted in 1984 by the Evergreen Legal Services, a Wa shington-based advocacy group. Every state and the District of Columbia was surveyed about its isolation policies and practices. Some states had clear criteria for isolation , while others had no criteria, or vague cr iteria such as "out of control " behavior. A few states had requ irements for supervision of an isolated youth (e.g., visual checks every 10 minutes , supervisory rev iew) and required a minimum of daily recreational activity . Most, however, had no such guidelines. The upper time limit of isolat ion was another important variation in practice , as illustrated in Table I . Some state s required youths to be out of isolation within a few hour s. At the other end of the spectrum , one state allow ed isolation for up to 15 days, and seven had no upper limit. Parentheticall y , the adherence of state s to their own guide lines may be questioned , since one of the states reporting a 24hour upper limit was found during litigation (Danny O. v. Bowman) to isolate residents for up to 3 month s. Reasons for isolation can be dive rse, as illust rated by one author' s (J.M .) review of the use of a maximum security isolation unit in a large training school. Five hundred and twent y-seven reports of incidents leading to isolation, involving 30 randoml y selected resident s , were revie wed and classified according to type and seriousness. The number of incidents per resident ranged from I to 98. Th e data , presented in Table 2, reveal that most (5 1.3%) of the isolations were for noncompliance or rule violations . Although
252
I . Telephone Sliney" of 50 States and the District of Columbia (/ 984 ) Regarding Isolation Practices in State-run Juvenile Correctional Facilities"
T ABLE
Time Limit Under 24 hours ' 24 hours 48 hours 72 hours Four days Five days 6- 10 days 14 days 15 days No limit
No . of States 10 9 1 9 I 8 4 I 1 7
" Unpubl ished data quoted with the permission of the Evergreen Legal Services, Washington State . b Upper time limit allowed for isolation. ' Range: I to 8 hours .
the program directors stated during litigation (Gary H. v . Hegstrom ) that they had a beh avior modification program , it was evident from the data that the principal , if not first line , intervention was isolati on . The se data represent only one institut ion' s response to a wide range of behaviors . However, in the author's experience, they exemplify programs that overrely on isolati on . There is also variation in isolation site from one institution to another. Som e facilities simpl y confine residents in their rooms. Others have special isolation rooms in living unit s, similar to the "quiet room s" on psychiatric ward s. A third kind of isolation occ urs in separate buildings designed solely for this purpose . These structures , usually referred to as "adjustment" or "security" units , often require full-time staffing, and thus constitute a drain on resourc es. The rooms in these units usually have the heavy metal doors used in adult maximum security pri sons , with small plexiglass windows and feedh oles a few feet above the ground. Isolated young people spend most of their day on the floor, looking and talking through the feedholes. As illustrated in Table 2, security unit s can become the de facto behavioral manage ment system for a facilit y . The authors have found that program s with these units are most likely to engage in prolonged isolation ; i.c.. confining a youth to a cell 23 hours a day for week s at a time. Is there any harm in this ? The literature sugge sts that a variety of mental and behavioral disturbances can be created by isolation for long periods of time . Prolonged isolation increases territorial aggression in rats (Valzelli, 1974) and dominance-related aggression in vervet monkeys (Raliegh et aI. , 1987). Impulsivity, per ceptual distortion, affective disturb ance , and paranoid ideati on have been observed in adult prisoners in maximum security isolat ion (Grassian, 1983). The authors are not aware of studi es using norm al or incarcerated adolescents. However, one rev iew (Zubeck , 1973 ) of exp erim ents on young adult volunteers studying the effects of social isolation and sensory depri vation , usually lasting I week , found that about one-third of the subjects withdrew befo re the end of the experimental per iod. Coml.Am.A cad . Child Adolesc . Psychiatry, 29 :2, March 1990
ISOLATION/RESTRAINT - JUVENILE CORRECTIONS
Incidents Involving Use of Physical Force
2. Classification of 527 Incidents, Involving 30 Juveniles, Leading to Transfer to a Maximum Security Isolation Unit of a Juvenile Correctional Facility"
TABLE
Type of Incident
KCJDC 1987, 1988
I
4.0'7c 24.7 26.6
21 130 140
~ .....
4.8
8 62 43 98
1.5 11.8 8.2 18.6
527
Incident Reports KCJDC 1987, 1988
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Nov
Dec
I. Decline in incidents in general in the King County (Seattle, WA) Juvenile Detention Center (KCJDC), following the closure of its isolation unit on January I, 1988. FIG.
l.Am.Acad. Child Adolesc. Psychiatry, 29:2 .March 1990
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
2. Decline in incidents involving use of physical force in the King County (Seattle, WA) Juvenile Detention Center (KCJDC), following the closure of its isolation unit on January I, 1988.
FIG.
Incidents Involving Injury to Youths
pared to subjects who completed the study, the "quitters" tended to be younger; to watch television more; to be nonreaders; to smoke; to dislike quiet, solitude, and darkness; and to score higher on psychological tests measures that are associated with aggressiveness, hyperactivity, and potential violence. The implication from these studies is that young people with these traits (e.g., juvenile delinquents) may be more vulnerable to the negative effects of isolation than a more stable population. It is the author's impression that programs relying on excessive isolation experience high rates of aversive behaviors among residents. A single case study supporting this impression comes from the authors' data on the effect of closing a maximum security unit in one of their consultee agencies, the detention center of the King County Juvenile Department of Youth Services (Seattle, Washington). This unit housed 15-25% of the detention population when it
s
'"
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.4
KCJDC 1987, 1988
0.6
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" Gary H. I' Hegstrom. " 27 (62.8%) of the verbal threats involved one youth. , 28 (28.6%) of the assaults involved one youth.
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Total
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'K 0.5
Administrative (e.g., parole violation) Rule violations Noncompliance Self-destructive behavior Youth requested isolation Escape-related Verbal threats" Assault'
I ,
l'l
No. and Percentage of Incidents N
q
0.7
0.5
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.c:
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FIG. 3. Decline in incidents resulting in injury to juveniles in the King County (Seattle, WA) Juvenile Detention Center (KCJDC), following the closure of its isolation unit on January I, 1988.
was in maximum use. After its closure on January I, 1988, a behavior modification program was instituted. There was resistance to this change from many staff members, who worried about the threat to safety and security. However, the data on incidents in the facility in the year before (1987) and the year after (1988) the closure indicate that their worries were unfounded. As shown in Figures 1-3, there were statistically significant declines in the rates (defined as the number of incidents in a given month, divided by the average daily population for that month) of incidents in general (means = 0.788 :±: 0.414 vs. 0.598 :±: 0.273; t-value [all t-values two-tailed] (II) = 2.56; p < .05), incidents requiring the use of physical force (means = 0.452 + 0.186 vs. 0.304 :±: 0.119; t-value (II) = 3.08; P < 0.02), and incidents resulting in injury to youths (means = 0.329 :±: O. I 15 vs. 0.232 :±: 0.060; t-value (II) = 2.67; P < 0.05) from 1987 to 1988. Restraint In juvenile correctional facilities, restraint practices are 253
MITCH ELL AND VARL EY
as diverse as isolation practices. Some facilities never use restraints, while others restra in residents on a dail y basis. Restraint time varies from hour s to , in extreme cases, days. The authors have also found that some facilitie s use the same " soft" restraints used in medical and psychiatri c settings, but many use hand cuffs. Designed for police work , handcuffs are unsuited for restraint. The y can be overtightened , thus constricting circulation and causing nerve damage. In addition , they do not adequatel y contain an individual, thereby placing the youth and staff members at risk for injury . Unusual restraint practices involving handcuffs have evolved in some ju venile correctional program s. Litigation (Costello and Jame son , 1987) has exposed programs that handcuff youth s in unnatural positions (e.g ., spreadeagle, hands above heads) and to fixed objects such as bedposts, window bars , table legs, and fences. Others have resorted to "hog-tying" ju veniles; i.e., handcuffing their wrists to their ankles behind their backs. In rarer instance s, cruel and dangerous pract ices, such as hanging a straightjacketed youngster unside down or blocking an airway of a restrained youth (D anny O. v. B owman ). have occurred . When giving expert opinio n about these practic es, psychiatri sts may be tempt ed to apply mental health standards; i.e .. rather than recommend cessation of restraint , they may recommend proper restraint. If, however, ju venile correctional programs exist that do not use restraint , why recommend them at all? In addition, the authors have found that the abilit y of ju venile corr ectional programs to properly equip themselves , tightly monitor the use of restraint , and train their staff to restrain j udiciously is limited , if not nonexistent. Thi s inability does not necessarily reflect malevolent intent. It may be deri ved from differen ces in architecture, training requirements, and staffing levels between mental health and correctional facilities. Regardless, the author s have recommended that ju venile correctional facilities avoid using restraints.
Comments and Conclusions This has been a critical assessment by mental health professionals of the use of two behavioral measures in juvenile correctional facilitie s. It should not be viewed as onesided, however. The broad lesson is that an intervention can appear as a reaction to day-to-day crises and evolve into an institutional practice with its foundation never being questioned. Mental health programs are not immune from this process (Gutheil, 1978). Also , it should be pointed out that a large number of juvenile correctional facilities have not been visited by the authors, nor have they been the subject of litigation. Generalization to these programs based on inform ation about a few facilitie s may be inaccurate or unfair. A scientific survey, perhaps conducted by the American Corr ectional Association or the National Commission on Correctional Health Care , would determine the extent of the problem . Until more accurate observation s are made , howev er , the authors tentatively conclude that ju venile correctional facilitie s use a wider range of interventions than psychi atric facilities, with abu sive isolation and restraint practices on one end of the spectrum. There may be a number of reasons
254
for this variation. Juri sdictions tend to build their co rrectional facilities in remote location s, far from resources and professional consultati on . Procedural manuals, in the authors' experience , are often none xistent, outdated , or unread . Written standards of practice in such facilities are recent developments, and their use is minim al. As of this writing, for instance , fewe r than 30 ju venile correctional facilities in the United States are accredited by the Nation al Commi ssion on Correctional Health Care (Pe rs. Commun ., Dr. J. Anno , NCCHC Secretary-Treasurer). Finally , even though profes sional orga nizations such as the American Correctional Association , National Ju venile Detenti on Association, and the National Commission on Correctional Health Care have been formed, there are little or no pressures to join them , attend their conferences, or follow their standards. However, programs that have not scrutinized their isolation and restraint practices are increasingly vulnerable to litigation (Costello et aI., 1987). The authors contend that lawsuits over these issues are avoidable . Effective and humane practi ces , posing no threat to security or safety, already exist in facil ities around the country. With this in mind , the authors make the following recommendation s to the administrators of ju ven ile correctional program s and their mental health consultants: I. Eliminate separate isolation units. They are a needle ss drain on the budget and personnel , undermine creative behavioral programs, and increase the likelihood that isolation will be overused . 2. Place a firm upper time limit on isolation . A 24-hour upper limit is more than suffic ient. One of the facilities the authors consulted found a 5-hour limit workable , and j udges who enjoin facilities from overu sing isolation tend to impose limits in the range of 2 to 5 hours (Costello et al . , 1987). 3. Eliminate restr aints. Programs have found that they do not need them. Thei r potential for abuse is great, and few, if any, juvenile correctional facilities are equipped for their proper use. 4. If a facility decides that it must use restraint , it is obligated to restrain correctly. Soft restraints should be used and attached to approp riate beds. Their use should be strictly supervised by admini strators and medical personnel. Hand cuffs should not be used for this purpose . Restraining a person in an unnatural position is forbidden . Restraining a person for more than an hour is rarely neces sary , and should require med ical approval. Med ical intervention (me ntal status evaluation , use of med ication s, tran sfer to a mental health facilit y) should occur whenever a youth requires restraint for more than 2 hour s. 5. It is essenti al for j uvenile correctional programs to provide their resident s with stimulating recreational programs, educational programs, well-administered beh avior management program s (e.g., level sys tem , token eco nomy), and team- generated , individualized serv ice plans. In some cases, judicious use of psychotropi c medications can reduce aberrant behavior in psychotic , depressed , or brain-dam aged youngsters (Mitchell, in press). For these reasons, adequate levels of ment al health consultation have the potential to improve a program ' s behavior al management repertoire . It l.Am.Acad. Child Adolesc.Psychiatry, 29:2, March 1990
ISOLA TION/RESTRAINT - JUVENILE CORRECTIONS
is disturbing to find that 29% of medium-sized (average daily population, 50 to 200) and 68% of small (average daily population fewer than 50) juvenile correctional facilities reported in a recent survey that they do not have ongoing mental health services (Anno, 1984). All of these recommendations are practical and serve to improve behavioral management. Administrators who eliminate abusive isolation and restraint practices find that they are in more control of their programs. It is presumed that their residents recognize this and behave accordingly.
References Alessi, N. E., McManus, M. Grapentine, W. L. & Brickman, A. (1984), The characterization of depressive disorders in serious juvenile offenders. J. Affect. Disord., 6:9-17. American Psychiatric Association, (1971), Standards for Psychiatric Facilities (2nd Ed.) Washington, DC: APA Press. - - (1973), Standards for Facilities Serving Children and Adolescents. (2nd Ed.) Washington, DC: APA Press. - - (1985), Seclusion and restraint (Task Force Report No. 22). Washington, DC: APA Press. Anno, J. B. (1984), The availability of health services for juvenile offenders: preliminary results of a national survey. Journal ofPrison and Jail Health, 4:77-90. Chiles, J. A., Miller, M. L. & Cox, G. B. (1980), Depression in a delinquent population. Arch. Gen. Psychiatry. 37: 1179-1184. Costello, J.C. & Jameson, E. 1. (1987), Legal and ethical duties of health care professionals to incarcerated children. J. Legal Med., 8:191-263. Danny O. v. Bowman. No. 84-1272 (D. Idaho July 12, 1985). Garrison, W. T. (1984), Aggressive behavior, seclusion, and physical restraint in an inpatient child population. J. Am. Acad. Child Psychiatry. 23:448--452. Gary H. v. Hegstrom. No. 77-1039-BU (D. Or. Dec. 17, 1984). Grassian, S. (1983), Psychopathological effects of solitary confinement. Am. J. Psychiatry. 140:1450--1454. Gutheil, T. G. (1978), Observations on the theoretical basis for seclusion of the psychiatric inpatient. Am. J. Psychiatry. 135:325328. - - & Tardiff, K. (1984), Indications and contraindications for seclusion and restraint. In: The Psychiatric Uses of Seclusion and Restraint. ed. K. Tardiff. Washington, DC: APA Press, pp. 1118. Hart-Davis, R. H. ed. (1963); The Letters of Oscar Wilde. New York: Harcourt, Brace & World, pp. 568-569. Hyde, T., Mitchell, J. & Trupin, E. (1986), Psychiatric disorders in a delinquent population. Paper presented at the annual meeting of the National Commission on Correctional Health Care, Washington, DC. Inamdar, S. c., Lewis, D. O. , Siomopoulos. G., Shanock , S. S. & Lamela, M. (1982), Violent and suicidal behavior in psychotic adolescents. Am. J. Psychiatry, 139:932-935.
l.Am.Acad. Child Adolesc. Psychiatry. 29:2. MarchJ990
Joint Commission on the Accreditation of Hospitals. Consolidated Standards Manual!85 :for Child, Adolescent, and Adult Psychiatric. Alcoholism. and Drug Abuse Facilities and Facilities Serving the Mentally Retarded and Developmentally Disabled (1985), Chicago, Illinois, pp. 81-84. Joshi, P. T., Capozzolli, J. A. & Coyle, J. T. (1988), Use of a quiet room on an inpatient unit. J. Am. Acad. Child Adolesc. Psychiatry. 27:642-644. Kashani, J. H., Manning, G. W., McKnew, D. H., Cytryn, L., Simonds, 1.F. & Woodperson, P. C. (1980), Depression among incarcerated delinquents. Psychiatry Res .. 3:185-191. Lewis, D.O., Shanock, S. S., Pincus, J. H. & Glaser, G. H. (l978a), Violent juvenile delinquents: psychiatric neurological, psychological and abuse factors. J. Am. Acad. Child Psychiatry. 18:307-319. - - Balla, D. A. & Shanock, S. S. (l979b), Some evidence of race bias in the diagnosis and treatment of the juvenile offender. Am. J. Orthopsychiatry. 49:53-6 I. . - - & Shanock, S. S. (1980), The use of a correctional settmg for follow-up care of psychiatrically disturbed adolescents. Am. J. Psychiatrv, 137:953-955. - - Shanock, S. S., Cohen, R. J., Kligfeld, M. & Frisone, G. (1980), Race bias in the diagnosis and disposition of violent adolescents. Am. J. Psychiatry. 137:1211-1216. Mattson, M. R. & Sacks, M. H. (1978), Seclusion: uses and complications. Am. J. Psychiatry. 135:1210--1213. McManus, M.• Alessi. N. E., Grapentine, W. L. & Brickman, A. (1984), Psychiatric disturbance in juvenile delinquents. J. Am. Acad. Child Psychiatry. 23:602-615. Miller, M.' L., Chiles, 1. A. & Barnes, V. E. (1982), Suicide attempters within a delinquent population. J. Consult. Clin. Psychol .. 50:491--498. Mitchell, J. (in press). Use of psychotropic medications in juvenile correctional facilities: practical considerations. Journal of Prison and Jail Health. Phillips. P. & Nasr, S. J. (1983), Seclusion to restraint and prediction of violence. Am. J. Psychiatry. 140:229-232. Plutchik, R. Karasu, T. 'B., Conte, H. R., Siegel, B. & Jerrett, I. (1978), Toward a rationale for the seclusion process. J. Nerv. Ment. Dis., 166:571-579. Raliegh, M. J., McGuire, M. T., Brammer, G. L. & Yuwiler, ~. (1987), Social and environmental influences on blood serotomn concentrations in monkeys. Arch. Gen. Psychiatry. 41 :405-410. Soloff, P. H., & Turner, S. M. (1981), Patterns of seclusion: a prospective study, J. Nerv. Ment. Dis., 169:37--44. Trupin, E., Low, B" Forsyth-Stephens, A., Tarico, V. & Cox, G. B. (1988), Washington State children's mental health system analysis (special report to the Washington State Department of Social and Health Services). Valzelli, L. (1974), 5-hydroxytryptamine in aggressiveness. Adv. Biochem. Psychopharmacol .. 11:255-263. Zubeck, J. P. (1973), Behavioral and physiological effects of prolonged sensory and perceptual deprivation: a review. In: Man in Isolation and Confinement. ed. J. E. Rasmussen. Chicago, IL: Alpine Pub., pp. 9-83.
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