Clinton Signs Legislation Limiting Use of Restraints and Seclusion in Mental Health Treatment Settings

In late September Congress passed legislation establishing national standards that restrict the use of restraints and seclusion. The impetus for the requirements contained in the Children's Health Act of 2000 (see box) came largely from a 1998 report published in the Hartford (Conn.) Courant that documented 142 deaths over a ten-year period as a result of these procedures . Many of the deaths reported by the Hartford Courant were among children. On the basis of the report, the Harvard Center for Risk Management estimated that 50 to 150 patients die annually as a result of restraints and seclusion.

The legislation contains two separate sets of requirements, one for facilities receiving federal funds and one for nonmedical community-based treatment facilities for children and youth. The new national standards apply only to psychiatric treatment facilities—they do not affect use of seclusion and restraints in schools, wilderness camps, jails, and prisons.

Key provisions under the general requirements include the following:

• Restraints and involuntary seclusion may be imposed only to ensure the physical safety of a patient. They cannot be used as punishment or for staff convenience.

• Restraints and involuntary seclusion may be imposed only under the written order of a physician or other licensed practitioner as required under state law. Orders must specify duration and circumstances.

• Although no time frame is specified for a face-to-face evaluation of a patient who is restrained or secluded, the legislation declares that the absence of such a provision should not be construed as offsetting or impeding any federal or state regulations that provide greater protections. The effect is to affirm hospital rules promulgated last year by the Health Care Financing Administration, including the requirement for a face-to-face evaluation of a patient by a licensed professional practitioner within one hour after restraint or seclusion is initiated.

• Facilities must report every death that occurs within 24 hours after a patient has been removed from restraints or seclusion. The Department of Health and Human Services (HHS) will determine the agencies to which reports must be filed; most likely they will include state protection and advocacy agencies.

• Within 12 months HHS must issue regulations specifying adequate numbers of staff for facilities and appropriate training in the use of restraints and seclusion and alternative approaches.

For nonmedical community children's programs, the legislation specifies that restraints and seclusion may be used only in emergencies and only to ensure immediate physical safety. Mechanical restraints are prohibited. Seclusion is allowed only when a staff member continuously monitors the patient face to face. Time-outs are not considered seclusion, and physical escorts are not considered physical restraints.

In such children's programs, only individuals trained and certified by a state-recognized body may impose restraints and seclusion. Until a state certification process is in place, these procedures can be used only when a supervisory or senior staff member with skills and competencies specifically listed in the legislation conducts a face-to-face assessment within an hour after the procedures are imposed. The use of restraints and seclusion must then be monitored by the supervisory or senior staff member.

The children's facility must have staff members who are trained to understand the needs and behaviors of the population served and who have skills and competencies in relationship building, de-escalation measures, and alternatives to restraints and seclusion. They must also know how to monitor the patient for signs of physical distress, avoid position asphyxia, and obtain medical assistance.

Survey Finds Gaps in Adults' Knowledge About Children's Development

Many adult Americans lack important knowledge about children's development, according to a report released in October. The report points out that parents' and caretakers' erroneous beliefs may affect the way they interact with children and result in long-term negative effects on their children's intellectual, emotional, and social growth.

The report, What Grown-Ups Understand About Child Development: A National Benchmark Survey, is based on telephone interviews conducted by DYG, Inc., for two child advocacy organizations, Civitas and Zero to Three, and BRIO, a toy company that sponsored the project.

The survey included 3,000 adults and was conducted in June and July 2000. Respondents included 1,066 parents of young children. The objective was to measure the level of accurate knowledge adults possess about the development of children from birth to age six. Their responses were compared with knowledge gained from 40 years of developmental research, as cited in the report.

The survey found that most adults did not understand when children begin to "take in" and react to their world. Although child development research shows that this happens in the first days of life, 62 percent of the parents of young children in the survey believed that it does not occur until a child is two months or older.

Research shows that an infant as young as one month can sense when a caretaker is depressed or angry and will be affected by the caretaker's mood, according to the report. However, most of the parents with young children (55 percent) said that a baby must be three months old to sense a parent's mood, and 31 percent of the parents—42 percent of the fathers—said that a baby must be one year old.

Only 12 percent of the respondents knew that babies younger than six months can experience depression. The report cites research showing that four-month-old infants can be depressed. More than half of the 3,000 respondents (51 percent) said that a child could not begin to experience depression until age three. In addition, 26 percent of all respondents and 23 percent of those with young children believed that a six-month-old child will not suffer any long-term effects from witnessing violence. However, the report points out that children as young as six months can experience long-lasting detrimental effects on emotional and social development.

The report notes that the vast majority of parents of young children in the survey were able to identify activities that are critical in promoting intellectual development in young children. For example, more than 90 percent knew that it is critical to read to and talk with the child. About 85 percent knew that providing a sense of safety and security and feeding children a healthy diet are essential for intellectual development.

However, about 65 percent of the respondents believed that flashcards and educational television shows are very beneficial for young children, and 45 percent felt that solitary play on the computer is very beneficial. The report cites research indicating that such activities are much less beneficial than playing and interacting with others.

The survey also examined adults' expectations of young children. More than half of the parents believed that a 15-month-old should be expected to share his or her toys. A quarter of the parents believed that a three-year-old should be able to sit quietly for one hour. Thirty percent of the parents believed that a six-year-old who shoots and kills a classmate can comprehend what he did—meaning that he can fully understand that he took a life and that it cannot be undone. The report cites research indicating that none of these expectations are realistic. In addition, 40 percent of the parents of young children attributed a child's bad behavior to vengeful feelings in cases in which the child was too young to experience such feelings, according to developmental research.

How adults define spoiling, the report notes, is directly related to their expectations of children. Fifty-seven percent of the parents of young children believed that a six-month-old can be "spoiled," whereas research suggests that an infant this young cannot. The survey also uncovered confusion about what activities constitute spoiling. For example, 44 percent of the parents incorrectly believed that picking up a three-month-old every time the infant cries will spoil the child. Forty-five percent of parents incorrectly believed that letting a two-year-old leave the dinner table to play before the rest of the family has finished is spoiling. Thirty percent of parents incorrectly believed that letting a six-year-old choose what to wear to school is spoiling.

Sixty-one percent of the parents of young children and 62 percent of all respondents condoned spanking as a regular form of punishment. Thirty-seven percent of the parents believed it is appropriate to spank children age two or younger as a regular form of punishment. The report notes that this finding was surprising, because more than 60 percent of the respondents readily acknowledged the negative consequences of regular spanking, such as increased aggression in the child.

Among parents with young children, the single largest differentiator of those who knew more about child development was a four-year college degree. Household income was also a factor. Fathers knew less than mothers, and grandparents were more likely than current parents to view appropriate caregiving activities as spoiling.

The 229-page survey is available on the Zero to Three Web site at www. zerotothree.org.

New Law Permits Office-Based Heroin Treatment

President Clinton signed a bill in October that will allow persons addicted to heroin or painkillers to obtain prescriptions of buprenorphine, a promising new treatment drug, from qualified physicians. Federal health officials acknowledge that passage of a law permitting opiate addicts to be treated in the privacy of a doctor's office marks a significant departure from attitudes toward heroin users that have confined treatment to highly regulated clinics for the past 35 years. Supporters of the legislation believe that moving narcotics treatment out of government-sanctioned clinics will expand access to treatment for the 200,000 to 1 million untreated heroin addicts in the Unites States.

The Drug Addiction Treatment Act of 2000 allows qualified physicians to prescribe take-home doses of buprenorphine. The drug is a mild narcotic that is already used as an injectable painkiller. Buprenorphine is expected to be approved by the Food and Drug Administration in early 2001 for use in addiction treatment. Several studies funded by the National Institute on Drug Abuse have shown buprenorphine to be more effective than a low dose of methadone and that a direct dose-related effect exists between buprenorphine and reduced use of opiates.

A study of 220 heroin addicts published in the New England Journal of Medicine in November found that buprenorphine and levomethadyl acetate (LAAM) were just as effective as methadone in reducing heroin use. LAAM was approved in 1993 for narcotics treatment, but is not widely used. Methadone, developed in the 1940s and approved for treatment in 1964, is the predominant treatment for opiate dependence.

Buprenorphine is a partial or mixed agonist medication that is different in some ways from full agonists such as methadone and LAAM. Like those medications, it prevents withdrawal and blocks the feeling of euphoria during heroin use. However, its unusual chemical properties make it longer lasting, less addictive, and less likely to trigger a fatal overdose than methadone and LAAM. Like LAAM, buprenorphine can be taken three times a week. Methadone must be taken every day. Federal health officials believe that buprenorphine's properties will minimize the risk of its diversion to street use. The drug will be available in the form of tablets to be placed under the tongue. The tablets may include naloxone, an opiate antagonist, which will produce withdrawal if a person melts down the tablet and injects it.

The Center for Substance Abuse Treatment (CSAT) has been charged with developing standards to allow the use of buprenorphine by prescription as a schedule IV controlled substance. H. Westley Clark, M.D., director of CSAT, issued a statement in which he described the formation of a consensus panel of experts to prepare draft guidelines that will serve as best-practice standards for treatment with buprenorphine. According to Clark, the guidelines will likely set standards for the training and experience of physicians prescribing the drug. They will also address limits on the number of patients who may be treated by a single physician and limits on the amount of medication that may be prescribed. The guidelines will establish standards for medical and psychosocial services that should be available to patients.

News Briefs

Guide for families: The Nathan S. Kline Institute for Psychiatric Research has developed a guide to acquaint consumers' family members with the Internet and provide them with an annotated list of key mental health sites. Mental Health Resources on the Web for Families, a 15-page booklet, is designed to help families obtain reliable, up-to-date information on diagnosis, symptoms, treatments, and coping strategies. For a free copy, write to Stuart Moss, Health Sciences Librarian, Nathan S. Kline Institute, 140 Old Orangeburg Road, Orangeburg, New York 10962.

CD-ROM tutorial: The Agency for Healthcare Research and Quality (AHRQ) has created a tutorial on CD-ROM to help users navigate its National Guideline Clearinghouse. The clearinghouse is sponsored by AHRQ in partnership with the American Medical Association and the American Association of Health Plans. The clearinghouse is a database of evidence-based clinical practice guidelines available on the Internet at www.guide line.gov. The CD-ROM tutorial, which demonstrates most of the features of the clearinghouse, is free and can be ordered by calling 1-800-358-9295 and asking for the National Guideline Clearinghouse tutorial.

People and Places

Resignation: Laurie Flynn, executive director of the National Alliance for the Mentally Ill (NAMI) for the past 16 years, has announced her resignation effective December 31, 2000. A statement by the NAMI board cited Ms. Flynn's "keen intelligence and passion" as factors in NAMI's growth from "a virtually unknown group of grassroots advocates scattered through the country" to a leading advocacy organization with 210,000 members, 1,200 state affiliates, and a national staff of more than 60 persons.

Award: Eric Kandel, M.D., life member of the American Psychiatric Association, was awarded the 2000 Nobel Prize for medicine. Dr. Kandel of Columbia University discovered how the efficiency of synapses could be modified. He revealed molecular mechanisms that have a role in the formation of memories. Dr. Kandel shared the prize with Paul Greengard, Ph.D., of Rockefeller University, and Arvid Carlsson, M.D., of the University of Gothenburg in Sweden. The work of all three researchers has contributed to the understanding of mental illness.