ARTICLE IN BRITISH MEDICAL JOURNAL LANCET SUPPORTS THE VIEWS DR. D.L. EDMUNDS HAS EXPRESSED

The Lancet

February 21, 2009 - http://www.thelancet.com - pages 621 to 622 - Vol
373

Perspectives

Book Review

~~~~~~~~~~

The fool on the hill

The spinning chair. Bloodletting (copious). Removal of possibly
infected viscera. Extraction of teeth. Electric shock. Forcible
restraint, for days or weeks. Wrapping in cold blankets. Brain
damage. Repeated coma. Back-breaking convulsions. Slicing through the
brain with an ice pick. Sterilisation. Female genital mutilation.

Since the Enlightenment, all the above have been used to treat the
"mad". Even the most grotesque treatments have often been introduced
as humane alternatives to existing options. In the 1950s, the
chemical lobotomy, or "hibernation therapy" was introduced. Patients
were given a drug that rendered them immobile and semiconscious for
days, on the assumption that they would emerge improved. The drug was
called a "neuroleptic", or brain restrainer. Its name?
Chlorpromazine. Since marketed as an antipsychotic, it is used, at
lower doses, today. So too are a host of related drugs. Many doctors,
and some patients, swear by them (other patients swear at them).

Antipsychotics are, at times, cruel drugs. Some cause shaking,
salivation, restlessness, infertility, stiff ness, agitation, and
frail bones; others cause obesity, somnolence, and increase the risk
of heart attack, diabetes, and stroke. Antidepressants also have side-
effects, although theirs are typically less dramatic: sickness,
sexual dysfunction, a feeling of being numbed, or losing one's
personality, and acutely increased risk of suicide. But side-effects,
when they occur, seem justified, since mental illness is extremely
unpleasant; and evidence indicates that the drugs work.

What if they didn't? In "The Myth of the Chemical Cure: A Critique of
Psychiatric Drug Treatment," psychiatrist Joanna Moncrieff has
amassed copious evidence that perhaps the drugs don't work. What have
we missed, all these years? Selective and misleading outcome
measures; inadequate follow-up; selective attention to evidence;
publication bias; and our ability to define questions whose answers
are predictable, but partial. Robert Whitaker's "Mad in
America" (2001) provided a breathtaking overview; Moncrieff, by
contrast, examines many studies in detail. "The Myth of the Chemical
Cure" is not always easy reading, but I do not think that serious
psychiatrists can afford to ignore Moncrieff's book. It is a mine of
information; a provocation to think creatively and compassionately
about patients; and a momento mori, the equivalent of a mediaeval
scholar's skull staring back from his desk: our works are mortal, and
our paradigms always limited.

Psychiatrists are widely regarded (and not just by other
psychiatrists) as insightful and intelligent people. How can
systematic research errors influence practice? In "Side Effects: a
Prosecutor, a Whistleblower, and a Bestselling Antidepressant on
Trial," Alison Bass illustrates the method. The book lacks a little
in intensity; it could be shorter than it is. However, it manages to
illustrate that drug companies fund and design research; academic
advancement depends on procuring research grants; and, especially
with materialist approaches to the mind requiring expensive tools,
ambitious doctors often have little choice about the paymaster. Bass
indicates, as William Broad and Nicholas Wade did many years ago,
that research fraud is not merely anomalous, but the result of
pressures placed on academics, some of them self-generated. Even in
the absence of research fraud, the mechanisms of research would often
not be conducive to original or patient-centred thinking. Moreover,
acceptance of (in retrospect) bizarre and cruel remedies predates the
growth of the pharmaceutical industry.

This occurs although psychiatry, of all disciplines, ought to be
based on the art of listening. A patient's story is a symphony of
suffering, longing, meaning, understanding, hope, fear, loss, wit,
and wisdom. Not to accompany the person afflicted on his journey is
inhumane. People will always need psychiatrists. But do people always
need psychiatry? Instead of the art of expert companionship,
psychiatry has become the discipline of brain mechanics. Experiences
are matched to labels of descriptive poverty. "Depression" implies a
low level of something, presumably mood, rather than the rich and
complex turmoil felt by the patient. "Schizophrenia" means several
contradictory things, but does not reflect the search for meaning
that is at the heart of the disorder.

Is it a disorder at all? Madness is to sincerely hold beliefs that
society regards as insupportable. But no society's knowledge is
complete. Our ancestors would regard us as mad, or, charitably, as
ill-informed; we observe with relief that we do not share all their
beliefs. Healthy societies have often regarded at least some madness
as serendipitous. If reason follows from incomplete assumptions,
madness, by outflanking reason, can complete the human picture. The
notion was enshrined in the King's Fool: a measurelessly eccentric,
often holy, man who told the state, embodied in the king, what it
otherwise could not hear (the tradition died out in Britain after
Charles I was deposed, not long after his fool was expelled from
court, at the behest of a jealous archbishop). Our assumption that
madness is necessarily a disorder assumes that we are necessarily
sane. I would hate to make that an article of faith.

In focusing on, and stigmatising, people with mental illness, we tend
to ignore the context. In our fervour to understand mental illness,
we have applied grossly oversimplified biochemical models to the
brain, with usually unhelpful results. The search for a
"schizophrenia gene" has been heroic and, so far, labyrinthine; but
to be black, isolated, and urban in the UK increases the risk
manifold. Society, and circumstances, can drive people mad; the
epidemic of depression and anxiety is otherwise inexplicable. To
focus research on the person who has become ill can be a little like
concentrating on a damaged house after a tsunami has hit a village.
The cause may be elsewhere.

Some would argue that even if drugs work, they do not work. The
margin over placebo is not large; the number needed to treat is not
vanishingly small; prognosis may be worse than with the "moral
treatment" (rest, respect, good food, work, prayer) of 200 years ago;
patients' adherence, especially to antipsychotic drugs, is patchy;
drug treatment attends to the symptoms, but not to the human being
who has the symptoms. We would, as a society, achieve a great deal by
listening to patients' demands for good food, companionship, respect,
practical support, and gainful activity. As doctors, being with the
patient is one of the most powerful healing tools we have. It can
sound trite; but the phrase describes receiving the patient's
humanity, and allowing it to come through crisis intact and enriched,
without the loss of dignity and self almost inherent in labelling. We
rarely have the time, or encouragement, to treat patients according
to their story, rather than our diagnosis; outcome measures are too
coarse to consider whether the patient has been allowed to preserve
and fulfill his or her humanity. The work of Moncrieff and Bass is a
warning that the doctor must be intellectually and morally free.

Athar Yawar

The Lancet, London NW1 7BY, UK

EXPOSING CORRUPTION- EXPLORING SOLUTIONS- PROJECT ON GOVERNMENT OVERSIGHT

http://www.pogo.org/about/

PUBLIC CORRUPTION AND THE PROCESS OF DEHUMANIZATION

I wrote to Steve Corbett who hosts a radio program in Wilkes Barre, Pennsylvania in regards to my thoughts on why the former Judges Ciavarella and Conahan possibly were unable to show remorse for their actions. I have been very pleased with Mr. Corbett's coverage and commentary in regards to the public corruption scandal and his being a voice of integrity. It was an honor that he read my comments in full on his program today (February 17, 2009). What I noted was that throughout history, where individuals have been able to classify a certain group as 'less than human', that has led to tragic consequences, examples can be seen with the Holocaust and the Abu Ghraib prison scandal. In these situations, a group of people were seen as 'apart' and thus individuals felt justified in committing attrocities. It appears in the situation with the Judges, that they saw the youth they were dealing with as 'troubled' and not worth their attention, as people not of any intrinsic value, thus they could sadly feel justified in profiting at their expense because these youth were seen as without worth or purpose.

-Dan L. Edmunds, Ed.D.
www.humanepsychiatry.info

JUDICIAL ACCOUNTABILITY INITIATIVE LAW/ ROTTEN JUDGES

http://www.jail4judges.org
http://rottenjudges.blogspot.com

CIAVARELLA AND CONAHAN ARE ONLY THE BEGINNING...

It is very positive development that Judges Ciavarella and Conahan of Luzerne County, Pennsylvania have entered their guilty pleas in regards to public corruption for tkaing kickbacks for sending youth into detention facilities. I am hopeful that many will continue to keep their eyes on these scoundrels and insure that they do not receive any special treatments as they violated the trust of the people and have impacted negatively the lives of countless children. This should be seen as a victory, but only the beginning. There is far more to uncover, and I am convinced that these issues of corruption will be found further within the judicial (and other systems) of Luzerne County, as well as the neighboring counties. Sadly, situations such as this are probably even more far reaching. In coordination with other advocates and activists, I personally remained committed to exploring the practices and possible corruption of others and seek to bring this to light so that true justice may arise. Whereas it is preliminary to make specific statements, many have brought to my attention questionable practices and unethical and harmful agendas by those in the judicial and child protective service systems within not only Luzerne County, but the neighboring counties. Hopefully individuals who are involved in disgraceful and harmful actions realize that particularly with the recent developments regarding Judges Ciavarella and Conahan, that the public is watching more closely and with greater scrutiny, and their actions will too be brought to light, they can no longer deceive the public and harm others.

-Dan L. Edmunds, Ed.D.
www.humanepsychiatry.info

FACT SHEET ON CHILDREN IN RESIDENTIAL CENTERS FROM THE BAZELON CENTER FOR MENTAL HEALTH LAW

Fact Sheet: Children in Residential Treatment Centers
I. Tens of thousands of children with mental health needs are being placed in expensive, inappropriate and often dangerous institutions.
The number of children placed in residential treatment centers (or RTCs)[1] is growing exponentially.[2] These modern-day orphanages now house more than 50,000 children nationwide.[3] Children are packed off to RTCs, often sent by officials they have never met, who have probably never spoken to their parents, teachers or social workers.[4] Once placed, these kids may have no meaningful contact with their families or friends for up to two years.[5] And, despite many documented cases of neglect and physical and sexual abuse, monitoring is inadequate to ensure that children are safe, healthy and receiving proper services in RTCs.[6] By funneling children with mental illnesses into the RTC system, states fail—at enormous cost—to provide more effective community-based mental health services.[7]

A. RTC placements are often inappropriate.
RTCs are among the most restrictive mental health services and, as such, should be reserved for children whose dangerous behavior cannot be controlled except in a secure setting.[8] Too often, however, child-serving bureaucracies hastily place children in RTCs because they have not made more appropriate community-based services available.[9] Parents who are desperate to meet their kids’ needs often turn to RTCs because they lack viable alternatives.[10]


To make placement decisions, families in crisis and overburdened social workers rely on the institutions’ glossy flyers and professional websites with testimonials of saved children.[11] But all RTCs are not alike.[12] Local, state and national exposés and litigation “regarding the quality of care in residential treatment centers have shown that some programs promise high-quality treatment but deliver low-quality custodial care.”[13] As a result, parents and state officials play a dangerous game of Russian roulette as they decide where to place children, because little public information is available about the RTCs, which are under-regulated and under-supervised.


To make it worse, far too many children are placed at great distance from their homes. For example, most District of Columbia children in RTCs are placed outside the District—many as far away as Utah and Minnesota.[14] Many families, especially those with limited means, find it impossible to have any meaningful visitation with their children.


B. Evidence is limited on the effectiveness of RTCs.
Children frequently arrive at RTCs traumatized by the process that delivered them there. They are often forcibly removed from their homes in the middle of the night by “escort companies.”[15] Other times, children are placed in RTCs not by their parents or doctors, but by overburdened child-serving state agencies, who know little about the children’s individual needs.[16]


Even more appalling, many children’s conditions do not improve at all while at the RTC.[17] In fact, there is little evidence that placing children in RTCs has any positive impact at all on their mental health state[18] and any gains made during a stay in an RTC quickly disappear upon discharge, creating a cycle where children return again and again to RTCs.[19]


There are many reasons why RTCs fail to deliver the results they promise, but most center on the type of services provided, the environment they are provided in and the lack of family involvement.


First, the reality of what occurs within an RTC is often quite different from the highly individualized, highly structured programs that are advertised. The RTCs often provide less intense services and the staff are often under-trained.[20] Children spend much of their day with staff who are not much more qualified than the average parent and they spend less time face-to-face with psychiatrists than they would if they were being served in appropriate community settings.[21]


The environment is also problematic because children in RTCs enter a situation where their only peers are other troubled children—a major risk factor for later behavioral problems.[22] Research has demonstrated that some children learn antisocial or bizarre behavior from intensive exposure to other disturbed children.[23]


Children are usually far from home in RTCs, often out-of-state.[24] Removed from their families and natural support systems, they are unable to draw upon the strengths of their communities and their communities are unable to contribute to their treatment. Few children thrive when they are hundreds or thousands of miles from their parents, friends, grandparents and teachers. Few can flourish without the guidance of consistent parenting. Yet, we expect that our most vulnerable and troubled youth will miraculously turn around in just such a situation. Instead, this isolation further reduces the efficacy of treatment and increases its cost.[25]


The fact that children and their families are far from one another creates a host of problems. For one, it makes family therapy difficult or impossible. As a result, when children leave the RTC, they return to an environment that has not changed. Also, because the RTC environment is inherently artificial—children are not asked to negotiate the obstacles that occur within their family setting or deal with the difficulties that trigger their behaviors in their neighborhoods or schools—the child does not gain new skills to better negotiate life outside of an institution. As a result, neither the children nor their parents learn better ways to overcome the obstacles that led to the RTC placement. Without family involvement, successes are limited.[26]


Among the rare children who are able to overcome these obstacles, few can sustain the gains they have made. In one study, nearly 50% of children were readmitted to an RTC, and 75% were either renstitutionalized or arrested.[27]


C. Children suffer because there is no watchdog.
The RTC industry is largely unregulated.[28] RTCs need only report major unusual incidents (or MUIs), but the interpretation of what constitutes an MUI and the reporting requirements vary widely.[29] Some RTCs fail to report MUIs at all—with little consequence.[30] Vulnerable kids are placed far from home where parents, social workers, or the state can offer little oversight or protection. Worse, many of the facilities limit children’s ability to have contact with their parents for extended periods, further restricting the parents’ ability to monitor the facilities.[31]


D. Children are abused in RTCs.
Children placed in RTCs have been sexually and physically abused, restrained for hours, over-medicated and subject to militaristic punishments; some have died.[32] The following are just a few documented examples of tragic occurrences at RTCs:

Medication is often used (and overused) to control behavior.[33] Children have been permanently disfigured because of over-medication.[34]

In some programs, the children’s shoes are confiscated to keep them from running away.[35]

There have been reports of behavioral ‘therapies’ being misused. As one author noted, “Such therapies do little more than systematically punish children, all under the guise of treatment . . . .”[36]

Sexual abuse by staff members and other residents is all too frequent.[37] In one case, a 13-year old girl performed sexual favors for staff members in return for snacks and carryout food.[38] At one RTC, four boys were accused of trying to sodomize another with a cucumber.[39] At another, a 19-year-old woman was charged with sodomizing a 14-year-old girl.[40]

Physical abuse is also too frequent an occurrence. For example, a 13-year-old boy was forced against a wall and slammed to the floor by employees of an RTC.[41]

Children are often restrained—sometimes for hours on end. The overuse of restraint has resulted in child deaths.[42]


E. Tragic outcomes at great public expense.
RTCs have grown to a billion-dollar, largely private industry.[43] Residential treatment care is exorbitantly expensive—costing up to $700 per child per day.[44] Annual costs can exceed $120,000.[45] Most of the time, the public foots the bill for these services.[46] In fact, nearly one fourth of the national outlay on child mental health is spent on care in these settings.[47]

II. Other Interventions Work Better for Less
Home- and community-based services are much more therapeutically effective than institutional services, and are also markedly more cost-efficient. As the Surgeon General reported, “the most convincing evidence of effectiveness is for home-based services and therapeutic foster care” and not for RTCs.[48] A comprehensive system of care would dramatically reduce the number of children in RTCs.[49]

Community-based alternatives produce better short- and long-term results and are less disruptive to children and families. These alternatives provide intensive mental health treatment, mobilize community resources and help children and their families develop effective coping mechanisms. Some models endeavor to “wrap services around” the child, while others emphasize multi-systemic therapy and crisis intervention. Randomized clinical trials found greater declines in delinquency and behavioral problems, greater increases in functioning, greater stability in housing placements and greater likelihood of permanent placement.[50] In Milwaukee, a wraparound project that has served over 700 youth involved in juvenile justice has shown similar promise; use of residential treatment has declined 60%, use of psychiatric hospitalization has declined 80%, and average overall care costs for target youth have dropped by one third.[51]

Notes
[1] According to the Surgeon General, a RTC is a “licensed 24-hour facility (although not licensed as a hospital), which offers mental health treatment.” U.S. Department of Health and Human Services. 1999. Mental Health: A Report of the Surgeon General. Washington, DC: Author. Available at: http://www.surgeongeneral.gov/library/mentalhealth/chapter3/sec7.html#treatment.

[2] In 1982, when Jane Knitzer wrote the seminal book, Unclaimed Children, the growth in the RTC industry was only beginning. Ms. Knitzer wrote that: “In contrast to the minimal efforts to create nonresidential services, 18 of the 44 states responding to our survey were working to increase residential care.” Knitzer, J., Unclaimed Children: The Failure of Public Responsibility to Children and Adolescents in Need of Mental Health Care, Children’s Defense Fund, 1982, at 45. By 1986, the number of children in RTCs had grown to 25,334, an increase of more than 30% over a three-year period. Rivera, V.R. & Kutash, K. (1994), Components of a System of Care. What Does the Research Say?, Residential Services: Psychiatric Hospitals and Residential Treatment Centers, at 8, Tampa , FL: University of South Florida, Florida Mental Health Institute: The Research and Training Center for Children’s Mental Health. This growth in continuing. See infra, at note 3.

[3] Latest Findings in Children’s Mental Health, Nearly 66,000 Youth Live in U.S, Mental Health Programs, Vo1. 2, No. 1 (Summer 2003). In 1997, the year in which the most recent data was available, more than 42,000 children were living in RTCs. Given the expansion of children living in RTCs, see supra note 2, this figure is likely well over 50,000 now.

[4] Reports to staff attorneys at the Bazelon Center for Mental Health Law. For example, in Washington, D.C., children are certified to go to RTCs by a “Multi-Agency Planning Team” process (or MAPT process). The MAPT meetings often do not include the voices of the people who know the child and family best.

[5] Ohio Rights Service Review of Fifteen Children’s Mental Health Facilities (October 2004) (on file with the Bazelon Center)

[6] See infra at sections I(C) and I(D).

[7] This development of long-term residential care occurred at the expense of community-based alternatives. Jane Knitzer, as far back as 1982, noted that: “In general, funds were used to develop long-term residential care, with few efforts to support or create emergency shelters, respite care programs, or specialized foster care for disturbed children and adolescents.” Unclaimed Children, supra note 2, at 46. Further, the Surgeon General noted that one of the primary reasons that RTCs are considered to be justified is because community-based alternatives are lacking. See Mental Health: A Report of the Surgeon General, supra note 1.

[8] Duchnowski, A.J., Hall, K. S., Kutash, K, and Friedman, R. (1998) The Alternatives to Residential Treatment Study, in Outcomes for Child and Youth with Behavioral and Emotional Disorders and Their Families. See also Mental Health: A Report of the Surgeon General, supra note 1.

[9] Mental Health: A Report of the Surgeon General, supra note 1, (“Concerns about residential care primarily relate to criteria for admission . . . .”).

[10] Lou Kilzer, Desperate Measures, Rocky Mountain News, July 2, 1999, available at: http://www.denver-rmn.com/desperate/site-desperate/front-pg.htm.

[11] Id.

[12] Mental Health: A Report of the Surgeon General, supra note 1, (“Settings range from structured ones, resembling psychiatric hospitals, to those that are more like group homes or halfway houses.”); Rivera, V.R. & Kutash, K. (1994), Components of a System of Care. What Does the Research Say?, Tampa , FL: University of South Florida, Florida Mental Health Institute: The Research and Training Center for Children’s Mental Health.

[13] Jane Knitzer noted this fact in 1982 in Unclaimed Children, supra note 2, at 46. The calls for reform have only increased as the population of children served in RTCs has grown. See infra at note 29 and accompanying text.

[14] Scott Higham and Sewell Chan, District Reexamines Out of Town Centers, The Washington Post, July 16, 2003, available at: http://www.washingtonpost.com/ac2/wp-dyn?pagename=article&contentId=A61386-2003Jul15¬Found=true. See also, D.C. Department of Mental Health Data from 2003 Children in Residential Treatment Centers (on file at the Bazelon Center).

[15] Kilzer, supra note 10.

[16] Supra, note 4.

[17] Mental Health: A Report of the Surgeon General, supra note 1.

[18] Burns, B.J., Hoagwood, K. & Maultsby, L.T., Improving Outcomes for Children and Adolescents with Serious Emotional and Behavioral Disorders: Current and Future Directions. (“A dominant observation is that the least evidence of effectiveness exists for residential services, where the vast majority of dollars are spent.”); Chamberlain, P. , Treatment Foster Care, US Department of Justice, Office of Juvenile Justice and Delinquency Prevention, Juvenile Justice Bulletin, December, 1998.

[19] Brown, E.C. & Greenbaum, P.E., Reinstitutionalization After Discharge from Residential Mental Health Facilities: Competing Risks Survival Analysis.

[20] Kilzer, supra note 10.

[21] Client reports to Bazelon Center staff attorneys.

[22] Mental Health: A Report of the Surgeon General, supra note 1.

[23] Mental Health: A Report of the Surgeon General, supra note 1.

[24] See, e.g., supra note 14 and accompanying text.

[25] National Council on Crime and Delinquency, Focus Newsletter, July 16, 2002 (“[Residential treatment centers] are usually some distance from the youth’s community, alienating the youth from his or her known environment and adding communication and travel costs to the families and communities.”)

[26] Myrth Ogilvie, Transitioning From Residential Treatment: Family Involvement & Helpful Supports, in Focal Point (2001), available at: http://www.rtc.pdx.edu/FPinHTML/FocalPointSP01/pgFPsp01Transitioning.shtml.

[27] Supra note 25.

[28] Since their inception, RTCs have been under-monitored. As Jane Knitzer noted in Unclaimed Children, supra note 2 at 46: “States have not emphasized continued monitoring of children’s care once they are in residential treatment.” Many RTCs are not accredited at all. Further, the RTCs that are certified are accredited by the Joint Organization on Accreditation of Healthcare Organizations (JCAHO), an independent, nonprofit organization. But as many have pointed out “JCAHO’s standards are geared mainly toward monitoring surgical and pharmacological procedures. And so RTCs, which are more like boarding schools than traditional hospitals, can become accredited under standards that have little to do with the daily programs and activities practiced in them.” Meza-Wilson, A. & Harrison, C., Safe Choices for Troubled Teens: Residential treatment centers for troubled teens are plagued by allegations of abuse and ineffectiveness. But do anguished parents have an alternative?, August 12, 2004, available at: http://www.askquestions.org/articles/teens/.

[29] Ohio Rights Service Review, supra note 5.

[30] Id. Further, the Bazelon Center has been contacted by federally funded Protection and Advocacy organizations who never or rarely received MUIs from the RTCs serving children within their jurisdiction.

[31] Friesen, B.J., Kruzich, J.M., Robinson, A., Jivanjee, P., Pullmann, M. & Bowles, C., Straining the Ties that Bind: Limits on Parent-Child Contact in Out-Of-Home Care, in Focal Point (2001), available at: http://www.rtc.pdx.edu/FPinHTML/FocalPointSP01/pgFPsp01Straining.shtml.

[32] See e.g., Scott Higham and Sewell Chan, Poor Care, Abuses Alleged at Riverside, The Washington Post, July 15, 2003, available at: http://www.washingtonpost.com/ac2/wp-dyn?pagename=article&contentId=A56180-2003Jul14¬Found=true; Kilzer, supra note 10; Associated Press, Death At Residential Treatment Center Ruled a Homicide, May 16, 2002, available at: http://www.geocities.com/ahobbit.geo/residential_treatment.html; Tim Weiner, Parents Divided Over Jamaica Disciplinary Academy, The New York Times, June 17, 2003; Ohio Rights Service Review, supra note 5; Tanya Eiserer, Death of teen at therapy facility investigated: Richardson 17-year-old died being restrained by staff in Hill Country, Dallas Morning News, October 17, 2002; Jorge Fitz-Gibbon, Leah Rae and Shawn Cohen, Treatment Often Hampered By Bureaucracy, The Journal News, June 23, 2002, available at: http://www.nyjournalnews.com/rtc/rtc062302_01.html.

[33] Higham and Chan, supra note 32.

[34] Reports to staff attorneys at the Bazelon Center for Mental Health Law.

[35] Kilzer, supra note 10.

[36] Unclaimed Children, supra note 2, at 46.

[37] Kilzer, supra note 10.

[38] Higham and Chan, supra note 32.

[39] Fitz-Gibbon, Rae and Cohen, supra note 32.

[40] Id.

[41] Higham and Chan, supra note 32.

[42] Associated Press, supra note 32.

[43] Fitz-Gibbon, Rae and Cohen, supra note 32.

[44] Kilzer, supra note 10.

[44] Higham and Chan, supra note 32.

[45] Fitz-Gibbon, Rae and Cohen, supra note 32.

[46] Id.

[47] Mental Health: Report of the Surgeon General, supra note 1.

[48] Id.

[49] Id. The Surgeon General suggests that RTCs are often utilized because of the under-availability of community-based alternatives.

[50] Bruns, E.J., Serving Youths with Emotional and Behavioral Problems in Maryland: Opportunities for the Use of the Wraparound Approach, University of Maryland School of Medicine, Department of Psychiatry, September 17, 2003 (on file at the Bazelon Center).

[51] Id. at 2.

SSRI ANTIDEPRESSANT DRUGS LEAD TO VIOLENCE AND SUICIDAL IDEATION

http://www.kurtdanysh.com

Bill Would Help Children Undergoing Psychiatric Abuse in Residential Facilities

http://www.mindfreedom.org/kb/youth-mental-health/teen-residential-psychiatric-abuse

This link to the site of the advocacy organization, Mind Freedom also contains link to the Government Accountability Office's report which details concerns about abuses and deaths in residential facilities for juveniles.

SPIRITUAL REFLECTIONS

"Desire and anger are born of unrest. The former has limitless appetite; the latter is the greatest of all sinners. Know that they are the real enemies."
-Bhagavad Gita 3:37

"A person not committed to higher good is mindless- he lacks right thinking, he is bound to be restless. How can a restless person be happy." -Bhagavad Gita 2:66

"The good and the pleasant are two different things- they motivate a person to pursue different goals. The one who embraces the good meets with auspiciousness, but the one who chooses the pleasant is lost." Katha Upanishad 2:1

CHANGING OUR THINKING, CHANGING OUR SOCIETY

"Because our society has become so focused on greed and what is best for the individual rather than for others, because we have focused only on what we desire rather than looking for the good of all, that we have effectively begun a campaign of destruction of an entire generation of children. We have abandoned them, left them with no guidance, no acceptance. All we have provided them is the aftermath of our own fauly decisions. We have made our children frustrated and angry. This anger has become rage. It is no wonder that we see a rise in anti-social behaviors, for they are the product of this rage which we have created ourselves. In early childhood, children think little of whether one is black or white, Jew or Christian, or whatever. Over time, they learn to establish barriers between others, because they have learned this from us. Sadly, I would say by the age of 10, we have indoctrinated our children. If what we have modeled is faulty, it will be very hard for them to unlearn. Vicious cycles will sadly continue. Hope often appears dim in a society as we have, but I do believe that buried within in of us lies potential, a potential for benevolence, a potential for change, a potential to re-create ourselves, re-create our world, and ultimately to turn away from the destructive course we are choosing to head at present."

-Dan L. Edmunds, Ed.D., B.C.S.A.
www.DrDanEdmunds.com
International Center for Humane Psychiatry

MODELFAMILY.ORG- TACKLING ABUSES IN THE CPS/FOSTER CARE SYSTEMS AND ISSUES OF JUDICIAL MISCONDUCT

http://www.modelfamily.org

This is a wonderful organization tackling issues of CPS/foster care abuses, judicial and public defender misconduct, and taking a stand for the rights of children and families.

JUVENILE DETENTION/ RESIDENTIAL TREATMENT CENTERS- FOCUS SHOULD BE SHIFTED TO TRUE REHABILITATION- SCRANTON TIMES TRIBUNE

Editor: It is a positive development that Luzerne County Judges Mark A. Ciavarella and Michael T. Conahan are being brought to justice for their actions in profiting from placing youth in detention facilities.

However, it is necessary for us to examine the problems inherent with residential and detention facilities themselves. In these settings, youth are placed often under conditions that lead them to further emotional distress. The decisions to place children is often not based on a genuine interest in the child’s best interests, but what will be profitable and the easiest way out of having to actually rehabilitate youth and meet their emotional needs.

It is no wonder that the socio-economically disadvantaged youth are the ones that are so frequently seen in this system. How does placing a child into a detention center or residential facility, which often is geared toward the concept of staff forcing conformity through rewards, punishments and often deprivation, teach a child who seeks to use power inappropriately that this is wrong?

How does a militaristic system teach anything but that children must submit to someone stronger than themselves? It only reinforces wrong ideas about power and domination.

These facilities are bound to create new emotional problems for these children. But the system profits here, as well, because then they are able to label and drug the children and make money in the process of billing for this injustice.

A youth is removed from the home, programmed, and when they conform to the expectations, released back to the setting that led to their distress and misbehavior to begin with. It becomes a vicious cycle.

These facilities are also very costly and their efficacy is questionable. The Bazelon Center for Mental Health Law noted the ineffectiveness of these facilities in treatment of youth as well as the many documented abuses that occur in such places.

Community-based options have proven effective and need to be more readily available and implemented.

We need to shift our focus to true rehabilitation and to addressing actual social problems, not locking our children away, drugging them into submission, and ignoring their needs.

DAN L. EDMUNDS, Ed.D.

Residential Treatment for Youth- Do No Harm- by Charles Huffine, M.D.

Residential Treatment for Youth: Do No Harm! Charles Huffine, MD
AACP Newsletter, Volume 15, Number 3, Summer 2001

A few months after the tragedy of 10 year old Candace Newmaker’s re-birthing death in Evergreen, Colorado, come reports of further brutality against our most vulnerable and troubled children.

In June 2001 in Fountain Hills Arizona, a 14-year-old boy was taken from a residential treatment facility dehydrated and delirious and was pronounced dead when he arrived at the hospital. Prior to staff calling 911 they had forced him, along with other residents, to stand in the Arizona sun in temperatures that were regularly over 100 degrees. They were forced to wear black sweats and were punished if they asked for food or water by being forced to eat mud. These teenagers were often beaten. The "sergeants," or staff members, stomped on the boys chests and arms with boots if they didn’t perform tasks required of them. On one occasion a staff held a knife to the throat of a boy.

Earlier, at a school for troubled teens in Prince Georges County Maryland, a 17-year-old boy died of asphyxia as a teacher cut off his airway in the act of restraining him.

More recently, at a Christian school for troubled youth in Newark Missouri, five staff members were arrested and charged with felony child abuse. Their punishment for youth who were deemed disrespectful was to stand in cow manure pits in depths of a few inches to chest high.

These incidents are the latest in a steady drum beat of reports of egregious behavior on the part of staff members of some residential programs for troubled youth. These facilities go by a variety of names: attitude adjustment schools, behavior modification camps, social service shelters, wilderness survival camps. Others present themselves as psychiatric residential treatment facilities.

These programs claim to help troubled youth, but they often operate with minimal, ineffectual or absent psychiatric oversight. Reports of abusive practices in these facilities come from all over the United States, but more often from states with weaker laws protecting the rights of adolescents.

How common are such incidents?

Do they occur in violation of an agency’s policies, or do they result from practices that should be considered child abuse but are seen by program leaders as valid treatments for behaviorally disordered youth?

Why do parents seek out such programs for their troubled sons and daughters?

What are our obligations to seek oversight and regulation of residential programs for troubled youth and to educate parents and the public about risks and questionable practices in these facilities?

These are a few of many unanswered questions that trouble advocates and professionals concerned about the humane treatment of children and youth with psychiatric disorders that manifest as troublesome behavior.

What we do know is that there are many programs for such youth around the country. Some have contracts within their home states for serving difficult to manage youth and others receive reimbursement from private insurance carriers. Oversight of these contracts appears to be inadequate in many cases.

Many such programs are responsible only to the parents for the way they serve children and youth. Many programs tell parents to stay out of contact with their children for a period of time and provide parents with explanations of the treatment that may not represent what their child experiences.

Too often, prior treatment is viewed as failed treatment. Records are not obtained and prior therapists are disrespected or shunned if they try to coordinate.

There is no one regulatory agency that has responsibility for such facilities in any state as programs fall outside of usual regulatory frameworks for psychiatric facilities or schools. Deaths, serious harm and frank abuse have been reported on by journalists, starting with the 1998 Hartford Currant article on death and injury from restraint and seclusion.

To date, the medical and nursing professions have had little to say about troubled facilities and the reports of tragic incidents arising from them. Our professions have not defined best practices for addressing behavioral symptomology in such programs.

A psychiatrist speaking on behalf of a program that had a recent death stated in a legal setting that such incidents are rare, but can be unfortunate side effects of restraint, and are unavoidable.

At the very least, states should develop regulatory policies defining the various forms of residential care and assuring that all residential programs in their state are covered by some regulatory system. Regulatory policies should be placed in law and should hold the program administration accountable for assuring the safety of each youth in their care. Regulations should define the boundary for staff between allowable physical interventions and behavior with youth that is frankly abusive.

Psychiatrists and nurses should be on the forefront of advocating for such reforms and assurances for our youth.

The issue of residential treatment should be looked at from the perspective of community psychiatric, or community nursing practice.

What have we learned from nearly twenty years of practicing values and principles articulated for the Children and Adolescent Service System Program (CASSP) and the System of Care (SOC) reform movement it spawned?

The core values of the SOC reforms were the following:

Services should be

1) family centered
2) child and adolescent focused
3) community based and well coordinated
4) culturally competent

Sending youth across the country to a residential program, or limiting parental access to their children in a local program, is the antithesis of a family centered practice. Parents must be included in the assessment of each child, involved in regular contact with their child and central to planning the child’s reentry into their life outside the institution.

Programs that offer rigid programming, or frankly misuse behavioral paradigms, are not providing individualized and tailored care as is becoming a standard "best practice" for ever more child care communities around the country.

To provide a quality service, psychiatrists, nurse practitioners and other mental health professionals should have a strong hand in overseeing the treatment process.

Children and youth taken out of their communities, when those communities have seemed unable to help a youth modify their behavior, are not optimally served. They are deprived of the opportunity to learn social adaptations in the context of family, culture and all that is familiar to them.

When care is placed in the hands of a single entity, when information is not obtained from prior providers, and when parents are excluded from meaningful participation in treatment, the power and control of the staff over a resident in the facility is extreme and unlike most other situations except prisons.

This gross inequity of power is, understandably, fertile ground for abusive practices. The facility becomes the new culture for the child. Treatment becomes for the child the game he or she needs to master in order to survive, or curry favor so as to get privileges.

This is the essence of institutionalization that was recognized as harmful by the movement toward community based and culturally competent care. Regulations based on best practices might include a definition of what specific circumstances demand residential placement. They might assure that this aspect of care is brief, limited only to a period when it meets standards of medical necessity, and is well integrated into community based services.

The CALOCUS would be an ideal tool for such a level of care determination process as it offers alternatives to residential placement when intensive treatment is indicated. Regulations based on best practices should assure that parents be full participants in the care of their child in a residential treatment facility.

Best practices based regulations would demand documentation of critical incidents and would create a certainty of outside investigation of incidents involving death or serious injury. They would create a quality assurance protocol for licensed agencies providing residential care that would address such issues as treatment effectiveness and individualization, resident rights and humane practices and acceptable interventions for troublesome behavior.

Clearly more examination of the network of residential treatment, schools and other programs is warranted by the AACP and the International Society of Psychiatric-Mental Health Nurses (ISPN).

On the heels of two more tragic deaths and police action against residential care staff we would hope that the discussion might look more broadly at the phenomenon of residential care for children and youth. We would encourage an examination of the role of residential care as a treatment option and social intervention, and its impact on the life of a developing youth.

Charley Huffine, MD, AACP Immediate Past-President
Wanda Mohr, RN, ISPN
Carol Bush, RN, ISPN