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In this article we discuss the necessity of fully informing patients and their families of what constitutes physical interventions and their attendant risks under the established principles and obligations of informed consent. After a brief review of the elements of informed consent and the nature of the duty to advise patients and their families of treatment risks, we argue that physical interventions are an unvalidated treatment for aggressive and violent behavior and should be used only as a safety intervention. We focus our discussion on the informed consent issues for school aged children, adolescents, and emancipated minors and contend that if restraints are used they must pose less risk than the behavior they are trying to alleviate. We also opine that if restraints are misused by mental health or child welfare treatment settings, then their misuse may be considered a subject of a patient maltreatment, abuse, criminal or civil action. A central thesis of the article is that informed consent must be seen as an integral and dynamic process of treatment. We recommend strategies that gain parental permission and child assent, that view informed consent as a dynamic and individualized process that aids and supports the therapeutic relationship, and that stress the importance of simplicity and clarity.

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

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

This commentary was prompted by Dr. Sandra Thomas's (2008) editorial on wilderness programs that was published in Issues in Mental Health Nursing. It is laudable that Dr. Thomas has brought this to...

The purpose of the present study was twofold: (1) to test whether law enforcement officers could reliably use a standard protocol to collect data on domestic violence events (DVEs) across a large municipality, and (2) to use these data to examine prevalence and nature of the violence and children’s presence. Reliability checks indicated that data were collected reliably on over 5,000 substantiated DVEs. Findings showed that 48% of all assaults in the municipality were DVEs. Victims were predominantly females in their early thirties, and injuries were predominantly minor and resulted from body contact. Children were present in nearly 50% of the DVEs. They were disproportionately present in domestic violence households compared to all other households in the municipality. Domestic violence households with children were more likely to have mothers and fathers involved in the violence and were disproportionately minority households headed by single females in relatively poor neighborhoods.

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

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

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

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

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

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

The Example of Multiple Personality Disorder ABSTRACT This article reviews some of the history of the cultural forces that shaped the diagnosis of multiple personality disorder/dissociative identity disorder and the subsequent abuses that occurred at the time of its popularization. Some of the implications that can be drawn from these kinds of historical excesses in the field of mental health will be discussed. The article concludes by underscoring the ethical obligation inherent in maintaining healthy professional skepticism toward ideas driven by ideology and fad, rather than scientific empiricism.

1. The numbers of ethnic minority persons in the United States are increasing faster than Caucasian populations. This means that nurses will be caring for an increasingly diverse patient pool. 2. Ethnic differences have been discovered to play a role in the efficacy of psychoactive medication. These differences result from a number of biological as well as non-biological factors. 3. Nurses have a professional obligation to be aware and sensitive to differential responses to treatment.

One area in which children’s rights are rarely considered in the USA is that of autonomy over their bodies. This right is routinely ignored in the arena of health care decision making. Children are routinely excluded from expressing their opinions involving medical decisions that affect them. This article discusses the complex reasons why children’s voices are typically not heard in the USA, the consequences of their disempowerment, and the ethical obligations of health care providers to advocate for the rights of children, even in the absence of a legal mandate to do so.

This article presents an overview of bipolar disorder (BPD) in children, a condition that only recently has been recognized as a legitimate diagnosis. Bipolar disorder in children is underrecognized for many reasons including lack of awareness, diagnostic confusion, and the different clinical picture in children. Available data strongly suggest that prepubertal childhood BPD is a non-episodic, chronic, rapid cycling, mixed manic state. It may be comorbid with attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) or it may demonstrate features of ADHD and CD, further complicating recognition and subsequent treatment. Treatment issues are discussed, and some reasons for the urgency of early recognition and treatment are explained.

This paper describes a single aspect of an ongoing program of research that seeks to create an open dialog among low-income parents of young children, staff from a large urban Head Start program, and researchers on child and woman safety. Authors conducted a content analysis of three focus groups within a larger ethnographic study employing qualitative methods. Data emerging from this analysis illustrates the ingenuity with which women keep themselves and their children safe in unsafe contexts.

News media and advocacy groups have brought to public attention a disturbing number of recent deaths proximal to the use of physical restraints. This paper examines the evidence indicating that use of these procedures can be dangerous to patients; explores the theoretical basis and practical application of restraints; and argues not only that their use may be unethical as a therapeutic intervention, but that it may have constitutional implications.

This article discusses some of the most recent developments in US mental health services that follow on the heels of the for-profit hospital scandal that was brought to public attention less than a decade ago. As individuals and as a profession, nurses have a responsibility to uncover, openly discuss and condemn malfeasance when it occurs, yet there has been a collective silence about these developments. The authors explore the reasons for this and make recommendations for regaining nursing’s moral voice and integrity.

We discuss how organizations, as cultures, react to times of turbulence, stress, and the importance of their foundational values during those times. By adapting the framework pioneered by the organizational analyst Manfred Kets de Vries, we use psychodynamic concepts to discuss a descriptive typology of behavior in which persons and organizations engage under stress. We also discuss the hazards inherent in losing sight of common core values, the dangers in the disconnects between stated values and behaviors, and how those disconnects can be destructive to organizations and to persons. We conclude with a plan that involves achieving insight, trust, and open communication on which members of organizations can base discussion and find common ground in articulating common core values. Throughout the article, we make applications to nursing organizations to focus attention on the currency of this topic for the profession.

Restraints have been subsumed under the rubric of "interventions" in the nursing literature. However, alarming reports of lethal consequences proximal to their use raise the issue to a life and death matter that requires immediate attention from professionals. Little is known about the mechanisms of death and other adverse consequences of restraint use. This article describes these mechanisms and also considers some hypothesized factors and adverse effects associated with their use.

The belief that poor parenting and dysfunctional families give rise to mental illness has been perpetuated by psychodynamic and family systems theories that lack supporting scientific evidence, and interventions based on these theories have failed to produce clinical improvements. Nevertheless the National Alliance for the Mentally III (NAMI) found that many clinical training programs continue to teach these outdated theories and interventions and that the mental health system is often destructive to family systems. This article describes a new 10-week program that is designed to educate service providers that will include families in the care of their chronically ill loved one. The program is based on a competence and adaptation rather than a pathology foundation and it shifts the discourse from causes to effects of illness.

The authors argue that children who are exposed to violence constitute a vulnerable and understudied population. Assessment of these children, whether for purposes of research or practice, should meet certain criteria that may not be satisfied with technology presently available to practitioners and researchers. This article presents a number of principles that can improve the precision and utility of practitioner and researcher evaluations and assessments, as well as the instruments that they develop for these purposes.

Summary The absence of scientifically credible information about the nature and extent of children exposed to abuse of their mothers is an impediment to effective intervention and prevention efforts. This article proposes a research agenda based upon guiding principles of a public health surveillance model. Three major principles are presented and applied to this social problem. Additionally, a concrete example of the application of these principles is drawn from an ongoing university/community partnership in Philadelphia.

‘‘[T]he rest of the world has slowly grown accustomed to these symptoms of moral decay. One misses the elementary reaction against injustice and for justice—that reaction which in the long run represents man’s only protection against a relapse into barbarism. I am firmly convinced that the passionate will for justice and truth has done more to improve man’s condition than calculating political shrewdness which in the long run only breeds general distrust.’’ —Albert Einstein, (1937) Moral Decay

TOPIC. A comprehensizve concqhd framework that informs about the complexity of childhood psychopathology. PURPOSE. To discuss the importance of a unifying conceptual framework and multiple partnerships in research and practice that can inform critical evmts and ejfects of intementions at various system levels in the treatment of children. SOURCES. Literature review CONCLUSIONS. The most informative research and intervention will occur by tising multiple measures and sources of information. As understanding of children and their problem in develoyment and in context grows, intmmtion research that zoill be both usefid, timely, and cost-8ectiz)e inlist iizclude cross-discipline teams of researchers and practitioners who will speak to these complexities.

This article addresses the rights of children in areas of juvenile justice, child welfare, and mental health. Although a large proportion of the juvenile court's business includes child welfare and mental health cases, these important areas are rarely considered by authors concerned with the future of the juvenile court. In mental health, children have few, if any, rights. Yet, they are often subjected to abuse and constraints that would constitute major civil rights violations if they were adults. In child welfare, children have some basic rights, but they are often dependent upon the virtually unbridled discretion of child welfare and other administrative officials. More often than not, the juvenile court plays a perfunctory role in the process and merely rubber-stamps recommendations made by child welfare personnel. The article discusses the implications of these issues and how they should be addressed in the future.

Using data from a recent study on the outcomes of child psychiatric hospitalization, the author presents a critique of the intervention-outcome movement that dominates the health care agenda. Employing an exploratory descriptive study design and Denzin’s interpretive interactionism method, she presents data that illustrate how interventions can become distorted by contextual factors, conflicting ideologies, agendas, and failure to thoughtfully consider patient needs. She posits that research agendas are heavily tilted toward outcomes research that often discount the nature of structure and process. The marketplace emphasis of health care may result in environments in which a structure and process of caring is replaced by a focus of profits over patients. The value of focusing on interventions and outcomes in research without addressing broader ecosystem variables that influence practice is questioned in view of in-depth data that emerge from practice settings.

Undergraduate programs provide fertile ground from which future practitioners, researchers, and teachers of psychiatric mental health nursing will emerge. Health care haa changed dramatically, offering opportunities for new and innovative roles and prompting faculty to develop novel ways of thinking about the future role of psychiatric nurses. Nursing faculty are challenged to devise new and creative approaches to teaching psychiatric nursing at the undergraduate level in ways that will instill enthusiasm for the ß eld. In this article, the efforts of the University of Pennsylvania to approach psychiatric mental health courses in new ways will be described. These innovations are designed to stimulate passion for what the authors see as a complex and exciting field that requires revitalisation.

In September 1997, the NationalAlliance for the Mentally Ill issued a national report card asserting that managed care companies are falling short of their promise to deliver high-quality care to people with mental illnesses. This article traces how mental health care has evolvedfrom the overbuilding of psychiatric facilities in the mid and late 1980s to a situation in which millions of mentally ill Americans cannot receive adequate care. It traces events that led to the unprecedented boom in psychiatric care through the 1980s to the place where health care reform has evolved. The disparity between insur ance coverage of mental health care services and general medical care services is dis cussed, and the legislative outcome of recent mental health reform is described. Finally, implications for nursing and recommendations for action are considered. (J Am Psychiatr Nurses Assoc [1998]. 4, 153-161)

The number of ethnic minority persons in the United States is increasing faster than that of the Caucasian population. This means that nurses will be caring for an increasingly diverse patient pool. Ethnic differences have been discovered to play a role in the efficacy of psychoactive medication. These differences result from a number of biological as well as non biological factors. Nurses have a professional obligation to be aware and sensitive to differential response to treatment.

Children with behavior problems are put in units with milieu therapy for the support and guidance of a specialized health care team, supposedly experts in the care of children with these unique and urgent needs. The reality of such units, however, is that those with the most contact with the children are often inadequately prepared, both in terms of knowledge and skills, to manage disruptive behaviors. As a result, the milieu that is supposed to provide support and structure can actually exacerbate the trauma for the vulnerable child. Preliminary data are presented from an ongoing study that is investigating the experiences and memories of formerly hospitalized children. Three types of traumatic experiences are described: vicarious trauma, alienation from staff, and direct trauma. Many of the traumatic events endured by child patients are the result of an inappropriate use by staff of power and force. There was a marked lack of understanding by the children of why given interventions were used. Although coercive interventions are sometimes necessary, ethical, legal, and other professional considerations make it clear that more work is needed. Research to identify the patterns of lack of knowledge and skills, as well as to develop appropriate interventions are recommended.

The purpose of this article is to examine the language by which nursing staff described these patients in their medical records. Charts of former psychiatric patients were studied for the quality of the words used to communicate about patient behaviors. More than 4,000 entries were examined and descriptive words that appeared with most regularity were presented to a panel of expert psychiatric nurses who were asked to Q sort them as to connotation. Results show that nurses entries focus on patients in judgemental and unflattering ways. Recommendations are made to replace the use of negatively laden language and labels with descriptions in more behavioral and operational terms.

Norman Denzin's interpretive interactionism research method is presented and its value as an addition to the researcher's tool kit for studying interventions and outcomes is discussed. Examining a narrative example from a recent study, the richness of this method for evaluation research is demonstrated. Crucial links between personal experiences, structures, and public policies can be made through the examination of experiences that are elicited as "thick description, " analyzed through "thick interpretation," and made meaningful by enfolding relevant contextual material.

During 1985–1991 state, federal and media investigations uncovered widespread fraud, patient abuse, and unethical conduct in investor-owned psychiatric hospitals. The purpose of this research study was to determine how nurses who were employed in these settings during this time experienced their work situations. Inquiry centered on ethical misgivings, sense-making, and patient advocacy. The experiences discussed in this article are the results of interviews with a theoretical sample of 30 Texas nurses. Their experiences have research, policy, education, and practice implications in that health care settings are becoming increasingly corporatized and are under great pressures to maximize profits to increase returns on investors' equity.

Critical analysis can be used to examine potential inequalities and interferences with freedom in psychiatric nursing contexts. Multidisciplinary team meetings (MDTM) evoke a sense of egalitarian multiparty cooperation, when underlying philosophical, ideological assumptions and realities can operate to contradict consciously held beliefs. Traditional approaches toward structural aspects of organizations are built on several conventional and taken-for-granted assumptions. Deconstruction and critical analysis can create alternate ways of thinking about fixed aspects of practice. The MDTM can be analyzed through different images. Underlying realities about the disempowerment of nurses and patients in the team structure can be shown through such analysis.

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

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