Laws governing the psychiatric hospitalization of minors vary considerably from state to state.
Using Restraint: The Legal Context of High Risk Interventions
Sheila Suess Kennedy
Associate Professor, Law and Public Policy
School of Public and Environmental Affairs
Indiana University Purdue University Indianapolis
801 West Michigan Street #4061
Indianapolis, IN 46202
shekenne@iupui.edu
www.sheilakennedy.net
Paper prepared for Symposium
Researching the Safety of High Risk Interventions for Children and Young People
Cornell University June 1-4, 2005
Introduction
As Kennedy and Mohr have noted (2001), the treatment of children by mental health professionals—particularly in an institutional setting—implicates three sets of important, and frequently competing, interests. The first of these is the parental interest in preserving family autonomy: minimizing state interference in decisions made about what constitutes the best interests of their children, and their right to transmit to those children their particular personal and cultural values. The second is the state’s interest in protecting the child, preventing or controlling antisocial behavior, and, in furtherance of those goals, providing a system of mental-health care. Finally, there are the child’s own interests in “being cared for, loved, and helped to become an autonomous individual with the rights and privileges of an adult” (Hopcroft, 1995).
As Kennedy and Mohr have noted (2001), the treatment of children by mental health professionals—particularly in an institutional setting—implicates three sets of important, and frequently competing, interests. The first of these is the parental interest in preserving family autonomy: minimizing state interference in decisions made about what constitutes the best interests of their children, and their right to transmit to those children their particular personal and cultural values. The second is the state’s interest in protecting the child, preventing or controlling antisocial behavior, and, in furtherance of those goals, providing a system of mental-health care. Finally, there are the child’s own interests in “being cared for, loved, and helped to become an autonomous individual with the rights and privileges of an adult” (Hopcroft, 1995).
Navigating among those interests in a professional, ethical and legal manner is a delicate process. Doctors and other health care providers relate to their patients—adults or children—from a position of trust, based upon the presumed expertise of the medical professional. Given this relationship asymmetry, such professionals have a special obligation to be strictly at the service of their patients, and to be particularly solicitous of their well being. In the case of children, this obligation is more daunting, because children constitute a special class of vulnerable patient. Children generally do not initiate the professional relationship, and once they are party to it, they are disempowered by their presumed incompetent status under the law.
Laws governing the psychiatric hospitalization of minors vary considerably from state to state. The courts have uniformly held that children do not enjoy the same degree of constitutional protection as do adults. In Parham v. J.R. (1979), the United States Supreme Court explicitly held that the involuntary hospitalization of a minor without judicial review will not run afoul of the Constitution if the child’s legal custodian consents, the treating clinicians concur, and the clinicians periodically review the need for continued inpatient treatment. Individual states are free to grant their own citizens rights additional to those ensured under the federal constitution, however, so this disenfranchisement of children plays itself out differently in different states. A substantial majority of states do apply a “least restrictive alternative” mandate to their civil commitments, requiring that any infringement on a patient’s liberty be the minimum necessary to achieve the purpose for which the person was committed, but the scope of the protection offered—particularly to minors– is a matter of considerable dispute (Saks, 1986). In most states, the avenues for relief available to juveniles are considerably fewer than those available to adults. Without adequate provisions for judicial review, children can languish in psychiatric or residential treatment facilities for unspecified lengths of time and suffer the most basic deprivations of their rights as human beings.
Any discussion of the treatment of minors confined to psychiatric facilities must begin by recognizing that children are not voluntary patients in the commonly accepted meaning of the term. Forced hospitalization encroaches on their liberty by limiting their right to be free of unwanted bodily intrusion by way of physical restraint. To the extent that at least some of the more intrusive treatment techniques in psychiatric settings are experienced as painful and distressing, those treatments may be seen as “punishments” by their recipients. (This is particularly true when the recipient is a child institutionalized for treatment of a mental illness whose capacity to understand what is happening in the moment might be impaired.) While the Supreme Court has declined to extend the Eighth Amendment’s protection against “cruel and unusual punishment” to residents of hospitals and psychiatric facilities, it has ruled that even minors retain Fourteenth Amendment liberty interests[1] in freedom of movement and in personal security, interests which can only be outweighed by an “overriding, non- punitive” state interest (Youngberg v. Romeo, 1982).
The use of restraints by psychiatric facilities is a common, albeit hotly contested, practice. The term “restraint” can refer to immobilization by force (for example, being held down by staff), or it can refer to mechanical devices (being tied to a chair; being strapped to a bed). It can be environmental (being locked in a seclusion room) or pharmacological (medication, whether delivered orally or by injection). As David Day has noted, the use of the term “restraints” in the literature varies rather widely: Brendtro and Ness (1991) used the term to describe a “range of techniques including handcuffs and multiple point straps, interventions that are commonly referred to as mechanical restraints. Selekman and Snyder (1997) defined physical restrains as ‘material and/or equipment that prevents the movement of one or more body parts.” (Day, 2000; 8)
Restraints can be physical, mechanical or chemical. Physical restraints have been defined as external controls that involve the use of physical force or holding techniques that restrain a child’s movement. Mechanical restraints can include a variety of implements in addition to those described by Day—straps, belts, cuffs, body vests and even geriatric chairs have been employed to restrict the patients mobility. Chemical restraints are medications used to sedate or immobilize; those employed may include thioridazene, chlorpromazine, and haloperidol. (Day, 2000; 9) Some of the literature defines “restraint” broadly enough to include seclusion—the practice of isolating or segregating the child—although most treat these as separate, albeit closely related, treatment issues.
Such control methods are not confined to psychiatric facilities or hospitals. Their use has been documented in a number of other settings: residential treatment centers, detention facilities, and special schools and classrooms. Whatever the arguments against their use in such environments, restraints are especially problematic when used to control children whose ability to understand and cope is by definition impaired.
The few research studies available indicate that approximately thirty percent of the children on some psychiatric units have been secluded or restrained in some manner (Garrison, Ecker, Friedman, Davidoff, Haeberle, & Wagner, 1990). More recent studies have suggested that the actual incidence of restraint use may be higher than previously estimated. A 2001 article puts the number at 47 incidents per month, per psychiatric facility, and estimates the number of restraint uses in the U.S. each year at 282,000 (Luna, 2001).
In 1998, a study documented the deaths of 37 children during a ten-year period, attributable to the use of physical restraints in psychiatric facilities. (Weiss, 1998). The study reported deaths in all 50 states, and included only those that were reported and documented. In 1999, the General Accounting Office issued a report entitled “Mental Health: Improper Restraint or Seclusion Use Places People at Risk (GAO, 1999).
The use of restraints by psychiatric facilities is a common, albeit hotly contested, practice. The term “restraint” can refer to immobilization by force (for example, being held down by staff), or it can refer to mechanical devices (being tied to a chair; being strapped to a bed). It can be environmental (being locked in a seclusion room) or pharmacological (medication, whether delivered orally or by injection). As David Day has noted, the use of the term “restraints” in the literature varies rather widely: Brendtro and Ness (1991) used the term to describe a “range of techniques including handcuffs and multiple point straps, interventions that are commonly referred to as mechanical restraints. Selekman and Snyder (1997) defined physical restrains as ‘material and/or equipment that prevents the movement of one or more body parts.” (Day, 2000; 8)
Restraints can be physical, mechanical or chemical. Physical restraints have been defined as external controls that involve the use of physical force or holding techniques that restrain a child’s movement. Mechanical restraints can include a variety of implements in addition to those described by Day—straps, belts, cuffs, body vests and even geriatric chairs have been employed to restrict the patients mobility. Chemical restraints are medications used to sedate or immobilize; those employed may include thioridazene, chlorpromazine, and haloperidol. (Day, 2000; 9) Some of the literature defines “restraint” broadly enough to include seclusion—the practice of isolating or segregating the child—although most treat these as separate, albeit closely related, treatment issues.
Such control methods are not confined to psychiatric facilities or hospitals. Their use has been documented in a number of other settings: residential treatment centers, detention facilities, and special schools and classrooms. Whatever the arguments against their use in such environments, restraints are especially problematic when used to control children whose ability to understand and cope is by definition impaired.
The few research studies available indicate that approximately thirty percent of the children on some psychiatric units have been secluded or restrained in some manner (Garrison, Ecker, Friedman, Davidoff, Haeberle, & Wagner, 1990). More recent studies have suggested that the actual incidence of restraint use may be higher than previously estimated. A 2001 article puts the number at 47 incidents per month, per psychiatric facility, and estimates the number of restraint uses in the U.S. each year at 282,000 (Luna, 2001).
In 1998, a study documented the deaths of 37 children during a ten-year period, attributable to the use of physical restraints in psychiatric facilities. (Weiss, 1998). The study reported deaths in all 50 states, and included only those that were reported and documented. In 1999, the General Accounting Office issued a report entitled “Mental Health: Improper Restraint or Seclusion Use Places People at Risk (GAO, 1999).
This situation raises a number of thorny questions: what are the medical and psychiatric indications for restraint use? What are the ethical issues involved? And what are the legal implications of these interventions?
Professional Indications
The reasons given for the use of restraints on children in a treatment facility are for the safety of the child or for the safety of other patients in the case of severe aggression (Kennedy and Mohr, 2001). Most often, health professionals justify their use of restraints as a matter of patient protection (Kapp, 1998). However, it has been asserted that the real reasons for the use of restraints were convenience (to control individual behavior with otherwise inadequate staffing, or without the need for other clinical interventions), coercion (to force the patient to comply with the staff’s wishes), or retaliation (to punish or penalize patients) (NAMI, 1999). Coercive interventions for reasons of staff convenience or punishment are expressly prohibited by applicable standards and regulations (U.S. Congress Office of Technology Assessment, 1994; U.S. Department of Health and Human Services, 1997, 1999).
The reasons given for the use of restraints on children in a treatment facility are for the safety of the child or for the safety of other patients in the case of severe aggression (Kennedy and Mohr, 2001). Most often, health professionals justify their use of restraints as a matter of patient protection (Kapp, 1998). However, it has been asserted that the real reasons for the use of restraints were convenience (to control individual behavior with otherwise inadequate staffing, or without the need for other clinical interventions), coercion (to force the patient to comply with the staff’s wishes), or retaliation (to punish or penalize patients) (NAMI, 1999). Coercive interventions for reasons of staff convenience or punishment are expressly prohibited by applicable standards and regulations (U.S. Congress Office of Technology Assessment, 1994; U.S. Department of Health and Human Services, 1997, 1999).
Empirical literature addressing the use of coercive interventions with children is exceedingly sparse. There are no well-designed studies that compare interventions using equivalent groups of children, or studies that control for differences in staff knowledge. There are none comparing the use of less restrictive techniques with more restrictive ones, nor that explore the long-term effects of coercive interventions. Indeed, most studies available are anecdotal and non-generalizable (Mohr, Mahon, & Noone, 1998). In 2000, David M. Day reviewed the literature dealing with the use of restraints and seclusion on children, in an effort to determine how that literature might inform “the safe, appropriate and proper use of restrictive interventions” (Day, 2000;i). He found a high degree of variability in that literature: different definitions of what constitute restraints; different estimates of the frequency with which such strategies are employed; different theoretical justifications for their use; and very different opinions with respect to their appropriateness. There was some agreement that younger children were at greater risk as a result of such strategies, and that a relatively small pool of children—estimated at between seven and fifteen percent—account for the majority of incidents in which such strategies are employed (Day, 2000). Like others who have researched these issues, Day notes the need for a sounder theoretical grounding and the development of professional, evidence-based standards.
The lack of theoretical grounding for a potentially dangerous practice is one problem; the ambiguity of existing guidelines is another. In 1997, the Health Care Financing Administration (HCFA) (now the Centers for Medicare and Medicaid Services, or CMS), which finances and regulates Medicare and Medicaid, issued proposed rules for hospitals participating in these programs. These were known as “conditions of participation.” HCFA declared that its “expectation is that a hospital would impose restraints or seclusion only when absolutely necessary to prevent immediate injury to the patient or others and when no alternative means are sufficient to accomplish the purpose.” However, the rules contained no details, and HCFA has neither a monitoring plan nor clear enforcement provisions directly targeted to restraints and seclusion. HCFA asked for comments from a number of organizations and received a great many from members of the National Alliance for the Mentally Ill, but in the final analysis gave no details related to physician authorization, procedures for issuing orders, time limits on the use of restraints, or requirements for checking on patients. Similarly, the Joint Commission on Accreditation of Health care Organizations (JCAHO) has issued standards with vague provisions related to restraints. JCAHO requires that “special treatment procedures” which include “restraint or seclusion” be documented in the medical record. A physician’s verbal or written order is required, it must be time-limited, and there must be periodic observation. But none of these provisions is defined or explained. There are a number of similar examples (Kennedy and Mohr, 2001).
Braxton (1995) suggests that a major contributor to the problem is the scarcity of appropriate staff. Due to funding constraints, limited resources, and lack of regulations or regulatory oversight, virtually anyone can get a job taking care of these vulnerable children. This has been the case for many years despite the fact that the profession and the federal courts have recognized the importance of adequately-trained staff in the care of the mentally ill (Wyatt v. King, 1992). (Adequate training in this context would include specific knowledge of psychopharmacology, psychopatholgy, psychotherapeutic interventions, and interviewing and assessment of mental status. (Kennedy and Mohr, 2001)).
All of these problems are exacerbated by the fact that children in these facilities are exceedingly difficult patients. They are wounded and mistrustful and their main mode of coping is to lash out in attack—behavior that can be frightening to inadequately prepared staff. From a theoretical standpoint, if not for purposes of constitutional analysis, the use of restraints and other coercive methods of controlling these children is punishment (Kennedy and Mohr, 2001).The most that can be said for punishment, or any other aversive intervention, is that it usually stops a child’s misbehavior temporarily (Krumbolz & Krumbolz, 1972). Behavior theorists maintain that such interventions fail to teach children appropriate behaviors (Bandura, 1969; Skinner, 1953), and they clearly pose other risks to highly vulnerable children.
Ethical Considerations
Restraints pose a number of risks to young patients. There is the danger of further trauma to an already traumatized child who has, by definition, limited competence to understand what is happening to her, and few acceptable coping tools. (It bears emphasizing that these children are often being treated for problems stemming from previous traumatic experiences—physical and/or sexual abuse, a terrifying accident, etc.) There is the added danger that restraints will cause suffering—not just through the physical discomfort, but also by engendering feelings of isolation, anxiety, and humiliation. Of particular concern is the danger of significant physical injury, or even death or asphyxia, a danger that has been amply documented in the medical literature (Howard & Reay, 1998; Pollanen, Chiasson, Cairns, &Young, 1998).
Restraints pose a number of risks to young patients. There is the danger of further trauma to an already traumatized child who has, by definition, limited competence to understand what is happening to her, and few acceptable coping tools. (It bears emphasizing that these children are often being treated for problems stemming from previous traumatic experiences—physical and/or sexual abuse, a terrifying accident, etc.) There is the added danger that restraints will cause suffering—not just through the physical discomfort, but also by engendering feelings of isolation, anxiety, and humiliation. Of particular concern is the danger of significant physical injury, or even death or asphyxia, a danger that has been amply documented in the medical literature (Howard & Reay, 1998; Pollanen, Chiasson, Cairns, &Young, 1998).
If, as previously suggested, the use of restraints is an intervention that has little in the way of either theory or research to argue for its efficacy, its use raises serious ethical concerns. The fiduciary ethic, the principle of beneficence, and the obligation to do no harm require that professionals minimize any unintended adverse consequences of any intervention. Given the existence of substantial evidence of restraints’ negative effects, their continued use in circumstances where less-restrictive alternatives are available arguably violates the principles of beneficence and non-maleficence (Kennedy and Mohr, 2001). Given the risks, the dubious benefits, absence of clear guidelines, and lack of a research foundation validating their effectiveness, professionals must seriously question the ethics of continuing this practice.
This is not to say that there are no situations in which the use of restraints may be justified. When a child suffering from Lesch-Nyhan engages in auto-cannibalism, an autistic child persists in severe head banging, or an adolescent under the influence of PCP is in a homicidal rage, there may be no other choices. But as a routine intervention, as an assumed part of the repertoire of responses by staff members, restraints should be viewed as another non-validated therapy and be subject to the rules governing situations that require informed consent (Kennedy and Mohr, 2001).
The Legal Thicket: First Things First
There are two types of codified law that may constrain the use of restraints or other interventions. The first is sometimes referred to as “positive” law. Positive laws are statutes, like civil rights laws or the Americans with Disability Act. The second are rights guaranteed under the U.S. Constitution. Constitutional rights are negative in nature; these are our rights to be free of certain types of government interference. Because the Constitution restrains only government, in order to know whether a constitutional right has been violated, we must first ask whether the state—the government—has acted. And this is anything but a straightforward inquiry. In one such case, Lebron v. National Railroad Passenger Corporation (1995), Justice Scalia began his state action analysis by stating: “It is fair to say that our cases deciding when private action might be deemed that of the state have not been a model of consistency.” To suggest that this was an understatement would itself be an understatement.
There are two types of codified law that may constrain the use of restraints or other interventions. The first is sometimes referred to as “positive” law. Positive laws are statutes, like civil rights laws or the Americans with Disability Act. The second are rights guaranteed under the U.S. Constitution. Constitutional rights are negative in nature; these are our rights to be free of certain types of government interference. Because the Constitution restrains only government, in order to know whether a constitutional right has been violated, we must first ask whether the state—the government—has acted. And this is anything but a straightforward inquiry. In one such case, Lebron v. National Railroad Passenger Corporation (1995), Justice Scalia began his state action analysis by stating: “It is fair to say that our cases deciding when private action might be deemed that of the state have not been a model of consistency.” To suggest that this was an understatement would itself be an understatement.
The Bill of Rights was initially designed to limit the reach of the federal government; the Fourteenth Amendment later extended those limitations to bar similar action by the states. Over the years, by the process known as “selective incorporation,” most of the original eight amendments have been held to apply to state and local government units as well as to the federal government, (Twining v. New Jersey 1908; Palko v. Connecticut 1937; Adamson v. California 1947; Berger 1977; Ely 1980). But citizens are protected against public actions only. Discriminatory acts, or denials of liberty or due process by private parties are constitutional; indeed, they are entirely legal unless prohibited by virtue of legislation like the Civil Rights Act of 1964 or the Americans with Disabilities Act.
Blum v. Yaretsky is perhaps the best example of the inadequacies of current state action doctrine, and a case with obvious implications for the questions raised by the use of restraints. The case involved an alleged due process violation arising out of involuntary discharges and transfers of Medicaid patients in a nursing home. Rhenquist, writing for the Court, declined to find state action, saying that “…a state normally can be held responsible for a private decision only when it has exercised coercive power or has provided such significant encouragement…that the choice must in law be deemed to be that of the State” (Blum, 1983: 992). Acknowledging that over 90% (and perhaps as many as 99%) of the patients in the facility were being paid for by the government, and that the nursing home actions being challenged were based upon government regulations, the Rhenquist majority nevertheless declined to find state action.
As Justice Brennan noted in an acerbic dissent,
“The Court’s analysis in this case [proceeds] upon a premise that is
factually unfounded…A doctor who prescribes drugs for a patient on the
basis of his independent medical judgment is not rendered a state actor
merely because the State may reimburse the patient in different amounts
depending upon which drug is prescribed. But the level of care decisions
in this case, even when characterized as the ‘independent’ decision of the
nursing home, have far less to do with the exercise of independent
professional judgment than they do with the State’s desire to save money…”(ibid., p. 1014-19)
“The Court’s analysis in this case [proceeds] upon a premise that is
factually unfounded…A doctor who prescribes drugs for a patient on the
basis of his independent medical judgment is not rendered a state actor
merely because the State may reimburse the patient in different amounts
depending upon which drug is prescribed. But the level of care decisions
in this case, even when characterized as the ‘independent’ decision of the
nursing home, have far less to do with the exercise of independent
professional judgment than they do with the State’s desire to save money…”(ibid., p. 1014-19)
Brennan and Marshall dissented again in Rendell-Baker v. Kohn (1982) a case involving the education by a private institution of “problem children” referred to the school by state officials. Nearly all of the school’s funding came from the state, the facility was heavily supervised and regulated, and almost all its students were assigned to it by the state. Nevertheless, the Court once again declined to find state action, holding that “the school’s fiscal relationship with the State is not different from that of many contractors performing services for the government.”
Even constitutional lawyers have difficulty anticipating when, and whether, the actions of ostensibly private actors will be attributed to the state for purposes of applying constitutional constraints. Medical and psychiatric professionals can hardly be expected to know when they might be considered government actors, especially since results can be extremely counter-intuitive: for example, in Wade v. Byles (1996), a private company providing security to a public housing project was held not to be a public actor despite the fact that the guards had authority to carry guns, arrest people, and use deadly force.
Complicating state action jurisprudence even further is the tendency of reviewing courts to apply different standards of analysis depending upon the nature of the Constitutional right involved, without, however, articulating the basis for those differences. Commentators have noted that, in cases involving racial discrimination or implicating First Amendment religious liberties, the Court has been much more willing to find—or assume—state action.
The point of this extremely cursory review of state action doctrine is that constitutional constraints will only apply against state actors, and in many situations, it is by no means clear who those actors are. Employees (but not necessarily doctors or nurses providing services under contract) of state-run facilities will be state actors. Private psychiatric institutions will probably not be bound by constitutional limitations, even if the patient’s care is being paid for by the government. Prisons will be considered state actors for most purposes (although the law applicable to private prisons is still being sorted out), but it is simply not possible to predict in advance what a court may decide with respect to halfway houses, residential treatment facilities and other venues where restraints may be used. The constitutional discussion that follows must be understood in the context of that uncertainty.
Restraints as Eighth Amendment Cruel and Unusual Punishment
The point of this extremely cursory review of state action doctrine is that constitutional constraints will only apply against state actors, and in many situations, it is by no means clear who those actors are. Employees (but not necessarily doctors or nurses providing services under contract) of state-run facilities will be state actors. Private psychiatric institutions will probably not be bound by constitutional limitations, even if the patient’s care is being paid for by the government. Prisons will be considered state actors for most purposes (although the law applicable to private prisons is still being sorted out), but it is simply not possible to predict in advance what a court may decide with respect to halfway houses, residential treatment facilities and other venues where restraints may be used. The constitutional discussion that follows must be understood in the context of that uncertainty.
Restraints as Eighth Amendment Cruel and Unusual Punishment
To the extent that therapy approaches are carefully designed to be serious attempts to extinguish maladaptive behavior patterns, they may legitimately be deemed treatment as opposed to punishment. On the other hand, logic suggests that inappropriately designed behavioral programs that constitute punishment disguised as treatment should be subject to analysis under Eighth Amendment standards. Some lower courts have so ruled. (Converse v. Nelson, 1995). However, the Supreme Court has expressly held that the Eighth Amendment standard can be applied only in a correctional context, and that the Eighth Amendment is inapplicable in a mental institution setting (Youngberg, 1982). The disparity occurs because the courts distinguish between prisons, as punitive institutions, and hospitals, where the object is to provide treatment (Ingraham v Wright, 1977). Persons who have not been convicted of a crime have a constitutionally recognized right to be free of state- imposed punishment (Bell v Wolfish, 1979). Restraints have frequently been held to violate the prohibition against cruel and unusual punishment when used in a penal institution; prison officials have a duty under the Eighth Amendment to provide “humane conditions of confinement” and can be held liable for acting with “deliberate indifference” to the health and/or safety of an inmate. (Farmer v. Brennan, 1994). In the non-criminal, non-punitive context of a residential treatment facility, the Court has explicitly found Eighth Amendment analysis inappropriate. (Youngberg, 1982) Innocent persons have a right to be free from punishment, and schools and hospitals are not penal institutions; therefore, Eighth Amendment standards governing the nature of punishment do not apply. (Ingraham, 1977). (Even if the Eighth Amendment does not offer protection, however, the Court has held that interventions which are not professionally indicated and which are unnecessarily restrictive may violate a patient’s Fourteenth Amendment liberty interest.)
Despite the legal distinction the courts have drawn between a “punitive” involuntary confinement triggering Eighth Amendment protections and a prophylactic one implicating Fourteenth Amendment interest, use of restraints seems factually to be little different from the corporal punishment that has been held to be cruel and unusual punishment in prison and juvenile cases (see, e.g., Jackson v. Bishop, 1968). It is difficult to defend the professional appropriateness of medical interventions that are considered too inhumane to be constitutionally applied to criminals in a penal facility.
The leading case on the issue of restraints is Youngberg v. Romeo, decided by the United States Supreme Court in 1982. The case involved a profoundly retarded youngster who was involuntarily committed to a Pennsylvania state institution, where he suffered injuries due to the conditions of his confinement. His mother brought suit, alleging that he had the right to safe conditions of confinement, freedom from bodily restraint, and appropriate training or “habitation.” The trial court had applied the Eighth Amendment standard, and had found the institution guilty of violating it. The Court of Appeals had reversed and remanded the case for a new trial, holding that a Fourteenth Amendment standard was the appropriate one. The Supreme Court agreed with the Appeals Court, but went further, holding that persons involuntarily committed to state institutions have a constitutionally protected liberty interest under the Due Process Clause of the Fourteenth Amendment to “reasonably safe conditions of confinement, freedom from unreasonable bodily restraints, and such minimally adequate training as reasonably may be required by these interests.” The Court explicitly adopted that portion of the Appeals Court decision holding that persons involuntarily committed “retain liberty interests in freedom of movement and in personal security. These are ‘fundamental liberties’ that can be limited only by an ‘overriding, non-punitive’ state interest.”
In determining whether the State has protected a patient’s right to freedom from “unreasonable restraint” a court must decide what is “reasonable.” In its opinion in Youngberg, the Supreme Court highlighted its concern that courts not invade the province of those whose job it is to make medical and custodial decisions. The test to determine whether the use of restraints was reasonable under the circumstances of a particular case is whether professional judgment was in fact exercised. Such professional judgment, the Court ruled, was to be considered “presumptively valid.” A presumption operates to shift the burden of proof to those alleging that the imposition of restraints was unreasonable.
The Court signaled its deference to the political realities of confinement, expressly noting that there are occasions in which it is necessary for the state to restrain institutional residents. This being the case, the proper inquiry for constitutional purposes will be not whether the patient’s liberty interest has been infringed, but “whether the extent or nature of the restraint or lack of absolute safety is such as to violate due process.” In short, the courts are to weigh an individual’s interest in liberty against the state’s asserted need to restrain. The standard to be used in making that determination is professional judgment. While the Court explicitly states that it is inappropriate for courts to specify which of several “professionally acceptable” choices should have been made, the emphasis on professional judgment highlights a central contention of critics of the use of restraints: the paucity of rigorous, clinically adequate research on restraints that can inform the necessary professional judgment, and the substantial existing evidence that restraints are rarely useful and frequently harmful. It is interesting to note that in Britain, psychiatrists have successfully done without the major forms of mechanical restraint for many years, and the British Mental Health Act Commission has even proposed forbidding their use (Saks, 1986). In 2005, the Welsh Assembly Government issued a Framework for Restrictive Physical Intervention Policy and Practice, disapproving certain types of restraints and restraint positions (Allen, 2005). A variety of Canadian scholars and practitioners have called for restrictions on the practice (Day, 2000). The evolution of such international professional standards casts further doubt on the legal adequacy of American professionals’ reliance on restraints, and will undoubtedly be cited in some future challenge to the professional basis of a decision to use restraints.
Non-Constitutional Considerations
Even when constitutional constraints do not apply, statutory, regulatory and case law may provide guidance to providers, or offer remedies for litigants. In 1999, the United States Supreme Court applied the protections of Title II of the Americans with Disability Act to mentally disabled people in government custody (Olmstead, 1999), and held that keeping such patients in an overly isolated treatment environment amounted to discrimination under the terms of that Act. The implications of the Olmstead decision continue to be clarified as litigation citing the decision fleshes out the scope of the state’s duty; however, it seems inevitable that the Court will eventually be asked to determine the propriety of specific psychiatric interventions in the context of the ADA.
Non-Constitutional Considerations
Even when constitutional constraints do not apply, statutory, regulatory and case law may provide guidance to providers, or offer remedies for litigants. In 1999, the United States Supreme Court applied the protections of Title II of the Americans with Disability Act to mentally disabled people in government custody (Olmstead, 1999), and held that keeping such patients in an overly isolated treatment environment amounted to discrimination under the terms of that Act. The implications of the Olmstead decision continue to be clarified as litigation citing the decision fleshes out the scope of the state’s duty; however, it seems inevitable that the Court will eventually be asked to determine the propriety of specific psychiatric interventions in the context of the ADA.
Also in 1999, Congress passed the Children’s Health Act (P.L. 106-310), setting out rules for the protection of young patients’ rights. Section 3207 of that Act provided that patients be free from restraints used for discipline or convenience. (Luna, 2001) While this was a relatively mild regulatory prohibition, the Act allows states to pass measures that are substantially more protective of children’s rights, and some have done so.
In 2001, the Centers for Medicare and Medicaid Services (the new name for what had formerly been the Health Care Financing Administration or HCFA) promulgated a more protective version of the regulation applying to non-hospital psychiatric residential treatment facilities that are serving individuals under 21. The regulation provided that restraints can only be used when necessary to ensure patient safety or the safety of others, and must end when the threat to that safety is over, and that only a physician or other licensed practitioner can give the order to employ the intervention. It also required a number of procedural safeguards, including prompt notification of the patient’s parents or legal guardians; “debriefing” sessions, and a reporting requirement (Fed. Reg., 2001). It should be noted that the interim rule did not meet with uniform approval in the psychiatric community; the APA, for one, did not support it, citing—among other things—the costs of implementation, and the burden imposed in situations where repetitive use of restraints is necessary.
In the early 1970’s, most states enacted so-called “Patients’ Bills of Rights,” and those have been further amended and construed over time. While the provisions of such laws vary across the states, most began as efforts to codify the protections mandated by cases like Wyatt v. Stickney (1972). Depending upon the specific provisions of the laws of the state where the use of restraints occurred, patient bills of rights may provide yet another avenue for claims against either a public or private psychiatric institution arising out of the use of restraints.
In addition to these codified legal standards, of course, there is traditional tort law, including medical malpractice. It is important to note the intensely “fact-sensitive” nature of these cases; even more than the statutory and constitutional challenges, the resolution of such cases will ultimately depend upon the interpretation of a number of facts specific to the particular incident involved. In the majority of these cases, recovery has been denied—sometimes because the patient cannot prove damages, or prove that the damages involved were caused by the restraints. At other times, recovery is denied because the court defers to the professional judgment of the provider. Even when a challenge is successful, however, the deterrent value of the lawsuit may not be significant; in Clark v. Ohio Department of Mental Health (1989), for example, the court found that the use of restraints had indeed been punitive, rather than prophylactic, but since the patient could demonstrate no substantial harm, she was awarded only one dollar in damages.
Cases involving children are inevitably more complicated than lawsuits brought on behalf of adults, and any discussion of tort principles must acknowledge the special place children occupy in our society and jurisprudence. American laws concerning children have been informed by two very distinct approaches: a paternalistic, or progressive, approach which focuses upon nurturance and protection; and an individual-rights approach, which emphasizes the child’s age-appropriate right to personal autonomy (Kennedy, 2002). To the first approach we can attribute legislation making school attendance compulsory, establishing juvenile courts, and prohibiting child labor. These are measures that assume a large degree of dependence by children on adult society. In the second category, we might list court cases such as Brown v. Board of Education (1954) which recognized children as rights-bearing individuals, or In re Gault, (1967), which entitled juveniles to court-appointed counsel, or Tinker v. Des Moines (1969) which protected the right of minors to express political opinions in a non-disruptive manner in a public-school setting. Studies have shown that in the U.S. there is strong political support for the extension of the protective, “nurturant” rights, but far less support for rights of self-determination. The legal system has struggled with the balance between these two approaches, a struggle made more difficult because—as noted earlier—rights and duties of parents and (to a lesser but not inconsiderable extent) the interests of the state are also implicated. As one commentator has noted, the courts have tried to mediate the conflict between “democratic ideals of individual freedom and the sanctity of the family unit.” The result is a framework that rests on a sharp distinction between public and private responsibility for children’s welfare, with the public assuming responsibility only when the private actors have defaulted. The primacy of the power given to parents and family rests on a belief that children need authority rather than autonomy.
Children—even healthy ones—have no political power, and the laws affecting them reflect that reality. Child labor laws went nowhere until labor unions decided that such laws would be economically beneficial to their members; similarly, court opinions affecting children typically arise in the context of other conflicts: child custody disputes, religious liberty cases, the criminal justice system and conflicts around medical treatment and intervention. If parents have often been accorded unreasonably wide latitude over childrearing decisions, the Court has just as steadfastly refused to limit the scope of state interference with children’s liberty interests. In 1979, in Parham v. J.R., referenced above, the Court declined to require that a hearing be held before a child could be institutionalized; and in 1984, in Schall v. Martin, it permitted the “preventive” detention of juveniles said to “pose a risk” of committing crime. The Court in Schall held that a minor’s liberty interest was subordinate to his “best interests” as the state might define them. The trend since 1980 has been to diminish even such children’s rights as the Court had previously established. In the infamous DeShaney v. Winnebago County Department of Social Services (1989), the Court declined to find county social workers liable for severe brain damage suffered by a child at the hands of his father, despite the fact that the agency had been aware of the situation for months, had removed the child from the home at one point, had returned him to the father’s custody and then allowed him to remain despite the father’s noncompliance with required counseling and documented evidence of continued abuse. The case stands as a stark example of current legal principles sharply limiting the state’s affirmative responsibility for the well-being of children. Litigation challenging the propriety of the use of restraints occurs in an environment that is heavily influenced by these conflicting approaches to the rights of children and the duties of the state.
Finally, it is important to note that tort and malpractice cases are also brought against facilities alleging neglect for failure to restrain. When patients do harm themselves or others, and they were not restrained at the time, it is not uncommon for lawsuits to allege that the failure to restrain amounted to negligence, and was compensable. For providers, the decision to restrain or not can easily be experienced as a “lose-lose” situation—they are truly caught between “the devil and the deep blue sea.”
Conclusion
The law governing the use of restraints is not unambiguous, but it is evolving, and certain trends are evident. The Fourteenth Amendment liberty interest test enunciated by the Supreme Court in Youngberg is a highly deferential one; nevertheless, deferential is not non-existent. Providers will risk legal liability when a decision to employ restraints is so substantial a departure from accepted professional judgment, practice or standards as to demonstrate that the person responsible actually did not base the decision on such a judgment. Given the limited evidence of efficacy, the self-referential nature of such research as is available, and the debate over guidelines for the use of such interventions, even that seemingly simple test may be impossible to meet.
The law governing the use of restraints is not unambiguous, but it is evolving, and certain trends are evident. The Fourteenth Amendment liberty interest test enunciated by the Supreme Court in Youngberg is a highly deferential one; nevertheless, deferential is not non-existent. Providers will risk legal liability when a decision to employ restraints is so substantial a departure from accepted professional judgment, practice or standards as to demonstrate that the person responsible actually did not base the decision on such a judgment. Given the limited evidence of efficacy, the self-referential nature of such research as is available, and the debate over guidelines for the use of such interventions, even that seemingly simple test may be impossible to meet.
The Supreme Court’s decision in Olmstead brought mental health facilities within the contemplation of the Americans with Disabilities Act, and a wide variety of associations working for the rights of the mentally ill have lobbied successfully for other state and federal standards—statutory and regulatory—that also restrict the use of these interventions, and apply to public and private facilities alike. The absence of any sound clinical basis for the use of restraints strengthens the case of plaintiffs bringing malpractice actions in wake of their use. All of these developments evidence a clear trend against the employment of restraints.
It would thus seem to be high time to revisit the issue. The profession should produce standards governing the use of restraints that can be supported by sound theory and methodologically credible research, and justified under appropriate ethical and legal standards. Until such time as that research has been produced, restraints should be applied rarely and with extreme caution.
Adamson v. California, 322 U.S. 46 (1947)
References
Adamson v. California, 322 U.S. 46 (1947)
Bandura, A. (1969). Principles of behavior modification. New York, N.Y.: Holt, Rinehart & Winston.
Bell v. Wolfish, 441 U.S. 520 (1979)
Berger, R. (1977) Government by Judiciary.
Blum v. Yaretsky, 457 U.S. 991 (1983).
Braxton, E.T. (1995) Angry children, frightened staff: Implications for training and staff development: Residential Treatment for Children and Youth, 13(1), 13-38.
Brooks. University of Pennsylvania Law Review.
Brown v. Board of Education, 347 U.S. 483 (1954).
Civil Rights Act of 1964.
Clark v. Ohio Department of Mental Health, 573 NE2d 794 (1989).
Converse v. Nelson, No. 95-16776 (Mass. Superior Ct. July 1995)
DeShaney v. Winnebago County Department of Social Services, 489 U.S. 189 (1989).
Farmer v. Brennan, 511 U.S. 825 (1994)
Garrison, W.T., Ecker, M.A., Friedman, M.D., Davidoff, M.D., Haeberle, K, & Wagner, M. (1990. Aggression and counteraggression during child psychiatric hospitalization. Journal of the American Academy of Child and Adolescent Psychiatry, 29(2), 242-250.
Gilmour, R. and Jensen, L. (1998) Reinventing Government Accountability: Public Functions, Privatization, and the Meaning of State Action. Public Administration Review.
Government Accounting Office (1999). Mental Health: Improper Restraint or Seclusion Use Places People at Risk.
Health Care Financing Administration (1999). Hospital Condition of Participation in Medicare and Medicaid, Federal Register, 64, 127, Friday, July 2, 36089.
Health Care Financing Administration (1999). Hospital Condition of Participation in Medicare and Medicaid, Federal Register, 64, 127, Friday, July 2, 36089.
Hopcroft, T.E.(1995). Civil commitment of minors to mental institutions in the Commonwealth of Massachusetts. New England Journal on Criminal and Civil Confinment, Summer
Howard, J.D. & Reay, D.T. (1997). Positional asphyxia. Annals of Emergency Medicine, 32(1), 116-118.
Ingraham v. Wright, 430 U.S. 651 (1977)
Jackson v. Bishop, 404 F.2d 571, 579-80 (8th Circuit 1968) (Blackmun, J.).
Jackson v. Metropolitan Edison Co., 419 U.S. 345 (1974)
Joint Commission on the Accreditation of Healthcare Organizations. (1966)
Kapp, M.B. (1998). Our hands are tied: Legal tensions and medical ethics. Westport, CT.: Auburn House.
Kennedy, S.S. (2001) The Muffled Voice of the Child: American Health Care and Children’s Rights. Journal of Medicine and Law, Michigan State University. Vol. 6, Issue #1.
Kennedy, S.S. and Mohr, W.K., (2001) A Prolegomenon on Restraint of Children: Implicating Constitutional Rights. American Journal of Orthopsychiatry. Vol. 71, Number 1.
Krumboltz, J.D. & Kurmboltz, H.B. (1972). Changing children’s behavior. Englewood Cliffs, N.J.: Prentice-Hall Inc.
Krumboltz, J.D. & Kurmboltz, H.B. (1972). Changing children’s behavior. Englewood Cliffs, N.J.: Prentice-Hall Inc.
Lebron v. National Railway Passenger Corporation, 513 U.S. 374 (1995).
Luna, J. (undated) Limiting the Use of Restraint and Seclusion in Psychiatric Residential Treatment Facilities for Patients Under 21. Health Law Perspectives.
Mohr,W.K., Mahon, M.M, & Noone, M.J. (1998). A restraint on restraints: The need to reconsider restrictive interventions. Archives of Psychiatric Nursing, 12(2), 95-106.
National Alliance for the Mentally Ill. (1999) Cries of Anguish: Reports of Restraint and Seclusion Abuse Received Since October 1998 Investigation by Hartford Courant.
National Collegiate Athletic Association v. Tarkanian, 488 U.S. 179 (1988).
Norwood v. Harrison, 413 U.S. 455 (1973)
Olmstead v. L.C. ex rel. Zimring, 119 S.Ct. 2176 (1999)
Palko v. Connecticut, 302 U.S. 319 (1937)
Parham v. J.R., 442 U.S. 584; (1979).
Pollanen, M.S., Chiasson, D.A., Cairns, J.T., & Young, J.G. (1998). Unexpected death related to restraint for excited delerium: a retrospective study of deaths in police custody and in the community. CMAJ, 158(12), 1611-1612.
Restaint Safety Act of 1999 briefing House Commerce Subcommittee on Health and Environment; House Ways and Means Subcommittee on Health. Cong., March 21, 2000.
Restaint Safety Act of 1999 briefing House Commerce Subcommittee on Health and Environment; House Ways and Means Subcommittee on Health. Cong., March 21, 2000.
Rendell-Baker v. Kohn, 457 U.S. 830 (1982).
Rosenbloom, D., Carroll, J. and Carroll, J. ((2000) Constitutional Competence for Public Managers.
Saks, Elyn R. (1986) “The Use of Mechanical Restraints in Psychiatric Hospitals” Yale Law Journal
San Francisco Arts & Athletics, Inc. v. United States Olympic comm.., 483 U.S. 522 (1987).
Schall v. Martin, 467 U.S. 253 (1984).
Skinner, B.F. (1953). Science and human behavior. New York, N.Y.: Macmillan
Tinker v. Des Moines, 393 U.S. 503 (1969)
Twining v. New Jersey, 211 U.S. 78 (1908)
U.S. Department of Health & Human Services. (1997). Health Care Financing Administration Conditions of Participation. Washington, D.C.
U.S. Department of Health & Human Services. (1999). Health Care Financing Administration Conditions of Participation. Washington, D.C.
Wade v. Byles, 83 F.3d 902 (7th Cir. 1996).
Weiss, E.M.(October 11-15, 1998) Deadly restraint: A nationwide pattern of death. Hartford Courant.
Wyatt v. King, 793 F.Supp. 1058 (1992).
Wyatt v. Stickney, 344 F.Supp. 373, 378-86 (1972).
Youngberg v. Romeo, 457 U.S. 307 (1982).
[1] The Fourteenth Amendment prohibited state governments from denying the “privileges and immunities” of citizenship to their own citizens; prior to passage of the Amendment, the limitations on state action imposed by the Bill of Rights did not apply to state and local governments. Subsequent cases have further defined the scope of the Amendment’s equal protection and due process clauses, and have described the fundamental rights which are protected. The “liberty interest” encompasses much more than personal freedom from confinement; it includes those aspects of life deemed fundamental to happiness, like the right to travel, contract, practice a profession and marry the person of ones own choosing.
Clark v. Ohio Department of Mental Health, 573 NE2d 794 (1989).
Converse v. Nelson, No. 95-16776 (Mass. Superior Ct. July 1995)
DeShaney v. Winnebago County Department of Social Services, 489 U.S. 189 (1989).
Farmer v. Brennan, 511 U.S. 825 (1994)
Garrison, W.T., Ecker, M.A., Friedman, M.D., Davidoff, M.D., Haeberle, K, & Wagner, M. (1990. Aggression and counteraggression during child psychiatric hospitalization. Journal of the American Academy of Child and Adolescent Psychiatry, 29(2), 242-250.
Gilmour, R. and Jensen, L. (1998) Reinventing Government Accountability: Public Functions, Privatization, and the Meaning of State Action. Public Administration Review.
Government Accounting Office (1999). Mental Health: Improper Restraint or Seclusion Use Places People at Risk.
Health Care Financing Administration (1999). Hospital Condition of Participation in Medicare and Medicaid, Federal Register, 64, 127, Friday, July 2, 36089.
Health Care Financing Administration (1999). Hospital Condition of Participation in Medicare and Medicaid, Federal Register, 64, 127, Friday, July 2, 36089.
Hopcroft, T.E.(1995). Civil commitment of minors to mental institutions in the Commonwealth of Massachusetts. New England Journal on Criminal and Civil Confinment, Summer
Howard, J.D. & Reay, D.T. (1997). Positional asphyxia. Annals of Emergency Medicine, 32(1), 116-118.
Ingraham v. Wright, 430 U.S. 651 (1977)
Jackson v. Bishop, 404 F.2d 571, 579-80 (8th Circuit 1968) (Blackmun, J.).
Jackson v. Metropolitan Edison Co., 419 U.S. 345 (1974)
Joint Commission on the Accreditation of Healthcare Organizations. (1966)
Kapp, M.B. (1998). Our hands are tied: Legal tensions and medical ethics. Westport, CT.: Auburn House.
Kennedy, S.S. (2001) The Muffled Voice of the Child: American Health Care and Children’s Rights. Journal of Medicine and Law, Michigan State University. Vol. 6, Issue #1.
Kennedy, S.S. and Mohr, W.K., (2001) A Prolegomenon on Restraint of Children: Implicating Constitutional Rights. American Journal of Orthopsychiatry. Vol. 71, Number 1.
Krumboltz, J.D. & Kurmboltz, H.B. (1972). Changing children’s behavior. Englewood Cliffs, N.J.: Prentice-Hall Inc.
Krumboltz, J.D. & Kurmboltz, H.B. (1972). Changing children’s behavior. Englewood Cliffs, N.J.: Prentice-Hall Inc.
Lebron v. National Railway Passenger Corporation, 513 U.S. 374 (1995).
Luna, J. (undated) Limiting the Use of Restraint and Seclusion in Psychiatric Residential Treatment Facilities for Patients Under 21. Health Law Perspectives.
Mohr,W.K., Mahon, M.M, & Noone, M.J. (1998). A restraint on restraints: The need to reconsider restrictive interventions. Archives of Psychiatric Nursing, 12(2), 95-106.
National Alliance for the Mentally Ill. (1999) Cries of Anguish: Reports of Restraint and Seclusion Abuse Received Since October 1998 Investigation by Hartford Courant.
National Collegiate Athletic Association v. Tarkanian, 488 U.S. 179 (1988).
Norwood v. Harrison, 413 U.S. 455 (1973)
Olmstead v. L.C. ex rel. Zimring, 119 S.Ct. 2176 (1999)
Palko v. Connecticut, 302 U.S. 319 (1937)
Parham v. J.R., 442 U.S. 584; (1979).
Pollanen, M.S., Chiasson, D.A., Cairns, J.T., & Young, J.G. (1998). Unexpected death related to restraint for excited delerium: a retrospective study of deaths in police custody and in the community. CMAJ, 158(12), 1611-1612.
Restaint Safety Act of 1999 briefing House Commerce Subcommittee on Health and Environment; House Ways and Means Subcommittee on Health. Cong., March 21, 2000.
Restaint Safety Act of 1999 briefing House Commerce Subcommittee on Health and Environment; House Ways and Means Subcommittee on Health. Cong., March 21, 2000.
Rendell-Baker v. Kohn, 457 U.S. 830 (1982).
Rosenbloom, D., Carroll, J. and Carroll, J. ((2000) Constitutional Competence for Public Managers.
Saks, Elyn R. (1986) “The Use of Mechanical Restraints in Psychiatric Hospitals” Yale Law Journal
San Francisco Arts & Athletics, Inc. v. United States Olympic comm.., 483 U.S. 522 (1987).
Schall v. Martin, 467 U.S. 253 (1984).
Skinner, B.F. (1953). Science and human behavior. New York, N.Y.: Macmillan
Tinker v. Des Moines, 393 U.S. 503 (1969)
Twining v. New Jersey, 211 U.S. 78 (1908)
U.S. Department of Health & Human Services. (1997). Health Care Financing Administration Conditions of Participation. Washington, D.C.
U.S. Department of Health & Human Services. (1999). Health Care Financing Administration Conditions of Participation. Washington, D.C.
Wade v. Byles, 83 F.3d 902 (7th Cir. 1996).
Weiss, E.M.(October 11-15, 1998) Deadly restraint: A nationwide pattern of death. Hartford Courant.
Wyatt v. King, 793 F.Supp. 1058 (1992).
Wyatt v. Stickney, 344 F.Supp. 373, 378-86 (1972).
Youngberg v. Romeo, 457 U.S. 307 (1982).
Skinner, B.F. (1953). . New York, N.Y.: Macmillan
San Francisco Arts & Athletics, Inc. v. United States Olympic comm.., 483 U.S. 522 (1987).
Skinner, B.F. (1953). . New York, N.Y.: Macmillan
San Francisco Arts & Athletics, Inc. v. United States Olympic comm.., 483 U.S. 522 (1987).
Adamson v. California, 322 U.S. 46 (1947)
The leading case on the issue of restraints is decided by the United States Supreme Court in 1982. The case involved a profoundly retarded youngster who was involuntarily committed to a Pennsylvania state institution, where he suffered injuries due to the conditions of his confinement. His mother brought suit, alleging that he had the right to safe conditions of confinement, freedom from bodily restraint, and appropriate training or “habitation.” The trial court had applied the Eighth Amendment standard, and had found the institution guilty of violating it. The Court of Appeals had reversed and remanded the case for a new trial, holding that a Fourteenth Amendment standard was the appropriate one. The Supreme Court agreed with the Appeals Court, but went further, holding that persons involuntarily committed to state institutions have a constitutionally protected liberty interest under the Due Process Clause of the Fourteenth Amendment to “reasonably safe conditions of confinement, freedom from unreasonable bodily restraints, and such minimally adequate training as reasonably may be required by these interests.” The Court explicitly adopted that portion of the Appeals Court decision holding that persons involuntarily committed “retain liberty interests in freedom of movement and in personal security. These are ‘fundamental liberties’ that can be limited only by an ‘overriding, non-punitive’ state interest.”
Paper prepared for SymposiumResearching the Safety of High Risk Interventions for Children and Young PeopleCornell University June 1-4, 2005
Paper prepared for SymposiumResearching the Safety of High Risk Interventions for Children and Young PeopleCornell University June 1-4, 2005
Paper prepared for SymposiumResearching the Safety of High Risk Interventions for Children and Young PeopleCornell University June 1-4, 2005
Paper prepared for SymposiumResearching the Safety of High Risk Interventions for Children and Young PeopleCornell University June 1-4, 2005
Paper prepared for SymposiumResearching the Safety of High Risk Interventions for Children and Young PeopleCornell University June 1-4, 2005
WHAT IS ALL OF THIS…AND WHY??????????????