A CHRONICLE OF SECLUSION AND RESTRAINT IN AN INTERMEDIATE-TERM CARE FACILITY

A CHRONICLE OF SECLUSION AND RESTRAINT IN AN INTERMEDIATE-TERM CARE FACILITY

Petti, Theodore A

The use of restrictive practices, particularly seclusion and mechanical restraint (S&MR), in psychiatric hospitals and residential treatment centers for children and adolescents has generated considerable controversy and consternation for policymakers, providers, consumers, and other interested parties. Health and mental health professionals have argued for employment of these restrictive interventions as therapeutically necessary. Advocacy and consumer groups have lobbied strenuously for their attenuation (American Psychiatric Association, 2001). The Joint Commission on the Accreditation of Hospital Organizations (JCAHO) has been urging reductions of restrictive practices in hospitals and residential treatment centers for many years through their standards. The Health Care Financing Administration (HCFA), in a sudden and surprising move, changed the entire landscape with regulations promulgated in August 1999. These regulations have had a major impact on S&MR utilization policies and practices. Confusion and widespread changes in procedures resulted from these changes in hospital and residential treatment of adolescents with severe psychiatric disorders.

The use of seclusion as a form of control has its roots deep in American history. The practice of seclusion for disruptive behavior can be dated to the first schoolhouse in the United States, located in what is now the historical district of St. Augustine, Florida. There, down an alley, can be found the building, with a closet specifically designated for managing unruly youth. The modern use of S&MR as medical or nursing interventions evolved following a pattern described by Gair (1980). He describes their initial use as measures to ensure the safety of youth in residential care. These measures evolved to become standard psychiatric treatment. Gair notes the poorly articulated rationale for this standard of practice. He considers seclusion to be a therapeutic necessity that becomes an endpoint of limit-setting following the failure of alternative interventions to control dangerous or disruptive behavior toward self or others. Restraint serves as a means to interrupt determined efforts at self-mutilation. S&MR have become routine practices in most institutional and residential programs for juveniles (Zusman, 1997). There are no rigorous methodological studies comparing S&MR to other interventions for youth undergoing psychiatric treatment or residential placement; only case reports, program descriptions, and overviews are available (Cotton, 1989; Garrison et al., 1990; Troutman et al., 1998; Singh et al., 1999; Petti et al., 2001; American Academy of Child and Adolescent Psychiatry, AACAP, 2002).

The paradigm shift reflected in rising S&MR utilization since the 1970s and accompanying concerns of advocacy groups suggested a need for S&MR reassessment. Since 1995, JCAHO has issued many Type 1 recommendations for noncompliance following accreditation reviews indicating that immediate improvement needs to be addressed to JCAHO standard on S&MR (Zusman, 1997). Guidelines for the use of S&MR continue to be promulgated in the tug-of-war between practitioners allied with professional organizations and consumers allied with advocacy groups. To date, HCFA and JCAHO regulations and standards seem more stringent than those desired by many professionals and providers, and less stringent than those desired by patient advocacy groups. The AACAP has developed the “Practice Parameter for the Prevention and Management of Aggressive Behavior in Child and Adolescent Psychiatric Institutions, with Special Reference to Seclusion and Restraint” (2002) to address this issue. We present a university-affiliated, intermediate-term state hospital’s successful efforts, initiated in 1995 and continuing to this time, to decrease S&MR utilization. We expect that the approaches employed and lessons learned in the process are similar to those experienced by many programs in managing the increasing numbers of more severely ill, destructive, violent, and dangerous youth in settings that must adjust to the changing fiscal and political climate in the human services system. We intend to chronicle these efforts and provide insights to those interested in understanding and learning from these experiences and advancing the field to be more effective and efficient in the care of such youth.

THE HOSPITAL AND ITS HISTORY

The evolution of the hospital, regarding the population of patients it serves and the dramatic shifts in role within the system of care in which it operates, is similar to that experienced by many other state hospitals throughout the nation. In the 1960s to 1980s, the Youth Service (YS) of Larue Carter Hospital (LCH) served youngsters of average intelligence who were often acutely disturbed or belonged to special clinical populations and came from relatively intact family systems. In the 1980s, the burgeoning public mental health centers and private hospital beds to serve these youngsters resulted in increasing referrals of more treatment-resistant, developmentally disabled patients. In the 1990s, the hospital began admitting droves of more severely ill youngsters who had demonstrated ineffective response to multiple acute, brief hospitalizations, residential and out-of-home placements, and/or prescription of multiple psychotropic agents and intensive outpatient treatment. Many of these youth had been physically and/or sexually abused. The adolescents included those who had been sexual predators, those who were severely violent and aggressive towards others, and those with dangerous self-injurious behavior, including females who would ingest foreign objects (e.g., paper clips, staples, tooth brushes, plastic utensils, batteries). Many had histories of injuring hospital or residential staff and/or regular S&MR utilization to control their behavior.

The following case represents a significant, small percentage of patients referred to our service. Chantelle was a large-for-her-age 15-year-old African American female when she was court-committed to Youth Service. During her 16-month residence in a for-profit hospital, her violence and aggression resulted in the hospitalizations of several staff members and peers. Her presenting symptoms included explosive, violent, and self-injurious behaviors. She had been hospitalized at the age of 13 for aggressive behavior, and two times thereafter. Her history was significant for suicidal ideation, homicidal threats, acute anxiety attacks, dissociative episodes, flashbacks, memory lapses, and trauma induced by sexual and physical abuse. Behavior problems of temper outbursts and stubbornness dated to the age of two. At the time of admission to LCH, she was on thiothixene 15 mg three times per day and albuterol as needed for asthma. Shortly after admission, she attacked and severely injured a nurse and assaulted a peer, who was not so badly injured. No psychotic symptoms were present, nor did she show remorse at the time of either attack. Her admission Axis I diagnoses were conduct disorder, mixed type, severe, and a number of rule-outs for depressive and anxiety disorders. She received an Axis II diagnosis of borderline personality disorder.

Chantelle came from a chaotic home situation. Her family of origin was very violent, abusive, and dysfunctional. Both parents had served prison time for violent acts. Removed from her mother’s care as a baby because of the mother’s physical abuse of Chantelle and her siblings, she lived with relatives for several years before returning to reside with mother in preadolescence. Following this, she reported being sexually abused by her mother, her mother’s lesbian lover, and, at the age of 13, by her uncles. The family denied this and reported that they were afraid of Chantelle because she had threatened to kill them and had lied about them. During Chantelle’s hospitalization on Youth Service, her mother was very inconsistent in her visits and phone contacts, which created a significant Stressor for Chantelle and often served as a trigger for aggressive behavior.

Upon admission, Chantelle was evaluated on a number of measures. Her projective assessment showed significant deficits in connecting cause and effect, attaching to others, engaging in empathy or understanding the perspective of others, and coping with intense emotions. Her thinking was contaminated by strong interfering emotions that prevented her from processing reality accurately, although she showed no psychotic symptoms. She viewed her external environment as being restrictive and dangerous; she appeared to be evasive and defensive and gave up quickly on challenging tasks. Her resources to cope with emotions were impoverished and her thinking rather concrete in nature. On communication assessment, she showed significant verbal language deficits in both receptive and expressive domains. Such deficits compromised her ability to process emotions and express them in a socially acceptable manner. It was also noted that she had difficulty retrieving information efficiently and in a timely manner, which made her school experience problematic and challenging. Chantelle was enrolled in intensive language therapy to address these deficits as well as a number of other communication issues.

Psychometric assessment revealed a significant improvement in functioning from the time of admission to discharge. Upon admission, she showed a full scale IQ of 78 with verbal IQ of 72 and performance IQ of 90. At the time of discharge, Chantelle revealed a full scale IQ of 91 with a verbal IQ of 86 and performance IQ of 100.

Chantelle’s course of treatment was unique due to her dangerous and violent behavior. After injuring the nurse and a peer, threatening others, and exhibiting self-injurious behaviors, she was placed on a strict behavioral protocol that included placement in wrist-to-waist restraints to keep her and others safe. This measure was taken after much deliberation with her physicians and treatment team members. The protocol allowed Chantelle to earn an hour out of restraints for each day she did not engage in abusive loudness or physical or verbal threats toward others, and complied with the unit rules. If she engaged in such adverse behaviors, she returned to ground zero, lost all accumulated time out of restraints, and began the process over again. Concomitant with the restraint protocol, Chantelle engaged in therapy that focused on anger control management, relaxation techniques, and supportive reinforcement of appropriate behavior. Over the course of about three months, with a number of ups and downs, she earned her way out of restraints and was able to tolerate a more normalized system of rewards and consequences.

The initial days of being restraint-free proved stressful for Chantelle due to her need to take personal responsibility and to exercise self-control through internal mechanisms rather than external ones. In order to assist her, restraints were made available to her and she could voluntarily ask for them. However, she never asked for or needed them. At the termination of the restraint protocol, significant changes occurred. She seldom struck out at others, she demonstrated less frequent violent or threatening posturing, and her anger shifted toward inanimate objects such as trash cans, pictures, or walls, or toward herself. She engaged in superficial mutilation of her arms, which usually consisted of using a pencil eraser “to erase myself.” All of these episodes eventually subsided. In addition, her speech was noted to be softer and more melodic, and she became less intrusive. Her personal hygiene improved, and she kept her bedroom tidier. In the three months before discharge, she had two episodes of challenging behavior and one incident of superficial self-mutilation that resulted in two room confinements, which she handled without incident. These three episodes coincided with court review dates and missed appointments by her mother. At the end of hospitalization, Chantelle’s behavior had improved to the point that she was accepted by three different residential placement facilities. She and her treatment team chose a therapeutic group home placement distant from her family, which Chantelle decided would be less stressful to her well-being. She was discharged on the following medications: albuterol inhaler, two puffs three times per day, diphenhydramine 50 mg at bedtime, lorazepam two mg every four hours as needed for severe agitation, clindamycin 1% to face daily, multivitamins, and lactase enzyme tablets. For a few years following discharge, she would visit YS regularly and proudly review the progress she had made.

The use of a rigid behavioral protocol using ambulatory wrist-to-waist restraints in combination with psychoeducational interventions was instrumental in helping Chantelle transfer external control measures to internal ones. In addition, her work in language therapy enabled better self-expression, which increased her ability to manage conflict and to engage more insightfully with psychotherapy. This case is meant to illustrate when restraint is the “least restrictive alternative for managing aggression” (Troutman et al., 1998, p. 557).

The intellectual level of youth admitted to the YS program has steadily dropped into the borderline range. This change has had a major impact on the S&MR rate. Many of these patients, like Chantelle, have developmental receptive and expressive language disorders. The proportion of families able to work regularly with staff for their children’s transition back to home and community has decreased markedly. The average length of stay had climbed to a year and more.

Our YS is located within a heavily bureaucratized state hospital. It consists of 42 beds, 31 of which are devoted to middle and high school populations. The patients are housed in three clinical units by school classification. In relation to the other Indiana state hospital programs serving youth, YS provides the only services for adolescent girls, is one of two hospitals providing inpatient services to elementary-age children, and is one of three programs serving adolescent boys.

During the period in which major effort was devoted to decreasing the S&MR rates and duration of use, many changes occurred. These included adjusting to the closing of another state hospital that led to the subsequent expansion of beds from 34 to 42 and a significant upheaval in staff composition. The eight additional beds were used to create a unit to house boys and girls of middle-school age. This unit had significantly higher rates of S&MR than did the other two units. Two years into this report, LCH moved away from the university campus and into a former Veterans Administration Hospital.

The new facility, a designated historical site, was notable for its “soft” interior as contrasted with the institutional hardness of the former state hospital, and for environmental blind spots that reduced the ability to monitor patients. In addition, the hospital itself experienced erosion in numbers of professional and direct care staff after the relocation. We unofficially estimate the turnover as about 60% due to replacement of LCH YS staff by those with greater seniority from the closed non-university-affiliated hospital. This merging of staff culminated in a significant blending of two different cultures. The occasional confusion and lack of consistency resulting from the merging process contributed to the perceived increasing need for restrictive interventions.

The use of S&MR became increasingly more problematic with these changes. Risk management data showed that YS accounted for over 70% of hospital S&MR episodes even though it represented only 30% of total hospital beds. Additionally, the data indicated that the high use of S&MR correlated significantly with staff and patient injuries. These factors raised concern in all involved, including consultants and evaluators during formal accreditation procedures.

INTERVENTIONS AND STRATEGIES EMPLOYED OVER SEVEN YEARS

Youth Service leadership committed itself in 1995 to decrease escalating S&MR rates. Multiple efforts were made to achieve this goal by focusing attention on the extant culture supporting excessive S&MR utilization. Presented sequentially, many of the approaches are similar to those attempted by other hospitals and residential treatment centers. In retrospect, they mirror and adhere to the principles presented in AACAP’s (2002) practice parameter addressing this issue. Early interventions from 1995 are discussed in the following sections.

A Mandate from on High

The hospital superintendent requested that the entire hospital decrease S&MR rates. She voiced concern about the escalating rates on Youth Service.

Feedback on Performance

An improvement of organizational performance (IOP) office systematically collected S&MR data from July 1996. Feedback to staff of S& MR rates were routinely provided quarterly, then monthly, and finally on a weekly basis in 1999.

Accentuating the Positive

A strength-based treatment approach was initiated to deal with the changing nature of the population served. In-service training was conducted hospital wide, and consultants with relevant expertise were invited to assist in using strength-based strategies and techniques.

Outside Assistance

A group was developed to provide an outside perspective, promote family and community involvement, and guide policies and procedures. This began as an effort to develop a parent advisory group in an attempt to elicit their views for YS direction. But we were rarely able to engage parents in this endeavor. The group began to evolve into an advisory group of advocates, consumers, and members of YS clinical leadership. It ceased to exist during early parts of the move but was later reconstituted after the move.

More Assistance

Consultation was obtained from a senior Indiana Division of Mental Health administrator/nurse with extensive experience in long-term psychiatric care of juveniles. Concrete suggestions regarding YS structure and procedures were provided, and attempts were made to implement the recommendations.

Decreases in S&MR frequency were noted during 1995 and early 1996. The YS leadership felt that significant progress was being made until announcement of the hospital relocation in mid-1996. Improvement had been seen even as changes of staff occurred, with the blending of a traditional state hospital (which had closed under a cloud of allegations) and a university-affiliated hospital with a major research and training mission. However, S&MR rates soon escalated, beginning in July 1996. Figures 1 (mechanical restraint) and 2 (seclusion) illustrate restrictive incidents from July 1996 through December 2001. Data collection prior to that time was insufficient for evaluation purposes. Interventions A, B, and C are noted in the figures. Figures 3 (restraint) and 4 (seclusion) provide the data in hours of restrictive intervention.

Following announcement of the impending move away from the academic campus, patients and staff became anxious and apprehensive. The tensions of moving and subsequent perception by both patients and staff of an unsafe environment in the new facility led to even more dramatic increases in S&MR rates, as demonstrated in Figures 1 through 4. The hospital relocated in November 1996. In the new facility, YS occupied the space formerly used as a nursing home for veterans. The youth learned quickly that they could punch holes in walls, climb into the space above dropped ceilings, and hide from staff in environmental blind spots. This arrangement significantly increased acuity and made behavior management extremely difficult.

Following the relocation, concerted efforts to reduce S&MR rates were initiated as follows (see Interventions B in Figures 1 and 2):

* Aversive paperwork through an overcorrection-like policy. Staff members were mandated to go beyond the customary documentation process with each S&MR incident. They were required to complete an additional form after each incident, indicating how S&MR would be avoided in the future.

* Prevention training. Staff received annual hospitalwide Conflict Prevention Institute (CPI©) training on early behavior awareness and nonphysical interventions. Booster CPI© sessions were provided to YS staff to review principles and, significantly, approved physical intervention techniques. The training emphasized anticipation of potentially explosive situations and use of techniques to lessen anxiety and agitation, thus preventing incidents likely to call for seclusion or restraint. A take-down procedure (known and used by many state hospital staff when confronting assaultive patients) was prohibited. This prohibition resulted in staff anger and feelings of frustration. The change in approach to violent patients required substantial effort by clinical leadership to demonstrate the utility and efficacy of the new approach.

* Indiana Division of Mental Health mandate. The state issued directives to decrease documented excessive S&MR rates.

* Staff empowerment. A model was implemented to give frontline staff more clinical responsibility and enhanced understanding of principles and practices of quality care through consultation with senior clinicians. This initiative was unsuccessful and short-lived, due to the failure of both staff and senior clinicians to accept it.

The interventions described above had little lasting impact in lowering S&MR rates or attitudes towards their use during the early post-move years. The following interventions did change the culture and entrenched attitudes, and S&MR rates decreased slightly (see Interventions C, Figures 1 and 2).

Addressing Self-Injurious Behavior (SIB) Directly

Female adolescents who had been engaging in self-cutting and ingestion of various objects such as batteries, plastic knives and forks, and pieces of jewelry were being admitted in increasing numbers. Such SIB is particularly difficult to manage in a residential setting that houses adolescent females with borderline personality disorder psychopathology. Copycat behavior or imitation results in the behaviors becoming endemic. The adolescent unit implemented a program for borderline personality disorder symptoms to reduce SIB, a frequent precipitant to use of mechanical restraint. As a framework of intervention, we adopted a model described by Barstow (1995). The goals of the intervention are to assist the patient to identify feelings that precede the SIB and to develop higher self-esteem by identifying positive qualities conveyed about her by staff and peers. Staff assisted in this process by 1) encouraging the patient to identify thoughts preceding the SIB; 2) asking the patient to stop any SIB and move to a neutral location; 3) assisting the patient in identifying feelings that trigger negative cognitions and replacing them with positive ones; 4) helping the patient to cope by encouraging her to communicate thoughts and feelings rather than engaging in harmful behavior; 5) inviting her to participate in unit activities, volunteer work, or peer interactions to reduce social isolation; and 6) encouraging the patient to engage in self-care activities (e.g., grooming and hygiene) and to record daily thoughts and feelings in a journal.

Increasing Predictability

A YS-wide behavioral-level system was instituted in 1998 to increase staff consistency, to reward constructive and compliant patient behaviors, and to decrease destructive modeling by the sickest or angriest patients.

Decreasing Punitive Features of the Program

A consultant with expertise in behavioral management of group living helped us in 1996 define bottom-line behaviors, stop strategies, and group and community rewards. Prior to this, the program depended upon privileges of restricted buildings or ground passes as rewards (motivators) and room confinement or “chair time” as consequences for negative behaviors. Greater emphasis was placed on implementing this more positive approach.

Providing Additional, Alternative Programming

Recreational therapy staff increased gym time and outside activities. In a general hospital, pediatrics generally needs to exert considerable effort to get the environment, support services, and other resources appropriately allocated to meet the needs of their pediatric patients. A similar situation exists when a youth service is housed within a general psychiatric hospital. Ongoing initiatives are necessary to get scheduled, usable time in the gym, opportunities for progression of independent functioning in the hospital setting, and related support.

Obtaining More Outside Assistance

A reactivated advisory committee, comprised of members from consumer and advocacy groups, Indiana Division of Mental Health, University Schools of Education and Nursing, parents, and YS senior staff, provided guidance for modifying YS policies and procedures. The committee was highly critical of our programming and of the level system, which the members viewed as punitive and negative. They were especially dismayed by Level Red (the bottom level), which was used to restrict students with dangerous behavior from participation in programming. Our staff had commented that these difficult-to-treat patients were unable to achieve the points or behaviors required to access the positive constructive rewards or reinforcers available. The group also felt that there were too few differences in the upper levels of the system to be meaningful to the youngsters. Fine-tuning was done, and the level system appeared to work especially well for adolescent boys as privileges were tied directly to level attained.

Although significant changes were made, high S&MR rates persisted. Lack of change was attributed to an influx of particularly difficult patients, including clusters of females with serious SIB, along with especially large-for-their-age, violent, assaultive boys who generally felt abandoned by their families. These youngsters had learned to depend on restrictive, coercive measures as their means of self-control. They were highly resistant to accepting responsibility for their actions. Patient and staff injuries and external pressures catalyzed reassessment of our strategies and demanded development of new approaches to reduce S&MR rates to more acceptable levels. Additional measures were then introduced, as noted in the following sections.

Changing the Locus of Control over the Decision to Use S&MR

Any ongoing restrictive intervention (i.e., 24-hour mechanical restraint program for dangerous behavior) had to be cleared through the YS medical director. This mandate was meant to eliminate the practice of mechanically restraining assaultive boys and SIB girls with repetitive ingestion of foreign objects to the bed for extended periods.

S&MR Elimination as Mandate

A zero-tolerance policy for S&MR was announced by the superintendent in 1998, and in-service training was accelerated.

Medication as an Aid

The use of as-needed (PRN) medication was encouraged to help decrease the agitation and anger experienced by the youngsters before they lost complete control and to shape their ability to regain control. Considerable discussion took place to legitimize the use of PRN medication, particularly for situations in which the adolescent requested medication. Many RNs and other staff believed that such a patient request was akin to a manipulation of sorts and should not be honored. Others felt that if the teens had sufficient control and were aware enough to ask for a PRN, that they should then be able to exert the effort to calm themselves and seek alternative ways to manage their problems. Nurses were directed to give PRN medication when requested or when the patient’s behavior was escalating to loss of control. They were also to note on the 24-hour sheet and elsewhere whether the PRN had been effective. Physicians became more willing to prescribe PRNs, and nurses ultimately began to administer PRNs with increasing frequency. As the youngsters were able to request PRN medication before they exploded, the incidence of S&MR seemed to decline.

Several dynamics may be operating in such a situation. These include a possible placebo effect (Vitiello, Ricciuti, and Behar, 1987; Vitiello et al., 1991; Petti et al., 2003) and the impact of the patients’ feeling that they may be making a contribution to their care. The simple act of honoring their requests may enable or assist them to be more active in helping themselves. Being able to monitor oneself is the first step in change for most psychotherapies. This ability to recognize an internal state that can result in loss of control is a major step in the treatment process. In a later study specifically addressing perceptions of the PRN medications they received, most hospitalized youth felt that the PRN medication was helpful (Petti et al., 2003). Unfortunately, many felt that there was no viable option besides the medication to assist them from losing control and hurting someone or damaging things. We are currently studying these perceptions over a period of 12 weeks to begin to understand the meaning of PRN medications and how they may change over time.

More Meetings and Paperwork

Systematic reviews of the care plan were mandated for any patient requiring three seclusions or restraints in a period of one week. The expectation was that understanding of the behavior would be shared with staff and that alternatives to help the youth in the situation would be developed.

Despite such concerted efforts, the S&MR rate doubled between July 1998 and March 1999. The senior leaders then initiated a set of interventions that seemed to demonstrate positive results. The first and perhaps most important was instituted in April 1999.

Debriefing Questionnaire

A structured debriefing questionnaire was developed, piloted and administered to patients as soon after their S&MR incidents as possible. The instrument is found in Appendix 1. The patients were generally very cooperative in responding to the questions. A decrease in incidents followed.

Summary Data

Summary data of the youth perceptions of S&MR from April through September 1999 were presented to unit staff for feedback and discussion in October 1999. Ongoing presentation to staff of the data followed. However, it was decided to broaden the debriefing effort to include staff, the other side of the S&MR equation.

Interviews with Staff

An analogous instrument was developed to interview staff participating in the S&MR incidents (see Appendix 2). These interviews began shortly after the summary results of the patient survey interviews were presented to staff in October 1999. A dramatic reduction of S&MR rates followed (see October to December 1999 in each figure).

Responses to the survey by the youth and staff involved in S&MR episodes are of interest. The results and a lengthy discussion can be found in an earlier work (Petti et al., 2001). Safety was the major item on the minds of both the youth and staff. Over 50% of patients (33 definite and 11 somewhat less definite of the 81 responses) reported that the restrictive intervention resulted from assaultive behavior or verbal aggression. Staff reported safety as the basic reason for the use of seclusion or restraint in 53 of the 81 responses. Noncompliance with staff request was the reason for S&MR use given by 15 patients, and anger by 5 others. Sixteen youth could not or would not provide a perceived reason for the restriction.

In constructing the questionnaire, we were most interested in the question asking about alternatives that could have prevented the seclusion or restraint. The largest number of responses to this item was of the generic variety, representing 21 of the 81 respondents. Examples included “Could have done what staff said” (from a 14-year-old white male), and “Ignored everything” from a 17-year-old white female. Nine youth were more specific in the alternatives they suggested; for instance, “Apologize to Sara and handle myself and think before [I] act” from a 15-year-old white female. Compliance with staff requests was suggested by 23 of 81 respondents, with 12 being specific to the situation and 11 more generic (e.g., to obey and do what staff asked). Directives to staff were reported by four patients (e.g., “Talk to me”). The qualitative difference between generic and specific responses in these cases related to the evidence that the youth had given thought to actually linking the behavior and consequences to the alternative as compared to simply giving a rote response from discussions they had had with staff or from their therapy sessions.

It is encouraging that most of the patients’ responses indicated that the solution to the situation should be with the teen himself or herself. The failure of the remaining 28 youth to give useful responses is a matter of concern, especially the 4 defiant responses (“Nothing; no one can help me when I’m angry”), the 10 coded denial or deflection (“I don’t know” or “Leave me alone”), and the 4 non sequiturs (“I got a shot, I was held down”). Perhaps of even greater concern are the staff responses to the same question. Over half of the staff (9 members) blamed the patient, the system (9), or the medication level (7), whereas 10 staff members reported being at a loss as to what could have been done differently. Only 12 staff members accepted responsibility for finding an alternative solution, and an equal number had no recorded responses. Sadly, one staff member, with regard to the episode of a 12-year-old African American male, responded, “Nothing, really.” A small percentage of such responses clearly indicated that much remained to be accomplished in this area.

When asked about what interventions were employed prior to the use of S&MR for the incident under discussion, discrepancies were noted between staff and patient perceptions. Because many patients responded with several answers for this question, more than 81 patient responses were coded. Confinement, broadly defined to include directing the patients to their room or quiet room by staff, was perceived to have been used by 37 youth as contrasted to 58 staff. Medication employed as a PRN was the intervention reported by 31 patients and 54 staff. Verbal interchange was reported by far more staff than patients. Therapeutic verbal interactions (e.g., one-to-one talks) were reported by 50 staff but only 18 youth; on the other hand, directives to behave from the staff were given as an answer by 21 staff and 9 youth. Other verbal interactions, such as verbal contracts and attempts to offer alternative activities, were reported by 21 staff. Coping skills are taught as a means to manage frustration or anger; five youth reported that deep breathing, counting to 10, and going off the unit to run were offered and attempted prior to the use of S&MR.

Given the horror stories surrounding the S&MR issues, including the number of deaths reported elsewhere with the use of seclusion or restraint in institutional settings (Ross, 1999), we queried youth and staff about the perceptions of safety during the seclusion or restraint process. Psychological adverse effects of S&MR have not been adequately researched. Feeling unsafe is a potential adverse effect of S& MR. Therefore, we wanted to determine if patients felt safe during the S&MR intervention. Even though 65% of patients reported that they had felt safe during the S&MR process, 25% said that they had not. Likewise, only 53% of staff reported feeling safe during the implementation of seclusion or restraint, with 36% reporting not feeling safe. No injury during the restrictive episode was reported by almost 75% of both patients and staff. Injury to staff or patient was reported by 12% of patients and 14% of staff. These findings have implications that require further exploration.

This study reveals the need to understand the underlying perceptions of both patients and staff concerning the use of seclusion or restraint. The employment of a formal debriefing process geared to the issues of relevance to our youth was highly useful in understanding the restrictive event and working with both youth and staff in developing more appropriate interventions. The form is no longer in use because the state has mandated that a uniform form be administered in the debriefing process. Though this statewide form is modeled after our interview, it contains extraneous questions that render it much less useful for our purposes.

Time-out frequently preceded loss of control, and we found this was of especial interest. Our inference is that time-out is often perceived as a form of punishment and isolation from support; this leads to increased anger and frustration. This reasoning is consonant with findings in younger children (Natta et al., 1990; Measham, 1995). As a result, we reexamined our policies and procedures regarding the use of time-out and assisted staff in understanding that time-out is an aversive consequence and may serve as a form of rejection for our youth. We were unable to determine the variables (e.g., tone of voice, demeanor, wording, or the directive itself) that could affect the manner in which the request or demand for taking a time out was made, or whether such factors influenced the perception of the time-out intervention that ultimately led to seclusion or restraint. We were also unable to determine the extent, if any, that a hands-on escort may have had on the subsequent need for a more restrictive intervention. These are questions that need to be considered in future studies in this area, because time-out has also been wholeheartedly embraced by milieu staff and families as a reasonable and effective intervention for agitated behavior. Children, however, prefer medication to time-out as a response to their inability to control themselves (Kazdin, 1984).

All of our efforts were occurring in a rapidly changing human services system. As we were making changes in the structure and process of our service delivery, JCAHO and HCFA were increasing the demand to eliminate restrictive practices in hospitals and residential centers.

Using Outside Pressure

The mandate to lower S&MR rates via the HCFA regulations (which were announced on August 1, 1999, and went into effect in November 1999) was duly noted. The hospital, along with all other entities receiving federal funding, significantly increased the effort invested in this task. An HCFA requirement limited the initiation of S&MR to a physician order, upon recommendation by a registered nurse, and mandated that a physician had to observe the patient within one hour after the youngster was placed into S&MR. The YS medical director also required physicians to routinely question any nursing request for S&MR orders with the following suggested list:

Have the staff:

1. Talked to the child in a quiet, neutral manner?

2. Asked the child what we can do to help him or her?

3. Suggested the usefulness of taking time to “chill out” and “get it back together”?

4. Offered a PRN?

5. Used a PRN?

Revamping the Level System

Considerable staff time and effort were devoted to modifying the level system for the middle school boys. With the patients offering their suggestions and feedback regarding various aspects of the changes, the program was simplified for this group and included an award chart. The program allowed the boys to earn points for appropriate behaviors on the half hour during waking hours. This change considerably reduced negative interactions with staff, reduced time out of school, and resulted in improved morale for the patients and staff.

Overall, the S&MR rates varied over the seven years, with notable peaks and valleys in response to changes in the hospital, changes in patient population, and admission of youngsters with challenging behavior. The trend in both rates and duration of S&MR is decidedly down. Periods of days and weeks without need for S&MR are common. Information collected prior to july 1996 has missing data points and cannot be considered. The average numbers of S&MR episodes by quarters from july 1996 through December 2001 are detailed in Figures 1 through 4. These data demonstrate the relationships between restrictive episodes, hours spent in each, and related injury rates for patients and staff. The data demonstrate substantial decreases in S&MR, even before the HCFA regulations were promulgated. Moreover, lower rates have been sustained since june 1999 and appear correlated with the initiation of formal, structured debriefing of patients and staff involved in S&MR episodes. Related injuries to patients and staff varied in association with changes in S&MR rates and demonstrated a slightly decreasing trend correlated with a decrease in both S&MR episodes and total hours. Change in mechanical restraint use is particularly dramatic. As noted above, the seclusion rate returned to low levels, except during periods when especially high-risk youth were admitted and then failed to become engaged in the program.

Our experience confirms an earlier report demonstrating that S& MR rates can be decreased even in a highly bureaucratized system (Singh et al., 1999). Goren, Abraham, and Doyle (1996) and Singh et al. (1999) decreased, then eliminated S&MR in their public, acute-care child and adolescent psychiatric hospital, which was threatened with a federal investigation regarding its excessive use of S&MR. This reduction was accomplished through planned programmatic change (i.e., implementing a number of interventions, including a discussion team that empowered direct line staff). Our study employing a different approach demonstrates similar results in a much larger intermediateterm care state hospital that includes a youth service. Our population is likely more chronic and treatment resistant, given the intensity and extent of interventions, including the number of prior hospital admissions.

However, even with total commitment of professional staff and senior administrators, there is a tendency to revert back to old habits. This reversion to restrictive and coercive interventions may occur even as decreased injuries to patient and staff accompany decreases in S& MR rates. The failure to demonstrate a significant increase in staff injuries as anticipated by the staff as a result of the zero-tolerance policy is a critical finding. Such data indicate that the measures to reduce restrictive interventions may ultimately decrease injuries to both patients and staff. Such an effort requires attention to the home and community as well as the patient or resident and institution staff.

Eliminating restrictive practices except when absolutely needed remains the challenge. We have placed greater emphasis on working with families and communities before the actual hospital admission, to address the resistance of some families and community agencies to having the most violent and impulsive youngsters return to the home community from the hospital. The preadmission procedures mandated as a component of the admission process have helped to identify salient treatment issues, to determine which interventions have worked or might work to reduce agitation, and to outline disposition options and to assign responsibility should further residential care or alternative placement be required in order to avoid having the youth wait for funding to occur once the decision is made that the patient is ready for discharge from the hospital. This approach ensures quicker, appropriate disposition when maximum hospital benefit is achieved and decreases the too-often-observed plateau of gains followed by behavioral regression and need for S&MR when a youngster remains in the institutional setting beyond that time.

We have noted the frequently occurring phenomenon of plateauing, during which a youngster who has achieved the objectives of the hospitalization must remain hospitalized for some reason. This is usually related to our inability to secure funding for a less restrictive intervention or to the family’s concern about their inability to manage the youth. The therapeutic and behavioral gains generally have been maintained for a finite period, but then the youth becomes discouraged and begins to use more primitive defenses to deal with the frustration and anxiety related to the lack of movement in returning home or back into the community. When the associated anxiety becomes too great, the youth regresses to earlier psychopathic behavior including aggression, violence, and destructive behavior. At that point in the hospitalization, under such circumstances, the need for seclusion or restraint is likely to recur. Having clear options for posthospital disposition is also important to alleviate the associated anxiety of patients who have done well but fear failing in the community. (This phenomenon is frequently experienced in nonhospitalized children with psychiatric disorders enrolled in special education when it is time for them to be mainstreamed back to their local schools.)

Hospital staff require frequent updates and boosters to maintain gains in improving the environment or milieu. Such updates include CPI© training; YS Advisory Committee feedback, structured interviews of those experiencing S&MR with feedback; level system review and inservices focused on specialized issues and populations (e.g., middle school boys and self-injuring adolescent girls). Creative strategies to assist those charged with direct care of these patients must be developed and tested to address the changing population of psychiatric patients admitted to hospitals and treatment centers. Altering established cognitive and behavioral patterns of patients and staff by modifying the culture in which they operate is difficult. The debriefing questionnaires have been used sporadically since completion of the original interventions because the modified form as noted above made it less useful and because S&MR rates maintained their decline. However, the modified form is used whenever rates begin to increase.

The findings relating S&MR episodes to the use of time-out in a quiet room resulted in attempts to find alternative solutions to disruptive behaviors before they elevate to the level of a restrictive intervention. Direction to take time in an unlocked room may be perceived as punitive by the youth and lead to escalation of dyscontrol by young adolescent psychiatric inpatients. Such perceived punitive or isolating staff behaviors towards them can be predicted to result in negative behavior by the youngsters (Natta et al., 1990). Employing an assessment of conditional probabilities of sequences of staff and child interaction, Natta and associates (1990) demonstrated with child psychiatric inpatients that positive staff behaviors tend not to be associated with subsequent changes in negative or positive patient behaviors. However, punitive and isolating behaviors (e.g., forced time-outs by staff holding the door) lead to decreases in child positive behaviors and increases in negative behaviors. Such negative behaviors in our study seemed to frequently precipitate seclusion. The relationship of holding the door and related coercive staff behaviors to increased restrictive interventions is tenuous but supported by the literature, even when safety is the issue (Singh et al., 1999). To associate it with regression in staff attitude towards condoning S&MR is speculative at best, because there are so many confounding variables. The more judicious use of time-out or isolation from the program will also need to be examined further.

Related S&MR issues are myriad and emotionally charged. Internal attempts to change the institutional culture exemplified by S&MR practice may be ineffective or brief unless accompanied by external threats or sanctions. Illustrations abound (Singh et. al., 1999). Our experience adds support to the value of external sanctions in encouraging residential programs to make necessary changes under a given set of circumstances. S&MR reduction was occurring in our case but might have been short-lived without the clout of HCFA regulations. There is no doubt that situations exist in which seclusion or mechanical restraint may be required (Singh et al., 1999; Troutman et al., 1998). The patient, Chanteile, described above and the case reported by Troutman and colleagues (1998) demonstrate the therapeutic value of mechanical restraints when applied judiciously.

Both Chantelle and the patient described by Troutman et al. (1998) were violent, aggressive, and explosive. Both cases demonstrate the utility of walking restraints to assure both safety and therapeutic caring. The danger associated with S&MR (Kennedy and Mohr, 2001) adds to the complexity of making the decision about when and when not to consider their use. The associated adverse effects of physical and/ or mechanical restraint have been recently reviewed (Mohr, Petti, and Mohr, 2003). Considerations such as psychological trauma with S& MR, or cardiac arrest, asphyxia, aspiration, and rhabdomyolysis (muscle breakdown) that can lead to death in adolescents as well as adults should be cause for concern and for reassessment of the use of mechanical restraint (Mohr et al., 2003). It is especially imperative that medical staff educate front-line caregivers concerning the adverse effects associated with the use of mechanical restraints or holding procedures. There is little in the literature concerning the effects of seclusion on adolescents. However, posttraumatic symptoms and lack of trust in mental health professionals have been reported by children and adolescents who have been physically restrained as a therapeutic measure in psychiatric facilities (Mohr, Mahon, and Noone, 1998). Traumatic symptoms were present in those same youngsters on 5-year follow-up (Mohr and Pumariega, 2002). In addition, deaths resulting from mechanical restraint or from holding techniques employed with younger children should be of serious concern; these require dissemination of information as we were able to do through grand rounds presentations.

The perceived need to find an effective response to increases in aggressive, assaultive, and self-injurious patients may explain critical attitude changes in nurses and nursing staff, over the past 25 years, related to limit-setting and restrictive authority. S&MR have become standard interventions in many facilities and have resulted in a change in culture from therapeutic milieu to one of coercion and quasi punishment. Because a rapid response to aggression or threat of such has been viewed as critical, the authority to initiate S&MR had moved from the physician and nurse and was increasingly delegated to front-line staff as a preventive measure against the imminent breakdown of a patient’s self-control. Historically, the failure to act quickly when patients begin losing self-control was considered to undermine patient and staff morale. Employing restrictive interventions was seen as reassuring to all involved. Physicians, if asked to authorize these decisions, were faced with a dilemma when justification for a seclusion or restraint order was ambiguous or questionable. Physicians usually erred in favor of supporting staff. Advocacy groups believe the authority to initiate S& MR has been abused and is detrimental to patient welfare. Reestablishing physician authority, with the advice of nurses, to order S&MR played a deciding role in our ability to maintain the gains in reducing S&MR rates. The debriefing exercise provided a better understanding of the issues necessary to make needed changes in policies and procedures (Petti et al., 2001). A strength-based program of interventions proved successful, in conjunction with planned decreases in the S&MR rate to zero in one case report (Singh et al., 1999).

Many factors continue to operate that can threaten the success of maintaining and further reducing the attenuation of S&MR rates in our service. One of these factors is that staff feel that they have lost their most effective means of control when faced with psychotic or angry youngsters who feel the need to hurt or be punished (Millstein and Cotton, 1990). Ongoing staff training must be implemented to counter-act such perceptions. This training needs to focus on detecting early signs of frustration or agitation that precipitate destructive or assaultive behavior, and on interventions to redirect the patient. This training must also assist staff in understanding the dynamics of a changing population admitted to psychiatric hospitals and the clinical skills that must be employed to divert violent behavior. Marohn (1992), for example, notes the need to consider violent adolescents’ desire and need for affectionate contact, their lack of insight into their own psychological world, and their difficulties in differentiating thoughts from feelings and action in evaluation and treatment of the assaultive adolescent.

Leadership and staff involvement are also keys to reducing and eliminating unnecessary restrictive practice (Singh et al., 1999). Training and continuing education about the counterproductive nature of such coercive interventions as S&MR and their adverse effects must be offered. The reduction of injuries accompanying decreased S&MR use, noted in this chapter and the case study offered by Singh and associates (1999), must be emphasized. Likewise, the task of acute and intermediate-term hospitals, residential treatment centers, and schools in teaching youngsters to control themselves rather than to be controlled by others must be given the highest priority.

The following situation illustrates the manner in which early efforts can serve as the base for interventions when slippage occurs.

The adolescent boys’ unit was experiencing a number of assaultive incidents resulting in restrictive consequences, including seclusion and restraint. The problematic behaviors included fighting, arguing, destruction of property, lack of respect for self and others, no investment in using therapy or groups for therapeutic benefit, and a decreased personal responsibility to make good choices. As a response to this increase in challenging behavior, members of the treatment team met to analyze environmental variables and to fashion a response to decrease dangerousness.

The tenor and thinking in the meeting reflected the work that had been accomplished in approaching challenging behavior in a more reflective and functional-analytic manner. The meeting began by identifying the four boys who were creating the majority of the violence and serving as provocateurs. Each boy’s behavior was delineated into concrete descriptors, which could serve as target behaviors. In addition, environmental variables were identified that could be contributing to the milieu’s deterioration. The team’s discussion represented a more problem-solving and supportive approach, which echoed the in-services on positive behavior interventions and feedback from the debriefing questionnaires.

The team also brought to light that the provocateurs were receiving a greater portion of the attention than the patients who were complying with the program. This recognition of disproportionate differential reinforcement led the team to think about how to reward patients who were adhering to the program and how to assist those patients who were causing chaos. This shift in focus represented a dramatic change in behavior-change philosophy and strategies. The team recognized that intense support rather than intense punishment was the answer to meeting behavior challenges. This is not to say that restrictive measures are not necessary to contain dangerous and violent behavior, but such interventions require concomitant positive behavior-intervention strategies.

The team made a decision to increase supportive therapeutic interventions by instituting the following changes:

* Helping program. The boys were asked to help staff plan a program that would increase safety on the unit.

* Peer monitoring program. A staff member became a peer buddy for each boy who posed the greatest challenge. The staff agreed to see the patient each day and spend brief quality time together. One of the authors chose a boy who had a very violent history before admission to the hospital. The author met with the patient each day for brief talks, checked in to see how he was doing, and played checkers on a periodic basis. Since that time, this boy has increased his level and has had no occurrences of aggressive behavior. He was able to earn a home visit rather quickly after the mentoring began.

* Intensive group programs. The charge nurse on the boys’ adolescent unit coordinated intensive programs for the most challenging patients. These programs were held off the unit, in the school area, to implement a divide-and-conquer strategy and to give the higher-functioning boys an opportunity to earn staff time and attention. The program consisted of groups for anger management, a focus group titled “stop the violence,” social skills, manners, and physical activity. During the first week of implementation, no aggressive episodes occurred during the day. The program was then extended into evening programming.

* Positive staff attitude. Staff were asked to adopt an attitude that conveyed to the boys, “The new intensive program will work, and everyone needs to support it.” This request represented a united and positive front, conveying an attitude that was expected to become contagious for the boys.

* Community meeting. A community meeting with the boys and girls was held to discuss their perspective of the situation and how they could help to reduce dangerousness and violence.

* Assignment of staff. A special staff was identified for each shift to coordinate and direct requests from the boys. This assignment reduced staff splitting by the boys and increased consistency. The staff members were instructed to check with the primary staff person before granting any privileges or requests.

* Privilege room. A room that had been reserved for higher-functioning boys now became an activity room where staff could interact with those boys who were demonstrating self-control. This change increased the ability to engage the patients on a more frequent and sustained basis.

* School programming. A plan was put into place that would place a nursing staff member as an assistant in every classroom. The plan was partially in place at this time and was viewed as helpful in decreasing disruptive behavior and increasing academic engagement.

* Consolidation of staff. A plan was discussed to close two of four patient units during the day to increase the number of staff available to program patients who were sick or could not attend school or activities due to precautions.

Although these strategies are certainly not novel, they represented a change in thinking for this team and a more positive approach to programming for disruptive adolescent patients. The array of interventions reduced the coercive practices that often increase resistance and retaliation by patients. It was encouraging to see staff think about behavior differently and to focus on supportive interventions rather than on punitive ones. The psychiatrist must be prepared to facilitate and support such a process in order for an appropriate intervention to be implemented.

As the authority of physicians and nurses is being reasserted into the process of initiating restrictive interventions in hospitals, day treatment, and residential treatment centers, the psychiatrist and other team leaders must continue to address the moral, ethical, and clinical factors influencing S&MR. We must continue to develop innovative strategies to study S&MR parameters, reasons for the use of restrictive practices, and outcomes of S&MR implementation that will inform and guide current and future practice. However, restrictive interventions need to be available when truly needed in situations where safety of patients and staff are at risk. This position has been supported by a leading advocate for the mentally ill (Ross, 1999). Guidelines for the use of restrictive interventions and development of a culture that questions the efficacy of such practice will be critical in assuring that S&MR are used only for emergency purposes. Internal and external pressure for change within facilities and professions may be required to effect such change.

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