Isolation and Restraint in Juvenile Correctional Facilities JEFF MITCHELL , M .D., AND CHRISTOPHER VARLEY, M .D . Abstract. Although mental health and correctional programs for juveniles house similar populations, their approaches to behavioral management can be quite different. This difference is evident in the use of isolation and restraint. Both of these interventions are effective behavioral management tools but are subject to abuse if not closely monitored. The authors. drawing from their experiences as mental health consultants to juvenile correctional programs and as expert witnesses in litigation, review the wide range of isolation and restraint practices in correctional programs and make recommendations for supervision and standardization. J. Am . Acad. Child Ado lesc. Psychiat ry 1990.29, 2:251-255. Key Words: isolation. restraints, delinquents. correctional facilities.

American Psychiatric Assoc iati on, 1973) now devote four pages to these interventions (Joint Commission for the Accred itation of Hospitals, 1985), Mental he alth professionals appear to have developed a se nse, if not an explicit awareness , o f their potential dange rs , This awaren ess does not ex ist to the same de gree in the fie ld of juvenile correctio ns , Th e authors ha ve provided consu ltation to in stitutions for delinquents around the country, and one (J ,M .) has been an e xpert witness in over a dozen suits against juvenile rehabilitation programs . From the se experiences and their review of litigation , they have observed a wide range o f isol ation and re straint practices . The purpose of thi s article is to describe the se practices and propose changes that will standardize the use of iso lation and restraint w ith out threatening safety and sec urity .

The terror of a child in prison is quite limitless. [ remember once in Reading , as [ was going out to exercise, seeing in the dimly lit cell right opposite my own a small boy . . . . The child's face was like a white wedge of sheer terror. There was in his eyes the terror of a hunted animal. . . . The terror that seizes and dominates the child. as it seizes a grown man also, is of course intensified beyond power of expression by the solitary cellular system of our prisons. Every child is confined to its cell for twenty-three hours out of the twentyfour. This is the appalling thing. To shut up a child in a dimly lit cell, for twenty-three hours out of the twenty-four , is an example of the cruelty of stupidity. .. Oscar Wilde, comments on his imprisonment in Reading G ao l, 189 7 (Hart-Davis. 1963)

Def initions Isolation in thi s paper refers to the practice o f removing a youth from the living en vironment to hi s or her room , or to a spe c ially built isolation room , for purposes of behavioral control. In juven ile correctio nal facil ities, young people who are isolated for 24 hours or more are usually allo wed to be o ut of their ce lls an hour per day . Restraint is defined as mechanical re straint; i.e., it doe s not include manual re straint (e .g, holding a person) . It also does not include the use of restraining devices such as handcuffs, for subduing and transporting a potentially dan gerous individual. It refers to co nta ining an individual with me chanical de vices in order to obtain a calming effect or prevent injury. In medical and mental health fac ilities , the de vice s used are four- or fivepoint restraints . de signed to sec ure the arms and legs in a natural po sition to a bed. Th ese are often referred to as " soft " restraint s because they are made of padded leather, de signed to secure the limbs with out threatening blood circulation or nerve functioning,

Introduction Isol ation and restraint are common int ervention s in mental health facilities treat ing childre n and adults . In the past dec ade, there has been considerable se lf-scrutiny in psych iatry over the uses and abuses o f such measures (G uthe il , 1978; Mattson and Sacks, 1978; Plutchik et aI., 1978 ; Soloff and Turner, 1981 ; Phillips and Nasr , 1983; Garri son , 1984; Gutheil and Tardiff , 1984, American Psychiatric Association , 1985 ; Joshi et aI. , 1988). As a result , mental health sta ndards, whi ch at on e time paid little attention to isolation and restraint (A me rican Psychi atric Asso ciation , 1971;

Accepted April 18. 1989. At the time of this study , Dr . Mit chell \I'as Assistant Prof essor. Division ofChild Psychiatry, Unive rsity of WashingIOn School ofM edicin e, Seattle , and Director of the mental health programs fo r the King County Depa rtment of Youth Services and the Echo Glen School for Children , a state -run training school . He is currently with the Departm ent of Mental Health , Lovelace Medical Cent er , Albuquerque . Dr. Varley is Ass ociate Prof essor . Division of Child Psych iatry, Departm ent of Psychiatry , University of Washington School of Medicine . Seattle, and serves as a consultant 10 ju venile cor rectional programs in the Pacific Northwesi . Request repr ints fr om Dr . Mit chell at Lovelace Medical Center , Department of Mental Health , 5400 Gibson Bl vd ., S .E., Albuquerque , NM 87108. 0890-8567/90/2902-0251$02.0 0/0© 1990 by theAmerican Academy

Overlap in Populations There are similarities between incarcerated and psychiatrically ho sp italized juveniles , Diagnosti c studies conducted in ju venile corre ctional facilities (Le wis et aI., 1979a . Chiles et aI. , 1980 ; Kashani et aI., 1980; Miller et aI., 1982 ; Ale ssi et aI., 1984: McManus et al ., 1984 , Hyde et aI. , 1986) report high rate s of neuropsychiatric morbidity among residents . According to a study of servic es for ch ildren and ado les ce nts in the state of W ashington (T ru pin et aI. , 1988),

of Child and Adolescent Psychiatry.

251

MIT CHELL AND VARLE Y

76% of incarcerated adolescents were as se verel y emotionally disturbed as their peers in a state-run psychi atric inpatient facility. A study conducted by Lewi s and Shanock (1980) concluded that juvenile co rrectional facilitie s tended to be "psychiatric treatment centers" for adolescent males who had been in mental health facilities during their preadole scen ce and were no longer welcome in ment al health programs becau se of their behavior. Their group also discovered a tendency for black, troublesome teen ager s to be incarcerated, while Caucasian youngsters with similar behavioral problems were psychiatrically hospitalized (Lewis et aI. , 1979b; Lewi s et aI., 1980). A stud y of antisocial behavior in hospitalized , psychot ic adolescents (Inarndar et al. , 1982) found histories of assaulti ve violence in 83.3 % of the males and 42.9 % of the fem ales . It seem s reasonable to conclude from these findings that incarcerated and psychiatrically hospitali zed juveniles are not totally distinct populations with reg ard to psych opathology and certain " acting out" behaviors .

Practices in Juvenile Correctional Facilities Isolat ion Similarities in client population s, howe ver, do not necessarily correspond to similarities in institutional practice . In programs for delinquents, for instance, the authors have found a tendency for staff members to view isolation as a prolonged interv enti on , lasting days, weeks, and, in some cases, months. There also appe ars to be a lack of standardization of isolation practices , an obser vation supported by a telephone survey of directors of state servi ces for incarcerated juveniles conducted in 1984 by the Evergreen Legal Services, a Wa shington-based advocacy group. Every state and the District of Columbia was surveyed about its isolation policies and practices. Some states had clear criteria for isolation , while others had no criteria, or vague cr iteria such as "out of control " behavior. A few states had requ irements for supervision of an isolated youth (e.g., visual checks every 10 minutes , supervisory rev iew) and required a minimum of daily recreational activity . Most, however, had no such guidelines. The upper time limit of isolat ion was another important variation in practice , as illustrated in Table I . Some state s required youths to be out of isolation within a few hour s. At the other end of the spectrum , one state allow ed isolation for up to 15 days, and seven had no upper limit. Parentheticall y , the adherence of state s to their own guide lines may be questioned , since one of the states reporting a 24hour upper limit was found during litigation (Danny O. v. Bowman) to isolate residents for up to 3 month s. Reasons for isolation can be dive rse, as illust rated by one author' s (J.M .) review of the use of a maximum security isolation unit in a large training school. Five hundred and twent y-seven reports of incidents leading to isolation, involving 30 randoml y selected resident s , were revie wed and classified according to type and seriousness. The number of incidents per resident ranged from I to 98. Th e data , presented in Table 2, reveal that most (5 1.3%) of the isolations were for noncompliance or rule violations . Although

252

I . Telephone Sliney" of 50 States and the District of Columbia (/ 984 ) Regarding Isolation Practices in State-run Juvenile Correctional Facilities"

T ABLE

Time Limit Under 24 hours ' 24 hours 48 hours 72 hours Four days Five days 6- 10 days 14 days 15 days No limit

No . of States 10 9 1 9 I 8 4 I 1 7

" Unpubl ished data quoted with the permission of the Evergreen Legal Services, Washington State . b Upper time limit allowed for isolation. ' Range: I to 8 hours .

the program directors stated during litigation (Gary H. v . Hegstrom ) that they had a beh avior modification program , it was evident from the data that the principal , if not first line , intervention was isolati on . The se data represent only one institut ion' s response to a wide range of behaviors . However, in the author's experience, they exemplify programs that overrely on isolati on . There is also variation in isolation site from one institution to another. Som e facilities simpl y confine residents in their rooms. Others have special isolation rooms in living unit s, similar to the "quiet room s" on psychiatric ward s. A third kind of isolation occ urs in separate buildings designed solely for this purpose . These structures , usually referred to as "adjustment" or "security" units , often require full-time staffing, and thus constitute a drain on resourc es. The rooms in these units usually have the heavy metal doors used in adult maximum security pri sons , with small plexiglass windows and feedh oles a few feet above the ground. Isolated young people spend most of their day on the floor, looking and talking through the feedholes. As illustrated in Table 2, security unit s can become the de facto behavioral manage ment system for a facilit y . The authors have found that program s with these units are most likely to engage in prolonged isolation ; i.c.. confining a youth to a cell 23 hours a day for week s at a time. Is there any harm in this ? The literature sugge sts that a variety of mental and behavioral disturbances can be created by isolation for long periods of time . Prolonged isolation increases territorial aggression in rats (Valzelli, 1974) and dominance-related aggression in vervet monkeys (Raliegh et aI. , 1987). Impulsivity, per ceptual distortion, affective disturb ance , and paranoid ideati on have been observed in adult prisoners in maximum security isolat ion (Grassian, 1983). The authors are not aware of studi es using norm al or incarcerated adolescents. However, one rev iew (Zubeck , 1973 ) of exp erim ents on young adult volunteers studying the effects of social isolation and sensory depri vation , usually lasting I week , found that about one-third of the subjects withdrew befo re the end of the experimental per iod. Coml.Am.A cad . Child Adolesc . Psychiatry, 29 :2, March 1990

ISOLATION/RESTRAINT - JUVENILE CORRECTIONS

Incidents Involving Use of Physical Force

2. Classification of 527 Incidents, Involving 30 Juveniles, Leading to Transfer to a Maximum Security Isolation Unit of a Juvenile Correctional Facility"

TABLE

Type of Incident

KCJDC 1987, 1988

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21 130 140

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1.5 11.8 8.2 18.6

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I. Decline in incidents in general in the King County (Seattle, WA) Juvenile Detention Center (KCJDC), following the closure of its isolation unit on January I, 1988. FIG.

l.Am.Acad. Child Adolesc. Psychiatry, 29:2 .March 1990

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2. Decline in incidents involving use of physical force in the King County (Seattle, WA) Juvenile Detention Center (KCJDC), following the closure of its isolation unit on January I, 1988.

FIG.

Incidents Involving Injury to Youths

pared to subjects who completed the study, the "quitters" tended to be younger; to watch television more; to be nonreaders; to smoke; to dislike quiet, solitude, and darkness; and to score higher on psychological tests measures that are associated with aggressiveness, hyperactivity, and potential violence. The implication from these studies is that young people with these traits (e.g., juvenile delinquents) may be more vulnerable to the negative effects of isolation than a more stable population. It is the author's impression that programs relying on excessive isolation experience high rates of aversive behaviors among residents. A single case study supporting this impression comes from the authors' data on the effect of closing a maximum security unit in one of their consultee agencies, the detention center of the King County Juvenile Department of Youth Services (Seattle, Washington). This unit housed 15-25% of the detention population when it

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" Gary H. I' Hegstrom. " 27 (62.8%) of the verbal threats involved one youth. , 28 (28.6%) of the assaults involved one youth.

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