Residential In-Patient Treatment: A Case Study
Impact Restraints have on Children in Residential In-Patient Treatment
1. Introduction
There have been many concerns regarding the use of physical restraint among children in residential and psychiatric in-patient treatment facilities. Many have debated the use of physical restraints among children as being dangerous, causing trauma or re-traumatizing a child, unethical, and taking away the legal rights of children. They have argued that the potential dangers within the practice of restraints raise questions on how beneficial the approach is (Saurander et al., 2002, p.161). Others have argued that physical restraints have a therapeutic benefit for children when being used appropriately. They have said that the use …show more content…
of restraints can be a vital part of helping children learn coping skills in order to manage their stress (Saurander et al., 2002, p.161) and that the use of restraints are “a necessary safety measure, perhaps even a necessary part of child/adolescent treatment” (LeBel et al., 2004, p.37). Although there is a risk for injuries during the practice of restraints, there can be a therapeutic benefit. We must further research and further our understanding, in order to diminish the use of restraints while bringing back the therapeutic benefits of the practice while maintaining the therapeutic milieu of the organization.
2. Concerns of Physical Restraints on Children
2.1 Legal Rights and Clinical Needs
Many argue that the “use of restraints potentially poses a conflict between a patient’s clinical needs and legal rights” (Saurander et al., 2002, p.162).
The practice of restraints used among the child population violates the “legal rights” a child has over their own self-determination. This argument is strong because, restraints take away a child’s right to at times act as a child their own age would. To disregard a child’s legal rights worries the child’s legal guardian. An issue with this is that, when a child is placed in residential or psychiatric in-patient treatment facilities, parents must give the organization permission to do what the professionals feel fit to do to help the clinical needs of their child. Therefore, this concern is one that raises further discussion on what needs to be done during the admission process to educate the child’s legal guardian on what could or could not happen during the child’s treatment …show more content…
process.
2.2 Injuries Due to Physical Restraints
Restraining an individual includes the use of an aggressive force being placed upon an individual, which evidently can cause acute and severe injuries. According to Steckley and Kendrick, children in these programs “should be able to look to adults to protect them from their own destructive behaviour” (p.558), rather than fear the adults working with them will cause further harm to them. Their argument is powerful because children come to these programs to learn new skills to help them recover from their crisis. Workers should not be causing harm to the children. It is alarming that a procedure used to maintain safety could cause more harm, emotionally and physically.
2.3 Trauma from Physical Restraints
One of the greatest concerns with the use of physical restraints is the potential traumatizing and re-traumatizing effects it can have on children.
Many argue that the use of restraints have a negative impact on children including psychological effects and physical harm (Singh et al., 1999, p.244). The use of restraints on children with histories of physical, sexual and emotional trauma are at a higher risk for these negative consequences (LeBel et al., 2004, p.38). Children are admitted to these programs to receive therapeutic treatment because of the behaviors they exhibit in the community due to previous trauma “the failure to recognize childhood trauma and abuse produces iatrogenic effects” (LeBel et al., 2004, p.38). For children with previous history of trauma, these programs are meant to be a place of healing, a place of serenity. With the use of restraints on these children, it can turn their place of serenity and healing into a place that represents new trauma, therefore continuing to affect their mental health and wellbeing (LeBel et al., 2004, p.38). In order to help a child, the programs should be looking at each child as an individual in order to avoid causing further trauma or re-traumatizing the child placed in their
care.
3. Restraints Effect on Children
Many studies have taken place over the years to help understand how the use of restraints affects children in in-patient treatment facilities. More recently, the use of restraints have been looked at as an emergency strategy rather than a necessary intervention and diminishing the use of restraints is an issue waiting to be resolved in order to better handle aggression in children, (Delaney, 2006, p.20). However, there is greater evidence proving that the use of restraints resulted in the children having primarily negative thoughts about their time in residential treatment (Singh et al., 1999, p.244).
3.1 Positive Components of Physical Restraints
As stated previously, studies have shown that children’s views on restraints have not only been negative, but positive as well. Children have reported that they have had felt safe, that the adult cared about them, possibility to work on difficulties in their relationship with the adult, and a calming effect. These feelings usually are a result of the comfort and verbal reassurance that childcare workers offer a child during a restraint (Sourander et al., 2002). According to the research done by Steckley and Kendrick (2002) children have also said that during a restraint they had felt “helped (i.e. kept safe or out of trouble)... better after the restraint occurred” (p.566), during this interview, one child said that “After a restraint…I feel better because everything’s out” (p.563). This statement is in reference to that once the restraint is over, the child’s feelings of anger and sadness are overcome by the overwhelming feeling that someone cares for him. For a child, the feeling of containment can be beneficial in the moment. Emotions can be overwhelming, sometimes they can be difficult for a child to verbally say and the frustration of this may lead them to become aggressive, which in turn, the feeling of containment brings or holds the child together emotionally.
It is important to realize that in order for a restraint to have a positive outcome, childcare workers must follow up and process the incident with a child. The childcare worker must speak with the child about what had happened leading up to the restraint; this includes how the child felt before he/she escalated and how that situation can be avoided in the future (Steckley & Kendrick, 2002, p.564). It is beneficial for the child to understand his/her actions and feelings and speak with adults after on how the situation could have been different and strategies and cooping skills could be beneficial. Processing with a child is possibly the most positive outcome of restraints.
3.2 Negative Components of Physical Restraint: Child’s View
For a number of years, children have criticized and raised concern about the use of and how staff restrains them. During Steckley and Kendrick’s (2008) interviews with children about their experiences with restraints, a child stated that they had “felt shocked, disappointed, humiliated in front of my peers. Disgusted, abused…Most of all I felt violated” (p.562). Others who have depicted their feelings during these incidents, ones that included them or they witnessed others endure, disclosed the feelings they often had of fear, abandonment (LeBel et al., 2004, p.38), as well as anger (Singh et al., 1999, p.244). While anger may be initially a component of why a child becomes aggressive, some children have expressed that while in or after the restraint they experience “feeling angry with themselves for their own behavior leading up to and during the restraint” (Steckley & Kendrick, 2008, p. 566). This feeling of anger towards themselves can result in a child to having a lower self-esteem and self-worth. Lowering a child’s self-worth and self-esteem can affect them negatively and in turn cause them to act out aggressively rather than using their coping skills. Many children already feel as though they are “worthless” and do not have much self-esteem when they come into the program, the program is supposed to help them rediscover their self-worth, not further take it away.
In Singh, Singh, Davis, Latham, and Ayers’s article, Reconsidering the Use of Seclusion and Restraints in Inpatient Child and Adult Psychiatry (1999), they shine light onto how children reported that they felt restraints were used as a punishment when they had not followed a direction that adults had given them. Many had also said that they felt that adults had used an unnecessary force to place them into restraints and feelings of being unprotected from potential harm in the process. They should be able to trust the adults working with them to keep them safe but how can one trust another if they feel unsafe in their care? A child should feel as though they can approach their caretakers in treatment with their feelings and talk about strategies they can use to help them rather than fear that if and “when they restrain you they just purely hurt you…it felt like he wasn’t trying to keep me safe” (Steckley & Kendrick, 2008, p.561).
The uses of restraints have also been proven to be emotionally traumatizing/re-traumatizing to a child (Mohr, 2010, p.7). When a former patient of residential treatment came forward to describe her experiences being in restraints as a child. She explained her experiences as ones that “recapitulated her childhood trauma”, she continued on to say that “the more I was restrained, the more humiliation I felt. The more shame and humiliation I felt, the more I dissociated, self-injured, and was restrained” (LeBel et al., 2004, p.38). Re-traumatizing a child can cause “further emotional distress”; this could be especially true for those who have been a victim of sexual abuse (Mohr, 2010, p.7). Being restrained can cause a child who has been a victim of sexual abuse to relive the moments that caused their trauma, leading the restraint to become more dangerous and un-therapeutic.
4. What Can be Done to Diminish the Use of Restraints?
4.1 Family Involvement
Hair (2005), describes a survey that had been given to childcare workers to determine whether or not that involvement of the child’s family was beneficial to their treatment. Evidently, the survey showed that children “who had more visits with family during residential treatment were more likely to meet their goals”. This gave evidence that “the relationship between family support and involvement with goal attainment and program completion” (p.557). Hair, continues on to say that parent’s involvement in their child’s residential treatment could be the route to a successful treatment plan, therefore diminishing the use of restraints on a child.
4.2 Use of Training Staff
Childcare workers working with this population have a demanding responsibility to keep the children in their care safe in difficult conditions. Due to the demanding nature of the job, it is important for us to continue to find ways to help adults learn new strategies and intervention techniques to help children in their care, as well as continuous training refreshers on what they already know and implement as well as familiarizing staff with policies relating to restraint and with the organization’s policies (Sourander et al., 2002, p.166). We must make sure that staff members are not only trained but utilizing therapeutic crisis intervention techniques to “anticipate and calm down possibly dangerous situations” (Steckley & Kendrick, 2008, p.555), without the use of restraints.
Childcare workers must be educated in the use of helpful strategies for children. Singh, Singh, Davis, Latham, and Ayer’s, report that the use of alternative methods for intervention can lead to a reduction or possible elimination of restraints (p.245). They believe that childcare workers should focus on building on the strengths of the children in their care (p.246). The approach and focus on building on the strengths of children has been used by Massachusetts. Massachusetts believes that this approach “emphasized youths’ positive behaviors, provided an affirming culture, and support” (Delaney, 2006, p.21).
Childcare workers must also be constantly refreshed on how to be aware of the environment in order to know what is are potential triggers for children in their care. This knowledge can help childcare workers to remove the trigger or possible trigger from the situation so that they would be “creating an environment that lowers stress, eliminates threat” (Delaney, 2006, p.25) and overall keeping the environment safe for everyone.
5. Moving Forward
The use of restraints on children in residential and psychiatric in-patient treatment has its advantages and disadvantages. Although there is a great concern and risk for trauma, re-traumatization, injuries, and ethical concerns, children have spoken both positively and negatively at the effects restraints have had on them. Further research and findings of new therapeutic approaches could help the system eliminate the use of restraints. Along with that, residential facilities must keep up with training their staff and encouraging them to implement the use of strategies and cooping skills. One must ask them self; do restraints happen more often due to childcare workers being burnt out from such a demanding job? To answer this question, further research and understanding of the viewpoints of those working in these high stress environments must be done. Research must be done to help diminish the level of stress put upon the workers, supporting them when situations that have risen have caused emotional distress upon them.
The question then asked needs to be; What can we do to further our understanding of the needs that these children need on an individual level so that we can best help them reach their goals? Each child’s treatment plan needs to be individualized. In order to look at the child as an individual in these environments, the clinicians must educate the workers working with each of these children on their prior experience and crisis the child has endured. Once that is taken into place, the child can be seen as an individual, helping the treatment team to work with the child as having their own plan while still implementing a teamwork type of environment with the children.
References
Bickman, L., Vides de Andrade, A., Lambert, E., Doucette, A., Sapyta, J., Boyd, S., Rumberger, D., Moore-Kurnot, J., McDonough, L., Rauktis, M.B. (2004) Youth Therapeutic Alliance in Intensive Treatment Settings. Journal of Behavioral Health Services & Research, 31(2), 134-148. Print
Delaney, K. (2006). Evidence Base for Practice: Reduction of Restraint and Seclusion Use During Child and Adolescent Psychiatric Inpatient Treatment. Worldviews on Evidence-Based Nursing. 19-30. Print
Hair, J. (2005). Outcomes for Children and Adolescents After Residential Treatment: A Review of Research from 1993 to 2003. Journal of Child and Family Studies, 14(4), 551-575. Print.
LeBel, J., Stromberg, N., Duckworth, K., Kerzner, J., Goldstein, R., Weeks, M., et al. (2004). Child and adolescent inpatient restraint reduction: A state initiative to promote strength- based care. Journal of the American Academy on Child and Adolescent Psychiatry, 43(1), 37- 45. Print.
Mohr, W. (2010). Restraints and the code of ethics: An uneasy fit. Archives of Psychiatric Nursing, 24(1), 3-14. Print.
Rivard, J.C., Bloom, S.L., McCorkle, D. Abramovitz, R. (2005) Preliminary results of a study examining the implementation and effects of a trauma recovery framework for youths in residential treatment. Therapeutic Community: The International Journal for Therapeutic and Supportive Organizations, 26(1), 83-96. Print.
Singh, N., Singh, S., Davis, C., Latham, L., & Ayers, J. (1999). Reconsidering the use of seclusion and restraints in inpatient child and adult psychiatry. Journal of Child and Family Studies, 8 (3), 243-253. Print.
Sourander, A., H. Ellila, M. Valimaki, and J. Piha. (2002). Use of Holding, Restraints, Seclusion and Time-out in Child and Adolescent Psychiatric In- patient Treatment. European Child & Adolescent Psychiatry 11(4), 162-67. Print.
Steckley, L., Kendrick, A. (2008). Physical Restraint in Residential Childcare: The Experiences of Young People and Residential Workers. Childhood 15(4), 552-69. Print.
1. Introduction
There have been many concerns regarding the use of physical restraint among children in residential and psychiatric in-patient treatment facilities. Many have debated the use of physical restraints among children as being dangerous, causing trauma or re-traumatizing a child, unethical, and taking away the legal rights of children. They have argued that the potential dangers within the practice of restraints raise questions on how beneficial the approach is (Saurander et al., 2002, p.161). Others have argued that physical restraints have a therapeutic benefit for children when being used appropriately. They have said that the use …show more content…
of restraints can be a vital part of helping children learn coping skills in order to manage their stress (Saurander et al., 2002, p.161) and that the use of restraints are “a necessary safety measure, perhaps even a necessary part of child/adolescent treatment” (LeBel et al., 2004, p.37). Although there is a risk for injuries during the practice of restraints, there can be a therapeutic benefit. We must further research and further our understanding, in order to diminish the use of restraints while bringing back the therapeutic benefits of the practice while maintaining the therapeutic milieu of the organization.
2. Concerns of Physical Restraints on Children
2.1 Legal Rights and Clinical Needs
Many argue that the “use of restraints potentially poses a conflict between a patient’s clinical needs and legal rights” (Saurander et al., 2002, p.162).
The practice of restraints used among the child population violates the “legal rights” a child has over their own self-determination. This argument is strong because, restraints take away a child’s right to at times act as a child their own age would. To disregard a child’s legal rights worries the child’s legal guardian. An issue with this is that, when a child is placed in residential or psychiatric in-patient treatment facilities, parents must give the organization permission to do what the professionals feel fit to do to help the clinical needs of their child. Therefore, this concern is one that raises further discussion on what needs to be done during the admission process to educate the child’s legal guardian on what could or could not happen during the child’s treatment …show more content…
process.
2.2 Injuries Due to Physical Restraints
Restraining an individual includes the use of an aggressive force being placed upon an individual, which evidently can cause acute and severe injuries. According to Steckley and Kendrick, children in these programs “should be able to look to adults to protect them from their own destructive behaviour” (p.558), rather than fear the adults working with them will cause further harm to them. Their argument is powerful because children come to these programs to learn new skills to help them recover from their crisis. Workers should not be causing harm to the children. It is alarming that a procedure used to maintain safety could cause more harm, emotionally and physically.
2.3 Trauma from Physical Restraints
One of the greatest concerns with the use of physical restraints is the potential traumatizing and re-traumatizing effects it can have on children.
Many argue that the use of restraints have a negative impact on children including psychological effects and physical harm (Singh et al., 1999, p.244). The use of restraints on children with histories of physical, sexual and emotional trauma are at a higher risk for these negative consequences (LeBel et al., 2004, p.38). Children are admitted to these programs to receive therapeutic treatment because of the behaviors they exhibit in the community due to previous trauma “the failure to recognize childhood trauma and abuse produces iatrogenic effects” (LeBel et al., 2004, p.38). For children with previous history of trauma, these programs are meant to be a place of healing, a place of serenity. With the use of restraints on these children, it can turn their place of serenity and healing into a place that represents new trauma, therefore continuing to affect their mental health and wellbeing (LeBel et al., 2004, p.38). In order to help a child, the programs should be looking at each child as an individual in order to avoid causing further trauma or re-traumatizing the child placed in their
care.
3. Restraints Effect on Children
Many studies have taken place over the years to help understand how the use of restraints affects children in in-patient treatment facilities. More recently, the use of restraints have been looked at as an emergency strategy rather than a necessary intervention and diminishing the use of restraints is an issue waiting to be resolved in order to better handle aggression in children, (Delaney, 2006, p.20). However, there is greater evidence proving that the use of restraints resulted in the children having primarily negative thoughts about their time in residential treatment (Singh et al., 1999, p.244).
3.1 Positive Components of Physical Restraints
As stated previously, studies have shown that children’s views on restraints have not only been negative, but positive as well. Children have reported that they have had felt safe, that the adult cared about them, possibility to work on difficulties in their relationship with the adult, and a calming effect. These feelings usually are a result of the comfort and verbal reassurance that childcare workers offer a child during a restraint (Sourander et al., 2002). According to the research done by Steckley and Kendrick (2002) children have also said that during a restraint they had felt “helped (i.e. kept safe or out of trouble)... better after the restraint occurred” (p.566), during this interview, one child said that “After a restraint…I feel better because everything’s out” (p.563). This statement is in reference to that once the restraint is over, the child’s feelings of anger and sadness are overcome by the overwhelming feeling that someone cares for him. For a child, the feeling of containment can be beneficial in the moment. Emotions can be overwhelming, sometimes they can be difficult for a child to verbally say and the frustration of this may lead them to become aggressive, which in turn, the feeling of containment brings or holds the child together emotionally.
It is important to realize that in order for a restraint to have a positive outcome, childcare workers must follow up and process the incident with a child. The childcare worker must speak with the child about what had happened leading up to the restraint; this includes how the child felt before he/she escalated and how that situation can be avoided in the future (Steckley & Kendrick, 2002, p.564). It is beneficial for the child to understand his/her actions and feelings and speak with adults after on how the situation could have been different and strategies and cooping skills could be beneficial. Processing with a child is possibly the most positive outcome of restraints.
3.2 Negative Components of Physical Restraint: Child’s View
For a number of years, children have criticized and raised concern about the use of and how staff restrains them. During Steckley and Kendrick’s (2008) interviews with children about their experiences with restraints, a child stated that they had “felt shocked, disappointed, humiliated in front of my peers. Disgusted, abused…Most of all I felt violated” (p.562). Others who have depicted their feelings during these incidents, ones that included them or they witnessed others endure, disclosed the feelings they often had of fear, abandonment (LeBel et al., 2004, p.38), as well as anger (Singh et al., 1999, p.244). While anger may be initially a component of why a child becomes aggressive, some children have expressed that while in or after the restraint they experience “feeling angry with themselves for their own behavior leading up to and during the restraint” (Steckley & Kendrick, 2008, p. 566). This feeling of anger towards themselves can result in a child to having a lower self-esteem and self-worth. Lowering a child’s self-worth and self-esteem can affect them negatively and in turn cause them to act out aggressively rather than using their coping skills. Many children already feel as though they are “worthless” and do not have much self-esteem when they come into the program, the program is supposed to help them rediscover their self-worth, not further take it away.
In Singh, Singh, Davis, Latham, and Ayers’s article, Reconsidering the Use of Seclusion and Restraints in Inpatient Child and Adult Psychiatry (1999), they shine light onto how children reported that they felt restraints were used as a punishment when they had not followed a direction that adults had given them. Many had also said that they felt that adults had used an unnecessary force to place them into restraints and feelings of being unprotected from potential harm in the process. They should be able to trust the adults working with them to keep them safe but how can one trust another if they feel unsafe in their care? A child should feel as though they can approach their caretakers in treatment with their feelings and talk about strategies they can use to help them rather than fear that if and “when they restrain you they just purely hurt you…it felt like he wasn’t trying to keep me safe” (Steckley & Kendrick, 2008, p.561).
The uses of restraints have also been proven to be emotionally traumatizing/re-traumatizing to a child (Mohr, 2010, p.7). When a former patient of residential treatment came forward to describe her experiences being in restraints as a child. She explained her experiences as ones that “recapitulated her childhood trauma”, she continued on to say that “the more I was restrained, the more humiliation I felt. The more shame and humiliation I felt, the more I dissociated, self-injured, and was restrained” (LeBel et al., 2004, p.38). Re-traumatizing a child can cause “further emotional distress”; this could be especially true for those who have been a victim of sexual abuse (Mohr, 2010, p.7). Being restrained can cause a child who has been a victim of sexual abuse to relive the moments that caused their trauma, leading the restraint to become more dangerous and un-therapeutic.
4. What Can be Done to Diminish the Use of Restraints?
4.1 Family Involvement
Hair (2005), describes a survey that had been given to childcare workers to determine whether or not that involvement of the child’s family was beneficial to their treatment. Evidently, the survey showed that children “who had more visits with family during residential treatment were more likely to meet their goals”. This gave evidence that “the relationship between family support and involvement with goal attainment and program completion” (p.557). Hair, continues on to say that parent’s involvement in their child’s residential treatment could be the route to a successful treatment plan, therefore diminishing the use of restraints on a child.
4.2 Use of Training Staff
Childcare workers working with this population have a demanding responsibility to keep the children in their care safe in difficult conditions. Due to the demanding nature of the job, it is important for us to continue to find ways to help adults learn new strategies and intervention techniques to help children in their care, as well as continuous training refreshers on what they already know and implement as well as familiarizing staff with policies relating to restraint and with the organization’s policies (Sourander et al., 2002, p.166). We must make sure that staff members are not only trained but utilizing therapeutic crisis intervention techniques to “anticipate and calm down possibly dangerous situations” (Steckley & Kendrick, 2008, p.555), without the use of restraints.
Childcare workers must be educated in the use of helpful strategies for children. Singh, Singh, Davis, Latham, and Ayer’s, report that the use of alternative methods for intervention can lead to a reduction or possible elimination of restraints (p.245). They believe that childcare workers should focus on building on the strengths of the children in their care (p.246). The approach and focus on building on the strengths of children has been used by Massachusetts. Massachusetts believes that this approach “emphasized youths’ positive behaviors, provided an affirming culture, and support” (Delaney, 2006, p.21).
Childcare workers must also be constantly refreshed on how to be aware of the environment in order to know what is are potential triggers for children in their care. This knowledge can help childcare workers to remove the trigger or possible trigger from the situation so that they would be “creating an environment that lowers stress, eliminates threat” (Delaney, 2006, p.25) and overall keeping the environment safe for everyone.
5. Moving Forward
The use of restraints on children in residential and psychiatric in-patient treatment has its advantages and disadvantages. Although there is a great concern and risk for trauma, re-traumatization, injuries, and ethical concerns, children have spoken both positively and negatively at the effects restraints have had on them. Further research and findings of new therapeutic approaches could help the system eliminate the use of restraints. Along with that, residential facilities must keep up with training their staff and encouraging them to implement the use of strategies and cooping skills. One must ask them self; do restraints happen more often due to childcare workers being burnt out from such a demanding job? To answer this question, further research and understanding of the viewpoints of those working in these high stress environments must be done. Research must be done to help diminish the level of stress put upon the workers, supporting them when situations that have risen have caused emotional distress upon them.
The question then asked needs to be; What can we do to further our understanding of the needs that these children need on an individual level so that we can best help them reach their goals? Each child’s treatment plan needs to be individualized. In order to look at the child as an individual in these environments, the clinicians must educate the workers working with each of these children on their prior experience and crisis the child has endured. Once that is taken into place, the child can be seen as an individual, helping the treatment team to work with the child as having their own plan while still implementing a teamwork type of environment with the children.
References
Bickman, L., Vides de Andrade, A., Lambert, E., Doucette, A., Sapyta, J., Boyd, S., Rumberger, D., Moore-Kurnot, J., McDonough, L., Rauktis, M.B. (2004) Youth Therapeutic Alliance in Intensive Treatment Settings. Journal of Behavioral Health Services & Research, 31(2), 134-148. Print
Delaney, K. (2006). Evidence Base for Practice: Reduction of Restraint and Seclusion Use During Child and Adolescent Psychiatric Inpatient Treatment. Worldviews on Evidence-Based Nursing. 19-30. Print
Hair, J. (2005). Outcomes for Children and Adolescents After Residential Treatment: A Review of Research from 1993 to 2003. Journal of Child and Family Studies, 14(4), 551-575. Print.
LeBel, J., Stromberg, N., Duckworth, K., Kerzner, J., Goldstein, R., Weeks, M., et al. (2004). Child and adolescent inpatient restraint reduction: A state initiative to promote strength- based care. Journal of the American Academy on Child and Adolescent Psychiatry, 43(1), 37- 45. Print.
Mohr, W. (2010). Restraints and the code of ethics: An uneasy fit. Archives of Psychiatric Nursing, 24(1), 3-14. Print.
Rivard, J.C., Bloom, S.L., McCorkle, D. Abramovitz, R. (2005) Preliminary results of a study examining the implementation and effects of a trauma recovery framework for youths in residential treatment. Therapeutic Community: The International Journal for Therapeutic and Supportive Organizations, 26(1), 83-96. Print.
Singh, N., Singh, S., Davis, C., Latham, L., & Ayers, J. (1999). Reconsidering the use of seclusion and restraints in inpatient child and adult psychiatry. Journal of Child and Family Studies, 8 (3), 243-253. Print.
Sourander, A., H. Ellila, M. Valimaki, and J. Piha. (2002). Use of Holding, Restraints, Seclusion and Time-out in Child and Adolescent Psychiatric In- patient Treatment. European Child & Adolescent Psychiatry 11(4), 162-67. Print.
Steckley, L., Kendrick, A. (2008). Physical Restraint in Residential Childcare: The Experiences of Young People and Residential Workers. Childhood 15(4), 552-69. Print.