The aggressive child

Acute assessment and management of the aggressive or violent child or adolescent are a challenge for clinicians. Early recognition of signs of impending violence and a clear understanding of the progression of violent behavior are essential to ensure safety of patients and staff. The management of violent and aggressive patients using behavioral interventions tailored to the stage of violence or aggression is critical to reducing the likelihood that the child or adolescent will attack staff or injure self or others. The indications and risks of chemical and physical restraints and hospital standards and guidelines that govern the use of behavioral and experience regarding the prevalence, presentation, and differential diagnosis of psychotic disorders in juveniles. The clinician must rapidly disentangle which elements of the clinical presentation indicate true psychotic thought processes versus elements that represent misunderstood developmentally appropriate phenomena, symptoms of nonpsychotic illnesses, or harbingers of an underlying primary medical illness. A thorough assessment is required before appropriate treatment can begin.

Charitable Choice regulations applicable to states receiving Substance Abuse Prevention and Treatment Block Grants, Projects for Assistance in Transition from Homelessness formula grants, and to public and private providers receiving discretionary grant funding from SAMHSA for the provision of substance abuse services providing for equal treatment of SAMHSA program participants. Final rule

On December 17, 2002, the Department of Health and Human Services (HHS) published a Notice of Proposed Rulemaking (NPRM) to implement the Charitable Choice statutory provisions of the Public Health Service Act, applicable to the Substance Abuse Prevention and Treatment (SAPT) Block Grant program, the Projects for Assistance in Transition from Homelessness (PATH) formula grant program, insofar as recipients provide substance abuse services, and to SAMHSA discretionary grants for substance abuse treatment or prevention services, which are all administered by the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services. The Secretary requested comments on the NPRM and gave 60 days for individuals to submit their written comments to the Department. The Secretary has considered the comments received during the open comment period and is issuing the final regulation in light of those comments.

The self-exclusion program: legal and clinical considerations

In recent years, attention focused on compulsive gambling(1), and its causes and cures, has increased at a notable rate. Among the measures taken to help the compulsive gambler is the voluntary(2) self-exclusion program which is either in place or being considered in various states.(3) Although the programs differ from jurisdiction to jurisdiction, the basic premise is that the gambler requests that he be banned from the gaming establishment and/or removed from its mailing list. This article examines this new concept primarily from a legal perspective. The self-exclusion program represents a state-created legal entity constructed upon a clinical foundation. It prominently includes several clinical references to mental health principles. Of necessity, there appear some analogies to the field of substance abuse; these have provided at least a starting point for more particularized study and research in the fledgling field of compulsive gambling treatment.

[The third pillar of psychiatric health care reform]

OBJECTIVE

Coordination of all psychiatric services is essential for the successful implementation of community oriented services, particularly in a decentralised health system like the one in Germany. This study investigates which mechanisms are implemented for coordinating and planning psychiatric services throughout the 16 German States (Länder).

METHOD

Analysing mental health legislation and policy documents of the States. Guided expert interviews with the psychiatry departments of the State governments.

RESULTS

Coordinating and planning panels exist in all States on district level and in most States on State level for various tasks. Most of these mechanisms are implemented without legal obligation. 4 States have a mental health evaluation panel, which scrutinises all psychiatric services once a year and reports publicly to the government. 12 States have a mental health legislation and 13 States published a central psychiatric planning document.

CONCLUSION

The continous implementation of mechanisms for coordinating and planning psychiatric services in the German States represent the dynamics of psychiatric reforms there. The effect of these mechanisms on the implementation of community oriented psychiatric care should be subject to further research.

Regulatory compliance issues in behavioral health

Behavioral health as a discipline has grappled with regulatory compliance issues on its own, tending to be isolated from other specialties and to benefit little from the mistakes and solutions of the rest of medicine. The most common problems with behavioral health regulatory compliance have to do with documentation, billing and coding, treatment plans, and medical necessity. Regulatory compliance is inextricably linked to quality of care. Providers can assess their compliance efforts by asking themselves a series of questions and, most important, by assessing the quality of the care they provide. Sound research and outcomes-based practice are the best ways to improve outcomes in behavioral health treatment and will be the most effective methods for aligning practice with regulations.

Pre-admission nursing assessment in a Welsh Medium Secure Unit (1991-2000): Part 2--comparison of traditional nursing assessment with the HCR-20 risk assessment tool

Pre-admission forensic nursing assessment is a tradition that has no research evidence base, little documentary support and is an expensive drain on nursing resources from clinical environments. Such an expensive practice warrants some evaluation of the quality of these nursing assessments. This study assessed the quality of nursing risk assessments through comparison with the HCR-20, a well-established and widely validated violence risk assessment instrument. There was a high degree of correspondence between nurse assessments and the contents of the HCR-20. The results offer support for forensic nurses' abilities to develop effective measures and practices based upon nursing knowledge and experience where no formal evidence base previously existed.

Pre-admission nursing assessment in a Welsh medium secure unit (1991-2000): Part 1--an analysis of practice and cost

Pre-admission nursing assessment is a widely accepted practice in forensic mental health services, yet has never been described or evaluated. The costs and merits of this practice have not hitherto been the subject of systematic investigation. This article describes the practice of pre-admission assessments and details a method for estimating the cost of forensic nursing assessments in terms of the investment of nursing time. The method was then employed to evaluate the cost of nursing assessments to a Welsh medium secure unit over a 9-year period. The results showed that the demand for, and location, of pre-admission nursing assessment varied considerably over 9 years. Assessments were expensive in the demands that they placed on the resources of the nursing department. Due to the high investment costs, evidence is required to support such practice.

Dr. Jekyll's waiver of Mr. Hyde's right to refuse medical treatment: Washington's new law authorizing mental health care advance directives needs additional protection

Mental health care advance directives are gaining popularity nationwide. Following a growing trend, the Washington State Legislature has recently passed a law allowing patients to draft mental health care advance directives that could be irrevocable. Patients who sign an irrevocable directive essentially waive their fundamental right to refuse treatment in the future. The United States Supreme Court has held that waivers of fundamental rights must be made knowingly, voluntarily, and intelligently. However, as passed, Washington's new law contains insufficient safeguards to guarantee such a waiver. This Comment proposes that the Washington State Legislature amend this law the require two additional protections: a "rights advocate" to explain the potential waiver of rights, and a written warning in the advance directive form. These safeguards will help ensure that patients make knowing and intelligent waivers of their fundamental right to refuse treatment.

Networking to support suicide survivors

This paper is the first report on a national program for increasing bereavement support for suicide survivors in the Flemish region in Belgium. A Working Group consisting of representatives of a wide variety of mental health institutions, social programs, and suicide survivor groups in the area determined that a program developing networks between the services seems to hold the greatest promise for both an increase in the number of services available and an improvement in the quality of services offered.

Implementing psychiatric advance directives: service provider issues and answers

Psychiatric advance directives (PADs) are an emerging method for adults with serious and persistent mental illness to document treatment preferences in advance of periods of incapacity. This article presents and responds to issues most frequently raised by service providers when planning for implementation of PADs. Issues discussed include access to PADs; competency to execute PADs; the relationship of PADs to standards of care, resource availability, and involuntary treatment; roles of service providers and others in execution of PADs; timeliness and redundancy of PAD information; consumer expectations of PADs; complexity of PADs; revocation and "activation"; legal enforceability of PADs; the role and powers of agents; liability for honoring and not honoring PADs; and use of PADs to consent for release of health care information. Recommendations are made for training staff and consumers, consideration of statute development, and methods to reduce logistical, attitudinal, and system barriers to effective use of PADs.

Sentenced to treatment: early experience of drug treatment and testing orders in England

Drug Treatment and Testing Orders (DTTOs) were introduced in the 1998 Crime and Disorder Bill and were piloted in three areas in England over the subsequent 18 months. The orders, funded by the Home Office, allow drug using offenders to be coerced into attending for treatment, to have regular urine tests and to be reviewed by the courts. In Croydon an equal partnership was set up between probation, a local statutory provider of drug services and a voluntary sector agency. Treatment plans were individualised and included a variety of treatment options. Forty-eight orders were imposed mainly for persistent shoplifting. Sixty-three percent of individuals had used heroin and 54% crack cocaine in the 30 days before the order was imposed. Ethical issues raised in coerced treatment were important for the individuals providing treatment although the clients all had to consent to treatment. The pilot programme raised issues about the nature of treatment, clinical responsibility, the selection of clients for orders and the objectives of treatment. Frequent urine testing was problematic but in the vast majority of cases clients were not breached just because of positive tests. The provision of DTTOs in an area created unacceptable inequalities in access to treatment. The paper concludes that partnership working and clear objectives are vital for treatment programmes to operate effectively. More research is needed to explore the most optimum way to deliver treatment in the context of a DTTO.

Research, policy, and the federal role in prevention initiatives for children

With the ability and the funds to implement programs on a national level, federal policy is a potentially potent tool in primary prevention. Despite the U.S. government's history of ambivalence toward intervening in child rearing and limited national support for primary prevention, several initiatives have been implemented for children and families with some measure of success. The successes, however, are mitigated by limitations of the initiatives themselves and by the inconclusive nature of much of the evaluation data. This review of 5 federal policy-based initiatives for children and families provides the backdrop for discussing aspects of federal prevention program design, implementation, policy, and research.