study. Klingberg Family Centers use a continuing education model, bringing in experts to train staff in specialized topics such as attachment disorder. Riverview Hospital for Children and Youth, within the Connecticut Department of Children and Families, launched a training program in cultural diversity after the facility discovered that staff members were more likely to use seclusion and restraint on minority children. And, the Devereux Glenholme School takes a high-tech approach to training. To help staff members assess their crisis prevention and intervention skills, the facility developed a CD-ROM that presents users with various scenarios and then automatically grades their responses. Background information on each child depicted in the program is available by clicking on the child's image; guidance is available from an on-screen "supervisor."

All the sites view training as just one part of the solution, however.

"Even though this is a training grant, it appears that training isn't everything," explained Principal Investigator Darren Fulmore, Ph.D., a research associate at the Child Welfare League. "Knowledge is only half the battle." What's really important, he said, are the expectations of facility managers as embodied in policies and practices.

In Michigan, the Lakeside Treatment and Learning Center's program takes to heart that kind of comprehensive approach. Ongoing training is a crucial part of the center's effort to reduce the use of restraint and seclusion. Focusing on crisis prevention, the training program teaches all staff members skills such as how to de-escalate crises verbally, resolve conflicts, avoid power struggles with children, and recognize what triggers incidents. Children who have been sexually abused or witnessed the abuse of others, for example, may come to the aid of peers being restrained and end up being restrained themselves. A child desperate for human contact may actively seek out restraint just to meet that need- need that could be

better met by building appropriate touch into the child's day. The training program also covers such topics as cultural competency, anger management, and the need to increase consumer involvement. Once trained, staff members receive feedback from mentors with proven de-escalation skills.

While underscoring the potential risks of restraint and seclusion, the program also teaches staff how to use such techniques safely and effectively if they become necessary. All direct-care staff undergo annual certification in physical restraint techniques, with interim training as needed.

Focusing on alternatives to

the use of restraint and seclusion is the real key.

But training is just one part of an overall strategy to reduce the use of restraint and seclusion, said Ms. Friesner. That commitment permeates every aspect of life at Lakeside. Supervisors, for instance, hire staff who have the temperament for relationship-building and then evaluate them in ways that reward those qualities. The center's group therapist, activities coordinator, and other staff members work to keep the children busy and happy. The children themselves learn coping skills, so they can manage their anger, frustration, and other emotions without misbehaving.

Thanks to this comprehensive approach, Lakeside has seen a steady decline in the use of restraint and seclusion. What's more, Ms. Friesner believes that the approach may represent a solution for the field's notoriously

high rate of staff turnover. "Staff members who feel the safest when they feel more in control have resisted the changes," she explained. "But those who believed all along in the primacy of committed relationships have embraced the changes with open arms." Preliminary Results

The project's implementation phase ended and its evaluation phase began in mid2002. According to the project's latest National Evaluation Quarterly Report Card, the average number of seclusion incidents has dropped by more than half. Two sites eliminated their seclusion rooms altogether. continued on page 10

SAMHSA Helps Reduce Seclusion and Restraint continued from page 9

The data on restraint use reveal more mixed results. The one site that submitted data on the use of mechanical restraintsdevices that reduce or restrict an individual's ability to move his or her arms, legs, or head freely-showed dramatic improvement, with incidents falling from 25 per 1,000 patient days to just under 4. The use of physical restraints the application of physical force by one or more people to reduce or restrict an individual's ability to move-rose slightly. However, a closer look at the data reveals that one site's consistently higher incident rate is skewing the numbers. And while the use of restraint is up overall, Dr. Fulmore

Resources

For more information on Grants to Support Restraint and Seclusion Training in Programs That Serve Children and Youth, visit the Coordinating Center's Web site at www.cwla.org/programs/behavior. The site features links to the project's report cards, an annotated bibliography, and other resources. D

notes that all of the non-medical, communitybased sites have reduced its use.

Similarly, the overall number of injuries and rate of injuries per incident are going up for both children and staff members. Again, one site has a disproportionate number of injuries, accounting for almost half of the reported injuries to children and almost 70 percent of injuries to staff.

Behind the Numbers

The Coordinating Center collected valuable data that help explain what's going on behind the numbers. For example, data reveal what kinds of events tend to precipitate interventions. Of the events reported, 60 percent were child-on-staff assaults; 25 percent were property damage; and 22 percent were child-on-child assaults. Several sites tracking non-physical interventions indicate that nearly 37 percent of incidents requiring intervention were de-escalated successfully. The most frequently used strategies employed to de-escalate crises were redirecting the child's attention, using time-outs, and encouraging the child to use self-calming techniques.

Focusing on crisis prevention, the training program teaches all staff members skills such as how to de-escalate crises verbally and resolve conflicts.

To help sustain the project's gains even after the grant ends, the Federation of Families for Children's Mental Health recently provided advocacy training to nine family members from three of the sites. The goal was to help them understand the value and possibilities for family involvement in the project, identify roles for themselves at their sites, and support them in their efforts to get families involved.

"Research shows us change is possible," said Dr. Fulmore. "Now we're looking to see what factors can help us really sustain those changes." ▸

-By Rebecca A. Clay

IN BRIEF...

Events

During the week of January 18, SAMHSA will launch Too Smart To Start, an underage alcohol use prevention initiative aimed at 9- to 13-year-olds and their parents. The initiative focuses on increasing the perception of harm, parent-child communications, and public disapproval of underage alcohol use. The initiative is a product of an interagency agreement between SAMHSA and the Centers for Disease Control and Prevention. (See SAMHSA News, Volume XI, Number 4.) "Too Smart to Start" offers communities technical assistance on a wide range of topics and a variety of materials free of charge. For more information, go to www.ncadi.samhsa.gov.

February 8 to 14 is Children of Alcoholics Week, and SAMHSA will join the National Association for Children of Alcoholics to highlight ways to reach and promote resilience among children and youth living in families with alcoholism. SAMHSA will be sending out materials, including a community action guide, to partner organizations involved in substance abuse prevention. Partners initiate local activities and build support among community leaders and the media to help reach these children and the adults in a position to help them. For more information, go to www.ncadi.samhsa.gov/seasonal/coaweek.

The 12th Annual National Inhalants & Poisons Awareness Week Campaign, sponsored by the National Inhalant Prevention Coalition, is set for March 21 to 27. The campaign is designed to increase awareness about the risks of inhalant use. SAMHSA Administrator Charles G. Curie, M.A., A.C.S.W., will make a presentation at the campaign's kickoff on Thursday, March 18, at the National Press Club. For more information, visit the Coalition's Web site at www.inhalants.org. And, see SAMHSA's online advisory on inhalants at www.samhsa.gov/centers /csat2002/pubs/ms922.pdf. ►

With a scar on her face betraying a history of physical abuse, Helen reported being homeless for 3 years. She had experienced audio hallucinations since girlhood. And, she never received any mental health treatment or managed to benefit from substance abuse treatment.

People like Helen were once thought to be unreachable. But after more than 15 years of study, research shows that homeless people who have mental illness and/or co-occurring substance abuse disorders can indeed benefit from integrated mental health services, substance abuse services, and supportive housing. Now, a forthcoming publication from SAMHSA's Center for Mental Health Services (CMHS) gathers that evidence and offers practical advice for planning, organizing, and sustaining comprehensive services designed to end homelessness. Featuring Helen's story, Blueprint for Change: Ending Chronic Homelessness for Persons with Serious Mental Illnesses and/or Co-Occurring Substance Use Disorders is available in an online version on SAMHSA's Web site. The print version of the book should be available early this year.

"We know what works," said Frances L. Randolph, Dr.P.H., Chief of the Homeless Programs Branch at CMHS, noting that the book will be sent to state officials nationwide. "Now we must put what we know to work. This book will be a useful roadmap for states and communities that are serious about ending chronic homelessness." Step-by-Step Guidance

An estimated 200,000 Americans experience chronic homelessness. More than 40 percent may have substance use disorders, and 20 percent have serious mental disorders. Some homeless persons have both.

Over the years, SAMHSA and other Federal Agencies sponsored research and demonstration programs to determine how to best serve this complex population. In addition, hundreds of community-based providers continue to work on the problem. Together, they have replaced many misconceptions with evidence-based findings. Consider outreach to homeless people with mental illness and/or substance abuse disorders. Once thought of as a nontraditional service, outreach is now recognized as the most important step in connecting such individuals to the services they need. Housing is another consideration. In the past, group homes for people with mental illness were the norm. Now, researchers know that these individuals prefer regular housing and that housing with

Organize Services. Communities don't have to start from scratch to organize services to help homeless people with mental illnesses and substance abuse. This section offers an overview of proven practices that have worked in the field in the past. Also, specific tips are provided on how to make the best use of Federal resources.

Sustain Services. It's often easier to create a new program than it is to sustain an existing program once the original funding ends. Evaluation is a critical step because funding entities need to see that a program is actually achieving its goals. It's also important to know how to put the wide array of mainstream resources to work for people who are homeless.

Blueprint for Change also includes a comprehensive list of additional resources.

According to Blueprint, these types of integrated services helped Helen regain control of her life. Referred by a homeless shelter, she moved into a supportive residential program at the local YMCA. There, she worked with staff on basic life skills like hygiene and food preparation, started seeing a psychiatrist at the on-site mental health clinic, and stopped drinking. Today, she lives in a large studio apartment, happy to be cooking her own meals again and enjoying her own space.

To download a free copy of Blueprint for Change: Ending Chronic Homelessness for

Persons with Serious Mental Illnesses and/or Co-Occurring Substance Use Disorders, go to SAMHSA's National Resource Center on Homelessness and Mental Illness Web page at www.nrchmi.samhsa.gov. For additional free copies, please call the Center at 1 (800) 444-7415. The Center's Web site also features fact sheets; additional publications; information about training and technical assistance opportunities; bibliographies; contact information for national organizations concerned with mental illness, housing, and homelessness; and other resources.

For more specific information related to this topic, contact Fran Randolph at the CMHS Homeless Branch at (301) 443-3706. ► -By Rebecca A. Clay

According to a new SAMHSA report, even when people recognize they are having problems with alcohol or drugs, many do not seek treatment because they are not ready to stop using. Reasons for Not Receiving Substance Abuse Treatment presents data collected by SAMHSA's National Survey on Drug Use and Health (NSDUH), formerly known as the National Household Survey on Drug Abuse. According to the report, many people do not believe they can afford to obtain substance abuse treatment.

The report estimates that about 6 million persons with illicit drug dependence or abuse in 2002 did not seek specialty treatment for their illicit drug use. An estimated 17 million persons in 2002 with alcohol dependence or abuse did not receive specialty treatment. Only 6 percent of those with untreated illicit drug problems and 4.5 percent of those with untreated alcohol problems perceived a need for treatment.

National Survey on Drug Use and Health

The NSDUH Report

November 7, 2003

Reasons for Not Receiving Substance Abuse Treatment

In Brief

In 2002, about 6 million persons
with illicit drug dependence or
abuse did not receive specialty
treatment for their liat drug
problem. Among these untreated
illicit drug abusers, only 6
percent perceived an unmet
need for treatment

In 2002 an estimated 17 million
persons with alcohol
dependence or abuse did not
receive specialty treatment for
their alcohol problem. Among
these untreated alcohol abusers.
only 4.5 percent perceived an
unmet need for treatment

• Among those who perceived an unmet need for treatment, the most common reasons reported for not receiving treatment were not being ready to stop using the substance and the cost of treatment

S

tudies show that many individuals who
have substance se problema do nos

receive treatment for those problem. "

The National Survey on Drug Use and Health NSDUH asks persons aged 12 or older to re port on their mans of dependence on or abuse of alcohol or dhe u drugs Am dicit drug" hacks marijuana hashash, coc sue in chcling crack, inhalwes, hali nogen, heran. ar prescription epe drugs used nemnedir ally NNDUH defines dependence or abune unang cri sena in the American Pyychiatrs. Association s Chagen and Station al Mrinal of Mental Disorders DSM-IV chinchades sach symp toms as withdrawal, teraner use in dangerous susture, trouble with the law, and interference in major obligatiom at work, school or home dearing the past year Table 1

Regondents were abo asked whether they had reed vattent for a militar une prob lem. In these analwes, an indis whizal was defined as receiving treatmem only if he or she reported receiving specialty treatment for alcohol or illicit drugs in the past year Specialty treatment is de Esered at akohol or drug rehabilitation facilities importsevat or chatpazara heita aquatent onds, and mental health centers. It en hades treatment at an emergency room pare doctor office, well help group, prison of jail, or hospital as an outpat. Person are confied

Of the 362,000 untreated persons who recognized the need for treatment for their drug problems, 39 percent indicated that they were not ready to stop using illicit drugs, and 37 percent perceived the cost of obtaining treatment as too high. Of the 761,000 untreated persons who recognized in the past year that they needed treatment

for alcohol problems, 49 percent indicated they were not ready to stop their alcohol use and 40 percent said that cost was a factor in their not receiving treatment.

"It is tragic that a major reason people continue to abuse illicit drugs and alcohol is that they do not believe they can afford appropriate treatment," said SAMHSA Administrator Charles G. Curie, M.A., A.C.S.W. "President George W. Bush has proposed a 3-year 'Access to Recovery' program to provide $200 million more each year for substance abuse treatment. This program would provide someone in need of substance abuse treatment with a voucher to pay for the services. We really need this program if we are to provide treatment to the large numbers who say they cannot afford it."

Reasons for Not Receiving Substance Abuse Treatment is based on interviews with 68,126 respondents in their homes. This NSDUH report is available online at www.DrugAbuseStatistics.samhsa.gov.▸