for funding. In addition, Dr. Sullivan hopes

that the new structure will enable SAMHSA to provide more time between the publication of NOFAS and the due date for applications.

According to Dr. Sullivan, the ultimate goal of redesigning the grants process is “to advance the SAMHSA mission of building resilience and facilitating recovery for citizens affected by substance abuse and mental health issues." Clarifying SAMHSA's expectations through the use of standard grant announcements will advance

applicants' understanding of the Agency's needs and priorities. Stronger applications and additional SAMHSA support can lead to better developed and better documentedcommunity-based programs.

"A clearer process," says Dr. Sullivan, "will help SAMHSA communicate goals and expectations more easily, and will help the field work with us more effectively. Good communication will help grantees learn and share the knowledge they gain. And, through that shared knowledge, we can advance the field of substance abuse and mental health services. Our collective knowledge is one of our greatest resources."

In addition to communicating more clearly with local, state, and communitybased organizations, SAMHSA intends the new grants process to facilitate cooperation across and within the three SAMHSA Centers. Using standard Services or Best Practices announcements, for example, the Centers could collaborate to develop a NOFA for programs targeting individuals with co-occurring mental and substance abuse disorders. The standard announcements will thereby assist SAMHSA in developing new field-ready programs.

SAMHSA staff, who will no longer be required to develop full grant announcements for each of several grant programs, will be better able to assist applicants and grantees in developing applications and delivering services.

"We want to shift staff energy from the front end of the process-writing and reviewing funding announcements-to emphasize grantee support, program productivity, and client outcomes," says Dr. Sullivan. "Preserving staff resources for grant monitoring and support will enable SAMHSA to help grantees more effectively solve problems they encounter as they activate their programs; help one another through their lessons learned; and help themselves through the development and implementation of evaluations that more clearly communicate the efficacy and cost efficiency of their programs."

For more information about the four new SAMHSA standard grant announcements and

the changes to SAMHSA Discretionary Grant Funding Opportunities, visit www.samhsa.gov/grants. This Web site also includes a downloadable manual on developing competitive SAMHSA grants, which contains a glossary of terms, references, and additional Web resources. A list of 2003 grant awardees is available at www.samhsa.gov/grants, along with dates for upcoming grant-writing training and technical assistance workshops for community-based, faith-based, and grassroots organizations across the Nation. ▷

-By Melissa Capers

During the grants re-engineering process in 2003, all of SAMHSA'S discretionary grant programs were reviewed and most were placed in one of the following four broad categories for funding.

Services Grants address gaps in services and/or increase the applicant's ability to meet the unmet needs of specific populations and/or specific geographical areas with serious, emerging problems. Up to 20 percent of grant funds may be used to monitor services and costs, and up to 15 percent of grant funds may be used to develop infrastructure for service delivery. Planned services should be evidenced-based, and should begin within 4 months of the grant award.

Infrastructure Grants increase the capacity of the mental health and/or substance abuse service systems through needs assessments, the coordination of funding streams, and/or the development of provider networks, workforces, data infrastructure, etc. Up to 15 percent of grant funds may be used to conduct implementation pilots to

assess the effectiveness of these changes on service delivery.

• Best Practices Planning and Implementation Grants help grantees identify substance abuse treatment and prevention and mental health practices that could effectively meet local needs, develop plans for implementation of these practices, and pilot-test practices prior to full-scale implementation. Planning and consensus building activities will be supported for up to 18 months, and up to 3 years of pilot testing and evaluation may be supported.

Service-to-Science Grants support and evaluate innovative practices that are already in place. Funds may be used to stabilize and document the practice prior to a full evaluation.

A few funding opportunities will continue to be announced as stand-alone Requests for Applications. All current funding opportunities are announced in the Federal Register, the Federal grants Web site at www.grants.gov, and the SAMHSA Web site at www.samhsa.gov/grants.▸

SAMHSA Helps Reduce Seclusion and Restraint

continued from page 1

use of seclusion and restraint in nonmedical, community-based, residential and day treatment facilities for children and youth. Lakeside and four other grantees across the country are developing methods to train staff who work with children and youth in facilities providing mental health services (see SAMHSA News, p. 9). The Child Welfare League of America, in collaboration with the Federation of Families for Children's Mental Health, serves as the project's coordinating center. Together, the coordinating center and demonstration sites are developing best practices in training to reduce the use of restraint and seclusion.

"Restraint and seclusion represent treatment systems' failures," said CMHS Director A. Kathryn Power, M.Ed. "Through this initiative and others, consumers of mental health services will have improved opportunities for recovery."

Emphasis on Training

Over the last decade, investigations revealed that inappropriate use of restraint and seclusion can result in psychological trauma, physical injury, or even death (see "Breaking the Bonds," SAMHSA News, Volume XI, Number 2). Children are at especially high risk.

Now, a patchwork of state laws and a series of Federal regulations and laws have been established to try to prevent such problems. The Children's Health Act of 2000

"Restraint and seclusion represent treatment systems'

failures."

-A. Kathryn Power, M.Ed. CMHS Director

requires SAMHSA and the Centers for Medicare & Medicaid Services (CMS) to develop regulations governing use of restraint and seclusion in health care facilities receiving Federal dollars and in non-medical, community-based facilities for youth.

As part of its Conditions of Participation, CMS already established standards that prohibit hospitals and residential psychiatric treatment facilities for people under age 21 from using restraint and seclusion except to ensure safety during emergencies. The regulations also require facilities to report deaths, debrief staff and consumers after incidents, and provide education and training to staff.

That last requirement is especially important, said Paolo del Vecchio, M.S.W., Associate Director for Consumer Affairs at CMHS. Because of the field's high turnover rates, staff may not receive adequate training. "Staff members need ongoing training on seclusion and restraint-most importantly, in how to prevent the use of such techniques in the first place," said Mr. del Vecchio. "Focusing on alternatives to the use of restraint and seclusion is the real key."

And that's just what the CMHS grants do. The program's goals are to develop a range of effective models for training professional and support staff in the appropriate use of restraint and seclusion and to analyze the training's impact on use, safety, and other outcomes. A Range of Approaches

Demonstration sites were chosen with diversity in mind, said SAMHSA project officer Karen Saltus Armstrong, M.S.S.W., J.D., of the Protection and Advocacy Section of the CMHS Division of State and Community Systems Development. "The demonstration sites are quite different in terms of the populations they serve, locations, and other factors," said Ms. Armstrong. "We're hoping to come out of this project with many different training models." For example, the three Connecticut facilities that joined together for the CMHS grant exemplify the range of models under

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- -a 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

Demonstration Sites

SAMHSA awarded Grants to Support Restraint and Seclusion Training in Programs That Serve Children and Youth to a wide range of programs:

Connecticut Collaboration for Training Excellence, which encompasses the Klingberg Family Centers in New Britain, the Devereux Glenholme School in Washington, and the Riverview Hospital for Children and Youth within the Connecticut Department of Children and Families, in Middletown

Girls and Boys Town National Resource and Training Center in Boys Town, NE, in partnership with the A.B. and Jessie Polinsky Children's Center, a public emergency shelter for children and youth, operated by the city of San Diego, CA

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. ▸

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