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restraint

    The Council for Children with Behavioral Disorders

    A Division of the Council for Exceptional Children

    CCBD’S POSITION SUMMARY

    ON

    The Use of Physical Restraint Procedures in School Settings

    Initially Approved by the Executive Committee on 5-17-09

    Revised and Approved by the Executive Committee on 7-8-09

     The document provides policy recommendations of the Council for Children with Behavioral Disorders (CCBD) regarding the use of physical restraint procedures in schools. It includes: (a) an Introduction, (b) a Declaration of Principles, and (c) Recommendations Regarding the Use of Physical Restraint in School Settings. Explanation or elaboration of specific recommendations is provided in italics. A similar and parallel document provides policy recommendations related to the use of seclusion procedures in school settings which is often associated with the use of restraint procedures.

    Introduction

    What is restraint?

    To restrain involves “preventing from doing, exhibiting, or expressing something,” and restraining means “limiting, restricting or keeping under control (Restrain, 2009). In the human services, the term restraint is used with three different types of restraint procedures: (a) mechanical restraint, (b) chemical restraint, and (c) physical restraint.

    One perspective is that seclusion is not part of the “time-out” continuum but is a form of

    restraint. This perspective has been more formally clarified in the new Colorado rules which indicate that the use of seclusion is a restraint. Colorado is now providing greater clarification on how the use of seclusion is different from time-out. This is an area of controversy for some of the practitioners.

    Mechanical Restraint. Mechanical restraint entails the use of any device or object (e.g., tape, ropes, weights, weighted blankets) to limit an individual’s body movement to prevent or manage out-of-control behavior. Mechanical restraints such as handcuffs are universally used in law enforcement, and restraints such as straightjackets and straps have been used in medical and mental health facilities. Mechanical restraints such as tape, straps, tie downs, and a wide variety of other devices have also been used by educators to control student behavior.

    Mechanical restraints to limit behavior should be distinguished from medically prescribed devices whose purpose is to compensate for orthopedic weaknesses to protect the student from falling or to permit the student to participate in activities at school. For example, mechanical restraints have been employed in school settings in situations where students with physical disabilities such as cerebral palsy may be placed in standing tables or chairs with restraints which permit them to participate in educational activities where their muscles or bones would not otherwise permit their participation. Recently, weighted blankets and a variety of other devices have been used with students with autism and attention deficit disorders, apparently to calm them and reduce their hyperactivity but these essentially are a form of restraint. The degree of restriction of these devices varies, and they are not themselves teaching strategies although they may increase the opportunity to learn. None of these devices should be employed in schools unless specifically recommended by an occupational or physical therapist, physician, or school nurse with specific recommendations for lengths of time of use and other circumstances for their use. When prescribed in this way, these assistive devices should not be considered mechanical restraints.

    Seat belts or other restraints in vehicles to promote student safety in school vehicles should also be distinguished from mechanical restraints and should be employed according to state, provincial, and federal policies. Vehicle restraints should not be considered mechanical restraints as described here. Similarly, law enforcement officers using mechanical restraints in accord with appropriate police procedures in school settings should not be considered mechanical restraints for purposes of this document.

    Very little is known about the extent of use of mechanical restraints to control student behavior in school settings. Little is also known about the circumstances when they are used. There are no evaluations of the use of mechanical restraints for students in school. Nevertheless, CCBD, Restraint, July 2009 Page 2 of 21

    anecdotal evidence suggests that mechanical restraints are being used inappropriately in some school settings to control student behavior (National Disability Rights Network, 2009).

    Chemical Restraint. The second category of restraint is chemical restraint. This type of restraint uses medication to control behavior or restrict a patient’s freedom of movement. One example of this type of restraint can occur in institutional or hospital programs where patients who become agitated are provided with medication specifically to control that agitation or other behaviors. A patient may be injected with medication to manage a crisis which is ongoing. This type of restraint is very unlikely in most school settings other than those schools within institutions or hospitals.

    However, the use of medications to manage behavioral symptoms has proliferated, including the widespread use in children of medications whose purpose is at least in part to control behavioral symptoms such as hyperactivity and inattention. As a result, one can conclude that the use of chemical restraints among school children in the United States is widespread. Educators have typically not been directly involved in the decision to employ these types of medications since they must be prescribed by a physician and since parents have the right to manage the medical care of their children. Educators, however, have been criticized for urging (or in some cases requiring) parents to seek medications to control the behavior of their children. Some states, provinces, or school districts have policies which regulate the involvement of educators in making any recommendations to parents regarding medications, and the Individuals with Disabilities Education Act of 2004 prevents schools from requiring the use of medication before receiving special education services. Nevertheless, it is generally agreed that if these medications are to be employed with students, special education teachers or other educational personnel should be involved in assisting physicians and parents where possible in the titration and monitoring of these medications to determine whether they are effective.

    Physical Restraint. The third type of restraint is sometimes referred to as ambulatory restraint, manual restraint, physical intervention, or therapeutic holding but herein is called physical restraint. A physical restraint is defined as any method of one or more persons restricting another person’s freedom of movement, physical activity, or normal access to his/her

    body (International Society of Psychiatric and Mental Health Nurses, 1999). It is a means for CCBD, Restraint, July 2009 Page 3 of 21

    controlling that person’s movement, reconstituting behavioral control, and establishing and maintaining safety for the out-of-control client, other clients, and staff (American Academy of Child and Adolescent Psychiatry, 2000). Physical restraints have been in widespread use across most human service, medical, juvenile justice, and education agency programs for a long period of time. While there have been some who have proposed physical restraint as a therapeutic procedure for some children, this view has no scientific basis and is generally discredited (Day, 2002). Today most schools or programs that employ physical restraint view it as an emergency procedure to prevent injury to the student or others when a student is in crisis, although there is some evidence that it is actually employed for various other purposes including student compliance to adult commands (Ryan & Peterson, 2004). While historically the use of these procedures in education has typically been in special education programs, these procedures are now widely believed to be used more broadly with any student and may be viewed as a part of the overall school program. Although data about the extent or circumstances of the use of physical restraint procedures in schools at the present time is not available, most believe that the use of these procedures in schools has increased as more students with difficult or severe behavioral needs are being served in general education schools and classes.

Focus on Physical Restraints

    Although some recommendations will be made in this document regarding mechanical and chemical restraints in schools, the primary focus of these recommendations relates to physical restraint procedures in schools.

What is the purpose of physical restraint?

     The purpose of physical restraint is to control the behavior of a student in an emergency situation to prevent immediate danger or possible injuries to that student or others in the environment. While preventing property damage is sometimes included as a purpose for physical restraint, most professionals do not include that as a legitimate purpose of these procedures.

CCBD, Restraint, July 2009 Page 4 of 21

What are the problems with the use of physical restraints?

     The Hartford Courant, a Connecticut newspaper, reported 142 restraint-related deaths

    occurred in the United States over a 10-year period in the 1990s, 33% of which were caused by asphyxia (Weiss, 1998). The Government Accounting Office in 1999 stated that an accurate estimate of deaths or injuries due to restraint was impossible since only 15 U.S. states have established reporting procedures for such incidents (U.S. Government Accounting Office, 1999). The Child Welfare League of America estimated that between 8 and 10 children in the U.S. die each year due to restraint procedures while numerous others suffer injuries ranging from bites, damaged joints, broken bones, and friction burns (Child Welfare League of America, 2000). A recent report from the National Disability Rights Network has graphically enumerated a wide variety of abuses of physical restraint procedures in school settings, with many resulting in death or injury (National Disability Rights Network, 2009). There is no precise or scientific way to measure the number or extent of the injuries to children or injuries to staff as a result of the use of physical restraint. These deaths and injuries continue to occur in the present in a variety of child care institutions, including public schools that employ physical restraint procedures.

     In addition to physical injury there are strong beliefs that psychological injury may also occur, particularly for those children who have experienced prior abuse by adults. There has also been attention to the psychological effects on those conducing restraints. These effects may range from short-term such as fear and an adrenaline rush of physical confrontation to long-term effects such as Post Traumatic Stress Disorder. While there is little research data to support this hypothesis, it is both plausible and supported by numerous anecdotal reports by those who have been restrained or engaged in restraining. In other contexts, no one questions such effects in connection with circumstances such as medical emergencies, physical assaults, or muggings.

     As a result of this situation, the federal government in the U.S. and many states are considering policy development or policy changes related to the use of restraint procedures in schools.

    What are the standards for using physical restraint?

    In most medical, psychiatric, and law enforcement applications, strict standards govern the use of physical restraint and seclusion. Hospitals and treatment centers which receive federal funds in the U.S. are governed by federal legislation regulating their use of restraint. Often CCBD, Restraint, July 2009 Page 5 of 21

    accreditation requirements from governing bodies such as the Joint Commission on Accreditation of Healthcare Organizations or other agencies such as the National Association of Psychiatric Treatment Centers for Children (Cribari, 1996) and the American Academy of Pediatrics (American Academy of Pediatrics, 1997) address the use of restraints. These requirements have resulted in widespread training and certification of staff in the medical and psychiatric programs that employ physical restraints, and many of these types of programs have attempted to reduce drastically their use of these procedures as a result of the deaths and injuries related to their use.

    Unfortunately, there has been no such accreditation requirement from national professional organizations in education for the use of these procedures in schools. The lack of these commonly accepted written standards in the school’s use of physical restraint leaves school settings more susceptible to misunderstanding, improper implementation, and abuse. Recent examinations of state policies or guidelines have found a substantial numbers of states have no regulations or guidelines for the use of these procedures in school settings, and those states which do have some policies or guidelines vary tremendously in their content (Ryan, Robbins, Peterson, & Rozalski, in press). No similar analysis has been conducted in Canada. To make matters worse, school staff may lack training regarding effective behavioral interventions necessary for the prevention of emotional outbursts typically associated with students who have severe behavioral problems (Moses, 2000). Such interventions are critical in preventing student behavior from escalating to potentially dangerous levels where restraint may be needed. Why has the use of physical restraint in education become an issue?

    Injuries and deaths associated with the ongoing use of physical restraint in school settings have come to the attention of the public along with the concern that these procedures violate basic human rights. As a result there is increasing awareness of the abuse of these procedures in school settings and increasing concern by protection and advocacy organizations and by parents.

    In addition, a confluence of problems in the educational system may be contributing to the misuse of restraint. Several factors have resulted in physical restraint being thrust into the mainstream of public education. Many students with emotional or behavioral problems, regardless of disability label, are now being “included” in public school environments, frequently in regular schools and classes. These students often have a history of serious psychiatric and CCBD, Restraint, July 2009 Page 6 of 21

    behavioral problems and need varying levels of supports for behavioral and academic difficulties. The use of procedures like physical restraint have moved with these students from therapeutic placements to more typical school and classroom settings and may be used more frequently in school settings than ever before, in part because these students are being served in environments where specialized supports are not well known and are not widely used. Teacher shortages and the movement to “generic” special education training for teachers may have resulted in school staff with limited or no training or experience with severe behavior disorders or the issues involved in employing physical restraint procedures. Additionally, high profile media attention has challenged schools to prevent or contain school violence, and physical restraint may be viewed as one intervention for this purpose (Skiba & Peterson, 2002). Physical restraint is often the first response in the face of actual violence such as fights and may even be a first-line intervention when there is potential for violence such as in incidences of verbal threats, threatening gestures, or intimidating behaviors.

What does research say about the use of physical restraint in schools?

    Very little research has been conducted on the prevalence, appropriate applications, or efficacy of physical restraint. Almost no research has been conducted on the use of physical restraint in school settings. We do not know how widely physical restraint is used in the schools or for what purposes. We do not know the extent or nature of student injuries occurring when physical restraint has been used in school settings, although it is becoming widely known that prone restraint where a child is laying on his/her stomach is a dangerous type of restraint (National Disability Rights Network, 2009). We do not know the extent or nature of teacher or staff injuries during restraint. We have no data about the type of physical restraints that are most commonly employed or the nature and extent of training received by educators who apply physical restraint. While most professionals view restraint as an emergency procedure, little is known about its intended purpose or outcomes when it is employed, let alone whether it achieves that purpose or is effective in achieving the desired outcomes. This dearth of information about nature, use, and outcomes of physical restraint is of great concern, particularly given the U.S. mandates of No Child Left Behind and IDEA 2004 and the fact that all educators are to rely on evidence-based practices that are supported by scientific research.

CCBD, Restraint, July 2009 Page 7 of 21

    Declaration of Principles

     Given the current situation related to the use of physical restraint procedures in school settings, the Council for Children with Behavioral Disorders wishes to support a set of guiding principles which, if fully implemented, would significantly diminish the need to use restraint procedures in school settings. These principles are adapted in part from the Declaration of Principles by the Council of Parent Attorneys and Advocates (COPAA, 2008). To highlight their importance, the principles provide a preface to the recommendations CCBD is making regarding physical restraint, and CCBD feels that these principles should be reflected in the goals and policies of schools. CCBD supports the principles which follow as part of its recommendations regarding physical restraint.

    Declaration of Principles:

    ; Behavioral interventions for children must promote the right of all children to be treated

    with dignity.

    ; All children should receive necessary educational and mental health supports and

    programming in a safe and least-restrictive environment.

    ; Positive and appropriate educational interventions, as well as mental health supports,

    should be provided routinely to all children who need them, and school staff should be

    trained to employ these techniques.

    ; Behavioral interventions should emphasize prevention and creating positive behavioral

    supports.

    ; Schools should have adequate staffing levels to effectively provide positive supports to

    students and should be staffed with appropriately trained personnel.

    ; All staff in schools should have mandatory conflict de-escalation training, and conflict

    de-escalation techniques should be employed by all school staff to avoid and defuse crisis

    and conflict situations.

    ; All staff should have mandatory training in the use of positive behavior supports for

    student behavior and in preventive techniques for addressing student behavior.

    ; Schools should have adequate staffing levels to effectively provide positive supports to

    student and should be staffed with appropriately trained personnel.

CCBD, Restraint, July 2009 Page 8 of 21

    ; All children whose pattern of behavior impedes their learning or the learning of others

    should receive appropriate educational assessment, including Functional Behavioral

    Assessments followed by Behavioral Intervention Plans which incorporate appropriate

    positive behavioral interventions, including instruction in appropriate behavior and

    strategies to de-escalate their own behavior.

    For physical restraint to be used effectively, it is essential that behavioral interventions which might prevent the need for restraint are in place. Included among these should be a variety of positive behavior supports including establishing and teaching behavioral expectations (acknowledging that for many students, this may require deliberate targeted instruction in what the behavioral expectations mean since being able to repeat the expectations does not necessarily guarantee the student understands them) , recognizing and reinforcing positive behavior, providing mental health services and interventions, and relying on functional behavioral assessment and related intervention plans for any student whose behavior indicates a need for intervention. Lack of resources to provide appropriate kinds of services should never be an excuse to employ restraint procedures. Without positive behavior supports, the number of “emergency” situations which might require restraint would be much greater than would

    otherwise be necessary.

    Conflict de-escalation appears to be a crucial intervention needed to prevent the use of restraint as well as useful generally to prevent and defuse behavior problems for students with emotional or behavioral disorders and for all students who may engage in power struggles or escalate emotional crises. As a result this is an area of training which should be provided to all educators and school staff members, not just those in special education, and should be a part of school curriculum for students.

CCBD, Restraint, July 2009 Page 9 of 21

    Recommendations regarding

    “Restraint Procedures” in School Settings

    Restraints should be used in school settings only when the physical safety of the student or others is in immediate danger. Restraints should not be viewed exclusively as an issue related to special education. Restraint procedures are employed in school settings with some students who are not in special education. Therefore, regulation and procedures should apply to all students, not just students in special education. The following are CCBD recommendations related to the use of restraints when employed in school settings.

Mechanical Restraints

    Mechanical restraints should never be used in school settings when their purpose is to manage or address student behavior.

    ; Mechanical restraints should only be used in schools for the purpose of providing

    mechanical support to students’ orthopedic needs in order to permit them to learn and

    participate in school activities.

    ; Use of mechanical restraints should only be under the supervision of and with a written

    order by a physician, occupational therapist, or physical therapist.

    ; Use of these devices for a student in special education should be included in the student’s

    IEP and with parent permission.

    ; There are two other exceptions: (a) Vehicle safety restraints should be used according to

    state, provincial, and federal regulations, and (b) mechanical restraints employed by law

    enforcement officers in school settings should be used in accord with their policies and

    appropriate professional standards.

Chemical Restraints

     Medications should never be used as chemical restraints or solely by school personnel to manage or address student behavior.

    ; Prescription medications delivered to students during the school day should be

    administered only following a written protocol provided by a physician and with the

    knowledge and support of the parent.

    CCBD, Restraint, July 2009 Page 10 of 21

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