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Physical Restraint in School
Joseph B. Ryan, Doctoral Student, and Reece L. Peterson,
Professor, Department of Special Education and Communication
Disorders, University of Nebraska-Lincoln
ABSTRACT: The current emphasis on educating children in the least
restrictive environment has resulted in the use of physical
restraint procedures across all educational placement settings,
including public schools. Since its initial use, restraint has been
controversial. Professionals who use physical restraint claim that
it is necessary to safely manage dangerous behaviors. Child
advocates, however, argue that far too many children suffer injury
and death from the very staff charged with helping them. The authors
review research literature, legislation, and court decisions on
topics related to the use of restraint in schools and identify
position statements and recommended practices from nationally
recognized professional organizations and advocacy groups.
Recommendations are given for research, policy, and procedures for
the use and practice of physical restraint in schools.
A
headline of the Austin, Texas, American-Statesman Staff stated that
a 14-year-old boy died after being restrained in a classroom by his
teachers. According to a preliminary autopsy, the child succumbed to
an intense amount of pressure to his chest (Rodriguez, 2002).
Unfortunately, newspapers across the nation carry similar stories.
The exact number of deaths caused by physical restraint remains in
dispute. The Hartford Courant, a Connecticut newspaper, reported
that 142 restraint-related deaths, 33% of which were caused by
asphyxia, occurred in the United States over a 10-year period
(Weiss, 1998). The U.S. Government Accounting Office (GAO) stated in
1998 that an accurate estimate was impossible because only 15 states
had established reporting procedures for such incidents. Based on
the information available, the GAO estimated that there were 24
restraint-related deaths in the United States among children and
adults in 1998 (U.S. Government Accounting Office, 1999). More
recently, the Child Welfare League of America (CWLA) estimated that
between 8 and 10 children in the United States die each year due to
restraint, while numerous others suffer injuries such as bites,
damaged joints, broken bones, and friction burns (CWLA, 2002). There
is no precise way to measure the number or extent of the injuries to
children and also to staff as a result of the use of restraint.
In
this article we review and provide a brief summary of research
literature, legislation, and court decisions related to physical
restraint used in school settings. We also identify position
statements and recommended practices from nationally recognized
professional organizations and advocacy groups. Finally, we make
recommendations regarding needs for research, policy, and procedures
for the use of physical restraint in schools.
Definition
As a
professional term, restraint is defined as any physical method of
restricting an individual's freedom of movement, physical activity,
or normal access to his or her body (International Society of
Psychiatric and Mental Health Nurses, 1999). The term is sometimes
used to address three different types of restraint procedures:
mechanical, ambulatory, and chemical. Mechanical restraint entails
the use of any device or object (e.g., tape, tiedowns, calming
blanket, body carrier) to limit an individual's body movement to
prevent or manage out-of-control behavior. Ambulatory restraint is
also known as manual restraint or "therapeutic holding" (American
Academy of Pediatrics Committee on Pediatric Emergency Medicine,
1997). It involves one or more people using their bodies to restrict
another individual's body movement as a means for reestablishing
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). Finally, chemical restraint
uses medication to control behavior or restrict a patient's freedom
of movement. This type of restraint is typically used only in
institutional or hospital programs; it has evolved only in the past
40 years as a result of developments in psychotropic medications.
Today,
physical restraint is used in numerous professional settings
including medical and psychiatric facilities, law enforcement and
correctional facilities, and schools. These different types of
restraint can be used with both adults and children in the event of
emergency situations stemming from aggressive, violent, or dangerous
behavior or as a precaution against such behavior.
The
primary focus of this article is on the use of ambulatory or manual
restraint as an intervention by educators in schools. There are
numerous instances in which mechanical restraint has been used in
educational settings, but its use will be addressed only in the
context of some court decisions and policies that relate to physical
restraint. While some might include confinement, such as that which
occurs in time-out rooms, as a form of mechanical restraint, it is
beyond our scope to address that controversial issue here. Since
chemical restraint is not typically used in schools, it is not
addressed here.
History
The
use of physical restraint originated in the psychiatric hospitals of
France during the late 18th century. Restraint procedures were
developed by Philippe Pinel and his assistant Jean Baptiste Pussin
for the same intent it is used today, as a means of preventing
patients from injuring themselves or others (American Academy of
Child and Adolescent Psychiatry, 2000; Fisher, 1994; Weiner, 1992).
From
their initial usage, mechanical and manual restraint have been
controversial procedures. Almost immediately after the procedures
became popular, a nonrestraint movement was started in England in an
attempt to prevent physical and often brutally aversive mechanical
restraint from being used on psychiatric patients in hospitals
(Jones, 1972; Masters et al., 2002; Scull, 1979). In response, a
Lunacy Commission was established in 1854 to monitor and regulate
the use of seclusion and restraint in asylums. In contrast to
England's decreased use of restraint during this time frame, the
United States viewed physical restraint as a form of therapeutic
treatment and adopted it as an accepted practice for dealing with
violent patients (Masters et al., 2002; Tomes, 1988).
For
many years, law enforcement and correctional agencies have employed
physical restraint and related conflict deescalation procedures as
tools in apprehending and managing prisoners. Physical restraint
also has a long history in hospitals and psychiatric institutions,
particularly in the clinical treatment of violent persons (Romoff,
1985). The use of physical restraint has been applied to children
with emotional disturbance since the 1950s, and it was included in a
list of "techniques for the antiseptic manipulation of surface
behavior" compiled by Redl and Wineman (1952). Redl and Wineman
stated explicitly that physical restraint should not be used as, nor
should it be associated with, physical punishment. They stated that
a child's loss of control should be viewed as an emergency situation
in which the educator or clinician should either remove the child
from the scene or prevent the child from doing physical damage to
himself or herself or others. The person performing the restraint
should remain calm, friendly, and affectionate while attempting to
maintain a positive relationship with the child, thereby providing
the opportunity for therapeutic progress once the child's crisis
subsides.
Standards and Guidelines for Using Restraint
In
most medical, psychiatric, and law enforcement applications, strict
guidelines govern the use of physical restraint. Often these
standards include 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 (1997). These requirements have
resulted in widespread training and certification for staff in these
programs.
Unfortunately, there has been no such accreditation requirement for
schools or many other child care agencies. The lack of these
commonly accepted guidelines or accreditation standards in schools
makes those who use physical restraint more susceptible to
misunderstanding and abuse, let alone improper implementation. To
make matters worse, school staff may lack training in effective
behavioral interventions necessary for the prevention of emotional
outbursts that are typically associated with children 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.
Use of
Restraint in Education
Once
thought of as an exclusive tool of psychiatric institutions,
physical restraint has been thrust into the mainstream of public
education. This is, in part, due to the Individuals with
Disabilities Education Act (IDEA), which established the principle
of serving children with special needs in the least restrictive
environment. Many students with emotional or behavioral problems,
regardless of disability label, are now being included in public
school environments, frequently in general education schools and
classes. The physical restraint procedures have moved with the stude\nts
to more typical school and classroom settings. In addition, because
of high-profile media attention, schools are now challenged to
demonstrate practices that prevent or contain challenging and
sometimes violent behaviors. Physical restraint may be one element
of these practices (Skiba & Peterson, 2002).
Professional Training Programs
Currently, most training in physical restraint for schools and other
child care agencies is done by a handful of organizations that
specialize in this type of training, usually in conjunction with
other strategies for conflict deescalation and problem solving. (See
Table 1 for a list of representative organizations and contact
information.) It is beyond our scope here to describe the
similarities or differences in these programs, but most include
procedures for conflict deescalation as well as holds and procedures
for physical restraint.
Most
of these programs evolved from training programs for staff at
residential treatment and psychiatric facilities or from psychiatric
hospitals, but these organizations now offer their extensive
training programs to various agencies, including schools. After the
initial training, they provide recurrent training, sometimes through
a local person certified in that particular program.
Research on Restraint
We
conducted an extensive search to identify articles related to
physical restraint. We searched computer databases of the Education
Resources Information Center (ERIC), LEGAL-TRAC, psychINFO, and
FindArticles for relevant articles. Keywords used in the computer
search included restraint, physical restraint, therapeutic holding,
ambulatory restraint, and mechanical restraint. In addition, we
conducted a hand search of studies published between 1970 and 2002
from the following journals: Journal of Psychosocial Nursing,
Journal of Special Education, Journal of Emotional and Behavioral
Disorders, Behavioral Disorders, and Exceptional Children. Finally,
we performed an ancestral search by checking the citations from
relevant studies to determine whether any of the articles cited
would qualify for inclusion in this review. Literature related to
restraint in the field of geriatrics was not reviewed.
After
conducting an extensive search, we identified 26 articles. These
included three articles that reviewed the legal aspects of restraint
(Coffin, 1999; Kennedy & Mohr, 2001; Lohrmann-O'Rourke & Zirkel,
1998) and five articles reviewing the use of physical restraint
(Day, 2002; Fisher, 1994; Soloff, Gulheil, & Wexler, 1985; Wright,
1999). While there were 15 experimental research studies
investigating the use of restraint with children, only 3 were
conducted in school settings (Grace, Kahng, & Fisher, 1994; Magee &
Ellis, 2001; Ruhl & Hughes, 1985). The majority of studies were
conducted in either a psychiatric facility or a hospital (Barlow,
1989; Hunter, 1989; Jones & Timbers, 2003; Miller, Walker, &
Friedman, 1989; Persi & Pasquali, 1999; Petti, Mohr, Somcrs, & Sims,
2001; Swell, Michaels, & Cole, 1989).
The
last five studies were conducted with children and adolescents
suffering from severe autism or mental retardation and focused on
attempting to reduce the use of mechanical restraint for the
prevention of self-injurious behaviors (SIB; Favell, McGimsey &
Jones, 1978; Fisher, Piazza, Bowman, Hanley, & Adelinis, 1997;
Luiselli & Waldstein, 1994; Milliken, 1998; Wallace, Zouh & Gaff,
1999). Finally, we found eight position papers offering guidelines
for the proper use of restraint with children (Cribari, 1996;
Luiselli, & Waldstein, 1994; Milliken, 1998; Mohr & Anderson, 2001;
Ross, 2001; Schloss & Smith, 1987; Selekman & Snyder, 1997; Stirling
& McHugh, 1998).
TABLE
1
Representative Training Programs on Ambulatory Restraint
Prevalence of the Use of Physical Restraint
After
an extensive search, we were unable to identify any research
indicating how widespread the use of restraint in schools has
become. Anecdotal information based on court cases and legislation
seems to indicate that it has become common at least for larger
school systems to have some staff performing physical restraint in
public school settings.
While
studies regarding the prevalence of physical restraint procedures in
more restrictive settings were also limited, Day (2002) asserted
that the use of these procedures in residential settings has become
commonplace. A survey of frontline child care workers from
psychiatric facilities found that restraint was used frequently,
with 34% of staff reporting to have used these procedures more than
twice per week (Hunter, 1989). Currently the accreditation of
psychiatric hospital programs requires written procedures and
training on these topics, presumably meaning that these procedures
are commonplace in these settings as well. An early study conducted
within an adolescent psychiatric unit found that 23% of the
population experienced at least one restraint during an 18- month
period. Additional findings of interest included higher occurrences
of restraint on Mondays and Fridays due to what the authors called
"weekend anxiety." Researchers also reported that restraint was more
common among younger children, perhaps because they possess fewer
mechanisms for coping with frustration. Male staff members were more
likely to initiate restraint than females (Miller et al., 1989).
One
study performed by Persi and Pasquali (1999) tracked the frequency
of physical restraint used among 281 children ages 4 to 1 7 who were
placed in four different types of segregated settings: psychiatric
inpatient unit, residential group home, day treatment program, and
day treatment program located in community schools. The study found
that 107 restraints were performed throughout the year. The
incidence of restraint varied among settings, with the group home
and day treatment programs using the procedure more frequently than
either the community day treatment program or inpatient unit. The
study also found lhcit males were slightly more likely Io be
restrained than females, and there was a mild significant
relationship between age and restraint. Researchers did not find a
linear relationship with age but noted that the onset of adolescence
brought about an abrupt increase in the level of restraint
administered. Surprisingly, in direct contrast to earlier findings,
the study found that female staff initiated a larger number of
restraints than their male counterparts. When comparing the use of
restraint among placement settings, the study concluded that the
pattern of physical restraint in actual settings is highly variable
and difficult to explain, requiring additional studies.
Physical restraint has not been researched as an educational
intervention (Selekman
& Snyder, 1997). A review of literature found several journals that
had published articles regarding restraint, but most articles
focused on addressing the controversial nature of the procedure. One
of the first studies on reducing restraint was performed by Swett,
Michaels, and Cole (1 989), who investigated whether the passage of
a Massachusetts state law addressing restraint effectively reduced
the number of chemical restraints and seclusionary procedures used
in a juvenile psychiatric facility. The researchers found that while
the number of chemical restraints had decreased significantly, the
number of physical restraints had actually increased. A later study,
by Berrios and Jacobowitz (1998), was conducted in a psychiatric
inpatient unit with children ranging in age from 5 to 12 years being
restrained with therapeutic holds (e.g., ambulatory restraints). The
study claimed that therapeutic holding reduced the duration of a
child's behavioral episode only slightly but was effective in
reducing the number of other restraints performed by 15.9%.
Situations or Behaviors That Prompt Use of Restraint
We
identified only one study (Petti et al., 2001) that examined the
circumstances when physical restraint was employed. Researchers
debriefed both staff and clients following 81 incidents of restraint
in a psychiatric hospital setting. Findings of interest included
staff reporting that 65% of restraints were initiated due to a
perceived safety threat, while 19% were the direct result of patient
noncompliance. An interesting finding from patient interviews was
that a staff member threatening time-ouls was a causal factor for
escalated levels of aggressive behavior. This may suggest that
patients perceive time-outs as a coercive intervention.
Unfortunately, no similar studies were performed in a school
environment. What is recognized by the professional community is
that physical restraint is a widely used protective procedure, often
implemented for a variety of reasons including prevention of
violence, self-injurious behavior, and injury or property damage due
to temper tantrums, as well as a response to noncompliance. However,
physical restraint has long been considered to be a behavior
management technique appropriate for teachers when crisis behavior
occurs (Fagen, 1996; Rizzo & Zabel, 1988), and it may be used for a
much wider set of student behaviors such as preventing children from
leaving a classroom or school grounds or from destroying private or
school property. One study conducted with teachers of students with
emotional or behavioral disorders (E/BD) in public schools found
that many had used restraint either as part of a planned behavioral
intervention or as a spontaneous reaction to aggressive behavior (Ruhl
& Hughes, 1985). The study reported that 71% of these teachers used
physical restraint with their students if they displayed aggression
toward others, 40% to prevent self-abuse, and 34% to prevent
destruction of property.
Efficacy of Restraint Procedures
Despite the belief that physical restraint is a commonly used
procedure in schools serving children with E/BD, little is known
about its efficacy, due to a lack of research (Persi & Pasquali,
1999). Few of the prop\onents of physical restraint have claimed
that the procedure has any therapeutic value in and of itself.
However, proponents of therapeutic holding justify restraint
procedures through the attachment theory developed during the early
to mid 1970s (Bowlby, 1973; Cline, 1979; Zaslow & Menta, 1975). Day
(2002) reviewed these theories and for the most part concluded that
there was very little empirical support for therapeutic benefits to
children receiving restraint. Most of the studies located were of
poor quality and relied upon "unverifiable, and hence questionable,
anecdotal evidence and case reports" (Day, 2002, p. 272). There was
also no evidence for any potential side effects of restraint. While
some might believe that children diagnosed with E/BD who are exposed
to restraint on a daily basis could be humiliated by such highly
aversive procedures, there is no scientific evidence of
psychological damage or harm beyond the clear physical danger of
injury or death. Instead, restraint is usually viewed as a physical
safety mechanism that may permit continuation of other therapeutic
interventions once the restraint is completed. Most educational
textbooks dealing with aggressive or violent behavior of students
with E/BD suggest that physical restraint might be warranted for
purposes of safety despite a lack of empirical research supporting
such claims.
Summary of Research
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 restraint in school settings. We do
not know how widely physical restraint is used in the schools, the
extent or nature of injuries occurring when it has been used in the
schools, or its effectiveness in achieving the desired outcomes.
Policy
Related to Restraint
An
extensive search was conducted to identify court or hearing officer
decisions, as well as legislation related to physical restraint. To
identify cases that have dealt with restraint, we conducted a search
of legal databases (i.e., Federal Supplement, which lists all
Federal Trial Court decisions; Federal Reporter 3rd Series, listing
all Middle Appellate Court decisions; United States Reports, the
official publication for all U.S. Supreme Court rulings; LEGALTRAC,
a database that indexes law reviews and other legal periodicals;
Individuals with Disabilities Education Law Report [IDELR], a
specialty law reporter that publishes case law specific to special
education, including some hearing officer reports). The results of
this search are described in the following sections.
Legislation
The
passage of the Children's Health Act of 2000 established national
standards regarding the use of physical restraint with children in
psychiatric facilities. Unfortunately, this legislation did not
affect schools. Five states-Massachusetts, Colorado, Illinois,
Connecticut, and Texas-have passed legislation over the past several
years addressing the use of physical restraint with children in the
school environment. Texas is the most recent state to do so
(Amendments to 19 TAC Chapter 89, 2002), while one additional state,
Maryland, has proposed legislation on this topic. Although state
guidelines differ, the legislation typically contains many similar
elements including (a) definitions of terms common to physical
restraint, (b) required procedures and training for staff, (c)
conditions when physical restraint can and cannot be used, (d)
guidelines for the proper administration of physical restraint, and
(e) reporting requirements when restraint is employed.
Court
and Hearing Officer Decisions
Over
the years, parents and advocacy groups have filed numerous lawsuits
and/or grievances against school districts and psychiatric units
regarding the use of restraint on children. Plaintiffs have
typically argued that restraint violates an individual's rights
under the Eighth Amendment, which prohibits administering cruel or
unusual punishment, and the Fourteenth Amendment, which provides for
an individual's liberty interests in freedom of movement and
personal security (Kennedy & Mohr, 2001). Cases resulting from these
complaints have been lodged through state education agency hearings
(e.g., under IDEA or state school disciplinary laws), with the
Office for Civil Rights (OCR) in the U.S. Department of Education,
and through state and federal court cases.
While
the constitutional issues mentioned earlier can be brought directly
in federal court, other options exist as well. The OCR serves as the
primary administrative enforcement mechanism for Section 504 and the
Americans with Disabilities Act (ADA) in relation to schools (Lohrmann-O'Rourke
& Zirkel, 1998). Educational cases frequently are handled by the
state education agency (SEA), which resolves disputes regarding IDEA
using a system of impartial due process hearings and, at the state's
option, a second-tier impartial administrative review. All OCR and
SEA hearing officer reports may also be appealed to a federal court.
A
potentially powerful but underutilized tool for protecting the civil
rights of confined or detained youths is the Civil Rights of
Institutionalized Persons Act (CRIPA). Established by Congress in
1980, CRIPA provides the Civil Kighls Division of the Department of
Justice (DOJ) the authority to bring legal action against state and
local governments for violating the civil rights of persons
institutionalized in publicly operated facilities. Under CRIPA, the
Civil Rights Division protects detained or incarcerated juveniles in
prisons, jails, psychiatric hospitals, and other publicly operated
facilities from dangerous conditions and unsafe practices of
confinement (Puritz & Scali, 1998). The Office for Civil Rights has
verified that CRlPA would apply to students in school settings.
(Complaints can be directed to: Special Litigation Section, Civil
Rights Division, U.S. Department of Justice, P.O. Box 66400,
Washington, DC 20035-6400. 202-514-6255.) However, we located no
records that demonstrated the use of CRIPA in relation to the use of
restraint in schools.
Court
rulings can be grouped into four general categories pertaining to
the use of physical restraint: (a) decisions affecting the use of
mechanical restraint; (b) decisions affecting the use of ambulatory
or manual restraint; (c) professional training pertaining to staff
who perform restraint; and (d) individual rights related to the
Eighth and Fourteenth Amendments, Section 504, and ADA.
Mechanical and Ambulatory Restraint
The
preponderance of rulings by the courts, SEAs, and OCR found the use
of any type of mechanical restraint other than a time-out or tray
chair to be unacceptable and in clear violation of a student's
individual rights. Specific rulings by each agency are shown in
Table 2. In contrast, the courts, SEAs, and OCR have consistently
found that ambulatory restraint may be used without violating an
individual's rights or threatening the individual's safety. Specific
rulings by each agency arc shown in Tables.
Professional Training
In
Wyatt v. King (1992), the U.S. Circuit Court determined that staff
working with individuals with mental illness required specific
training regarding interventions germane to their unique care. The
Court stated that training should include psychopharmacology,
psychopathology, and psychotherapeutic interventions, as well as
interviewing and assessment procedures for determining a patient's
mental status. These findings have since been supported by national
training prevention programs, which advertise that intensive staff
training in schools has reduced assaultive incidences by 80% and
resulted in a 77% reduction in disruptive incidents (Crisis
Prevention Institute, 2002). Similarly, the states of Pennsylvania
and Delaware experienced a 90% reduction in the use of physical
restraint in their state mental health facilities after instituting
intensive staff training programs. Training included crisis
management and crisis prevention procedures for staff, as well as
extensive training on methods for determining when and how to
conduct physical restraint. Texas legislation now requires school
personnel who use restraint to be trained; its supporting technical
assistance materials have identified critical components for
training programs (Amendments to 19 TAC Chapter 89, 2002). Courts,
hearing officers, and legislation strongly support adequate training
before these procedures are employed.
Individual Rights
Numerous court cases have addressed patient rights. This section
provides a synopsis of all decisions pertaining to an individual's
rights regarding the Eighth and Fourteenth Amendments, section 504,
and ADA. In essence, the courts have ruled that institutions must
take into account a patient's rights at all times and that any
restrictions to individual liberties must be in their best interest.
Specific rulings by each agency are shown in Table 4. Perhaps the
most influential decision regarding the use of restraint came from
the Supreme Court decision Youngberg v. Romeo (1982). The court
emphasized its concern that the judicial system should not invade
the province of those whose job it is to make medical and custodial
decisions. This case was critical in establishing a precedent for
the establishment of procedures used to determine whether the use of
physical restraint was considered reasonable and hinged on whether
staff exercised professional judgment. Professional judgment, the
court ruled, was to be considered presumptively valid. This
presumption effectively shifted the burden of proof from the
caretaker to the individual alleging that the imposition of
restraint was unreasonable (Kennedy & Mohr, 2001). However, to
ensure the restraint was not being used improperly, the courts
determined in Converse v. Nelson (1995) that inappropriate
behavioral programs that constitute punishment disguised as
treatment should be subject to analysi\s under Eighth Amendment
standards. Finally, as described earlier, CRIPA may also provide a
vehicle for advocacy and protection related to the use of restraint.
TABLE
2
Summary of Court, State Education Agency, and Office for Civil
Rights Rulings on Mechanical Restraint
Summary
A
review of state and federal policies regarding the use of physical
restraint in schools has resulted in several findings: (a) limited
forms of mechanical restraint are permitted; (b) ambulatory
restraint performed with trained personnel is authorized; and (c)
any agency, including schools, that uses restraint needs to
provide professional training for staff who perform these
procedures.
TABLE
3
Summary of Court, State Education Agency, and Office for Civil
Rights Rulings on Ambulatory Restraint
Advocacy Statements
While
professional organizations and advocacy groups frequently hold
differing opinions regarding specific issues, it is important to
recognize areas of agreement to promote standardization and policy.
Therefore, we reviewed and summarized position statements regarding
the use of physical restraint from nationally recognized advocacy
groups and professional organizations.
In
1998 the American Medical Association (AMA) reviewed existing
restraint guidelines and attempted to coordinate the development of
updated national guidelines for the safe and clinically appropriate
use of restraint techniques for children and adolescents. In a 1999
report, the AMA supported the development and use of guidelines
currently issued by the American Academy of Child and Adolescent
Psychiatry (AACAP), the American Academy of Pediatrics, and the
American Psychiatric Association regarding restraint, while
encouraging future empirical studies on physical restraint with
children and adolescents across all settings (AMA, 2001).
AACAP's policy statement suggests that institutions that use
physical restraint establish procedures and policies addressing the
circumstances in which restraint is permissible. AACAP also calls
for documentation procedures, as well as inservice training
requirements for all staff. They recommend that physical restraint
be used only as an emergency intervention to maintain safety and
that it be implemented in a manner sensitive to the child's
particular developmental level, specific vulnerabilities, and
overall treatment goals (AACAP, 2000). The American Psychiatric
Association policy statement is similar to AACAP's, but expresses
concerns regarding Children's Health Act terminology, specifically
that this legislation defines physical restraint so broadly that it
essentially encompasses any unwanted touching that might reduce an
individual's ability to move freely (American Psychiatric
Association, 2002). This definition would classify commonly used
escort procedures as a type of physical restraint.
Finally, the position statement by the International Society of
Psychiatric and Mental Health Nurses (ISPN) claims that restraint
should be used as a last resort and only when less restrictive
alternatives have failed. ISPN recommends that family members be
informed immediately after the use of a restraint and that the child
receive a debriefing from the caregivers in clear words that the
child can understand. The organization claims the debriefing process
is necessary to minimize negative effects related to patients'
experiences of being restrained. ISPN also advocates training all
staff members on the cycle of aggression, verbal intervention
skills, and critical thinking strategies designed to select the
least restrictive intervention that is best suited to the presenting
needs of the child (ISPN, 1999).
TABLE
4
Summary of Federal Court and OCR Rulings on Individual Rights
Parents and advocacy groups have argued for the outright banishment
of physical restraint, claiming its usage unfit for man, woman, or
beast (Williams & Finch, 1997). Many nationally recognized advocacy
groups have posted position statements regarding the use of physical
restraint on their Web sites. The National Alliance for the Mentally
III recently posted a position statement supporting the Children's
Health Act of 2000 regarding the use of physical restraint and
proposed similar standards be established for schools (National
Alliance for the Mentally III, 2001). Another group, the Child
Welfare League of America, called for a minimum national standard of
training in behavior management techniques, especially in the area
of deescalation. In addition, it called for future research to
develop a better understanding of what crisis prevention models work
best for specific situations (Child Welfare League of America,
2002). More recently, the Autism National Committee has called upon
Congress and state legislatures to limit the use of restraint on
children with disabilities to brief, emergency situations involving
serious threat of injury to the person with disabilities or to
others. They are also asking for standardized reporting procedures
following a restraint, with an investigation of circumstances
leading to the incident to develop supports and accommodations for
the prevention of future restraint (Autism National Committee,
2000).
Recommendations for Use of Physical Restraint in School Settings
After
reviewing the compilation of research, legislation, case law, and
position statements regarding the use of physical restraint, it
appears that schools should use extreme caution when contemplating
the use of physical restraint procedures. The following
recommendations regarding restraint procedures, staff training,
notification, and monitoring seem to combine the best practices
emerging from our review and would be appropriate for any school
that would employ physical restraint.
Restraint Procedures
Restraint should never be performed as a means of punishment or to
force compliance from a student. In addition, physical restraint
procedures should never be performed by untrained personnel. Through
numerous rulings, the courts have established that very limited
forms of mechanical restraint are permissible with students in a
school setting and that physical or ambulatory restraint should be
administered only when the safety of the student, peers, or staff
members is at risk.
When
physical restraint is administered, staff must use the safest method
available, using the minimal amount of force necessary to protect
the student and others from physical injury or harm. Once a
restraint is used, it should be discontinued as soon as possible. In
addition, no restraint should be administered in such a manner that
prevents a student from breathing or speaking. The student's
physical status, including respiration and skin color, should be
monitored continuously throughout the restraint procedure.
Professional Training
All
staff members who work with students with E/BD should be required to
receive specialized training in conflict deescalation, crisis
prevention, and behavior management techniques. Staff should receive
specialized training and recurring updates in the use of physical
restraint before any such procedures are used. Physical restraint
should never be used unless the person doing it is trained
specifically in the particular technique to be used. Training should
include recognition of the various phases of the cycle of
aggression, verbal deescalation strategies, and restraint and
counseling procedures. Staff should also receive certification in
first aid and cardiopulmonary resuscitation (CPR) in the event of an
emergency related to restraint.
Reporting and Parent Notification
Procedures for reporting and notification should be in place.
Following the administration of a physical restraint, a staff member
who administered the restraint should verbally notify an
administrator as soon as possible. Within 24 hours, a written report
should be provided to the administrator responsible for maintaining
an ongoing record of all physical restraint concluded by the school.
In addition, the administrator should verbally inform the student's
parents or guardians of the restraint as soon as possible. Written
reports to the parents, including a description of the event and
staff involved, should be postmarked no later than 3 working days
following an incident.
Advocacy
Policies, procedures, and legislation, even if noble in intent, are
all but meaningless if not enforced. The guidelines for schools
regarding the use of physical restraint on children are the result
of decades of professional practice, state and federal legislation,
case law, and grassroots efforts by advocacy groups, all concerned
with the safety of children. To ensure that empirically based best
practices are developed and become common practice among schools, it
is incumbent upon various professional and advocacy organizations to
monitor and hold school districts (as well as other agencies) across
the nation accountable. These organizations need to act as watchdog
agencies monitoring the compliance of schools to ensure that
children are kept out of harm's way.
Recommendations for Further Research
It is
evident that there is a strong need for additional research
regarding the use of physical restraint with students across all
settings. Areas for future research include the following:
The extent to which schools currently employ physical restraint, and
if so, which of the restraint systems are used.
The
nature of the antecedents or behavior that precipitated restraint.
The
Diagnostic and Statistical Manual diagnoses (American Psychiatric
Association, 2002), special education category (if applicable), or
other characteristics of students who receive restraint.
The
intended purposes or goals of restraint.
The
efficacy of restraint procedures in achieving these goals.
The
potential outcomes or side effects, including injuries and
fatalities, as a result of the use of restraint in schools.
The
training level of the staff who actually perform restraint.
The
degree to which procedures for deescalation of student behavior are
used before, during, and after restraint.
Using
the data compiled in states that require reporting will be very
useful in beginning to address some of these issues and make it more
likely that restraint will be used safely.
Conclusion
Due to
the current risk of student injuries and the mortality rates
associated with the use of physical restraint, immediate action is
required to ensure that schools employing restraint do not
jeopardize student safety. Based on the review of case law,
legislation, and recommended procedures from both professional
organizations and advocacy groups, there is a need for clear
standards regarding the use of restraint procedures in schools, as
well as mandatory training of staff before they use restraint.
Improved and standardized record keeping and notification of
administrators and parents of incidents in which restraint occurs
are also important. Additional research is needed to define
situations in which restraint is appropriate in schools, as well as
its effectiveness in containing or preventing violent or destructive
behavior. Unless these recommendations are heeded and action is
taken, headlines will continue to appear across our nation
describing these preventable fatalities.
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AUTHORS' NOTE:
A
special thanks to Dr. Michael H. Epstein at the University of
Nebraska-Lincoln for the professional expertise and guidance he
provided in the development of this manuscript. |
