Tied Up in Knots: Systemics, Occupational Therapy and Restrictive Practices
Johanna de Kort and Brett Williams, Adelaide Night and Day Family Therapy
23 February 2011
This article aims to consider issues relating to why therapists should be concerned about the use of mechanical restraints in working with children living with an intellectual disability and how to address the complexities associated with this. It will do this by describing the needs of children living with an intellectual disability and defining what restrictive practices, difficult behaviour, challenging behaviour are. As occupational therapists are often asked to prescribe restraints, and one of the authors is an occupational therapist, it will then explore what restrictive practices means from a philosophical occupational framework, what restraint means to children, how they can be an abusive and traumatic experience and the known risks associated with restraint. Finally the paper will explore important factors that lead to best practice and the evidence identifies as being essential for therapists to address.
Systems
When looking at restrictive practices from a systemic view, issues of what restrictive practices are in terms of the systems of the person being restrained. If we start with Family Structure Theory, we note that often the restrained person sits within a hierarchically ordered structure, with one part of the system being the parent or parents of the system, and the other being the child. This can carry across all types of systems in which the person lives. If incarcerated it may be a prison system. If in an educational setting it may be a school. If in a form of institutionalized care it may be their home. For children living with an intellectual disability, we might explore issues around and within these systems. The child may have many restraints placed on them within their system to allow them to function as the system would like. Each of the child’s systems will have rules, physical boundaries and narratives which define the system, and which in themselves may be restraints.
Yet at different points in the system’s journey with the child, critical incidents may occur which may result in the child being restrained in ways that would be considered above and beyond the normal practices of the system. When talking about restraint, the critical incident may take several forms. They may be regular and planned. For example the critical incident may be a regular activity such as toileting, transportation, eating or sleeping. Or the critical incident may be a particular difficult or challenging behaviour that is idiosyncratic to an event or specific precursors. For the purpose of this paper, whichever way a restrictive practice arises, it is used as an allegedly protective or therapeutic tool in response to challenging or difficult behaviour.
Two groups of questions may arise out of this that may allow us to start viewing the child in their system a little differently, or start us looking at the system in a way, that can assist us in the shift toward redefining the need for restrictive practices, and look for other therapeutic means of addressing critical incidents, or providing a safe environment and therapeutic systems for all.
The first is around restriction. How might the system itself be restrictive? How might the system be restrained? How might its therapeutic practices be restrictive or restrained? How might it be restraining itself with its practices? The second group is around behaviour. How is the system dangerous? How is the system in need of safety? How might the system need to be protected? How is the behaviours adaptive or maladaptive for the system? That is what might the purpose of the critical incidences be to the system?
Next one might start asking these questions across the system, asking it about each individual, each group, each process and procedure of the system.
If we can start answering these questions without only putting the focus on the child and seeing their behaviour as aberrant, or blaming the child for that matter, but seeing whatever is going on as an integral part of the homeostasis of the system in which they sit.
Tied up in knots
This then takes us to the title of this paper “Tied up in knots.” This evocative title might draw an image of a child living with a disability restrained into a deformed shape by straps, ties, clothing, therapeutic tools and other devices. So too, we might evoke a similar image of a system, institution, family, organisation or society restrained into a deformed shape by restrictive practice.
We actually came up with the “tied up in knots” because reflects the emotional feeling in our stomachs we sometimes feel when seeing children living with disabilities restrained or when being asked to assist to physically restrain a child engaging in challenging behaviour.
We tend to tie things up to be helpful, contain, protect and hold but when the ties become knotted and only restrictive and don’t allow freedom of any form then they become unhelpful and don’t do what they supposed to do. For example, we tie things for therapeutic for care reasons such straps on a car seat, high chair. There are many forms of restrictive practices that are seen as necessary and acceptable to keep children safe- kids in chairs, play pens, hold hands in shops or crossing road. But where do we draw the line?
Children living with intellectual disability
Just like any other child, a child living with an intellectual disability has the same occupational needs as other children. They need to play, participate in self-care and other productive activities such as going to school. Sadly, children living with disabilities are more likely to be excluded from the typical opportunities and activities that their peers without a disability are readily afforded. Therapists working with children and young people are concerned with enabling occupation that promotes a child and their carer’s well-being and social inclusion, however the overuse and misuse of restrictive practices with children living with an intellectual disability, in most cases, is in direct contrast to these core foundations and philosophies. While there are exceptions, in most circumstance restrictive practices are an example occupational injustice that deprives children of their basic human freedom and rights.
Restrictive practices
During the 1990s concerns about the use of restrictive practices for people with learning disabilities increased (Deveau and McDonnell 2009). Concerns focused on associated deaths, injuries, and the infliction of pain to enforce compliance and the role of restrictive practices as part of restrictive and abusive institutional environments. According to the Victorian Disability Act 2006 restrictive practices means any intervention that is used to restrict the rights or freedom of movement of a person with a disability including –
(a) chemical restraint;
(b) mechanical restraint;
(c) seclusion.
Restrictive practices often occur with children living with an intellectual disability whose behaviour others find difficult or challenging. Many children and young people are being unnecessarily restrained in violation of their human rights and contrary to the best practice evidence. At least a quarter of all people with an intellectual disability, including young people and children, are believed to have been subject to restraint in care, including physical, chemical, mechanical restraint and seclusion (The Australian Psychological Society (APS), 2010).
For a child living with a disability, there remains a gap in terms of their access, opportunity and experience to engage in meaningful healthy childhood occupations. Their access is yet to be on the same basis as their peers without a disability. Occupational injustices can occur for these children and their families as a result of the overuse and misuse of restrictive practices. Restrictive practices foster occupational apartheid and the experience of alienation and deprivation where client centred approaches are overruled to the extent that children living with a disability become more occupationally marginalised. Occupational apartheid, occupational imbalance and occupation segregation is an everyday experience for some children living with a disability because their primary occupations of playing, being a student, having a hobby, developing life skills, and participating in other regular activities are constantly challenged, compromised, trivialized and dismissed and as a result they are more frequently un-occupied, under-occupied, meaninglessly occupied or even abusively occupied in cases where they are the recipient of unwanted and unnecessary restraint. A child living with a disability who is forcibly made to engage in a restraint activity will also tend to be viewed as more deviant and less worthy than the peer counterparts who are not living with a disability. As therapists we the authors want to bring to public awareness the injustices that persist when participation in occupations is barred, confined, segregated, prohibited, underdeveloped, disrupted, alienated, marginalised, exploited, excluded or restricted (Townsend and Wilcock 2004).
Therapists have a mandated responsibility to ensure that children are protected and have a responsibility to provide best practice that enables occupation for the children and carers they work with, using culturally appropriate practices, which take differences in people and contexts into account. The therapeutic relationship promotes children and their family’s to fully participate in their daily life occupations, the decision making and in establishing the priorities of therapy. Despite the tensions of challenging systems, when a therapist encounters a restrictive practice or is asked to prescribe a restraint it is useful to consider this in the context of occupational justice and to use ethical, moral and civic frameworks to reflect on what extent this type of approach promotes client centered practices that use participatory empowerment orientated approaches (Townsend and Wilcock 2004), particularly in child settings, where unacceptable restrictive practices are used as a matter of convenience or as a punishment.
Requests for Therapist to prescribe mechanical restraints
Restrictive practices are a broad area affecting: numerous populations such as elderly people and those living with mental illness, a range of settings such as residential care facilities and hospitals. A range of restrictive interventions are often used such as seclusion and pharmacological restraints as well as a wide range of mechanical restraints are likely to be used with children living with disability both in home, childcare, respite and school settings. Often with both difficult and challenging behaviours families, carers and staff find it difficult to manage, and, as such, they need support to understand why the behaviours occur and understand what alternatives might be used. When we understand the adaptive functions of a child’s behaviour we are well on our way to reducing the need to use restraint. Therapists need to take the time and work with others to assess a child’s abilities and needs from occupational performance and occupational components (social, physical, sensory, intellectual, communication, emotional and psychological) perspectives.
Difficult behaviour
Some children living with an intellectual disability may display behaviours that pose difficulties for their parents, carers and staff to manage, such as: taking clothes off in inappropriate places; smearing faeces; masturbation or touching genitals at inappropriate times; and tampering with their incontinence or sanitary aid. Some of these behaviours can pose a risk to the child living with a disability themselves or to others, and sometimes parents, carers and staff may try to stop the behaviour by using some form of clothing that impedes the person from performing the behaviour (Hayward 2010 ). This is a type of restrictive practice.
Challenging behaviour
Restrictive practices are also common in populations that demonstrate challenging behaviour. Challenging behaviour is defined as “culturally abnormal behaviour(s) of such intensity, frequency or duration that the physical safety of the person or others is placed in serious jeopardy, or behaviour which is likely to seriously limit or deny access to the use of ordinary community facilities” (Emerson 1995).
Challenging behaviour is more common in children living with an intellectual disability who often experience varying degrees of difficulty in communication and expressing their needs, some of these children are even non-verbal (Montgomery and McVilly 2010). These behaviours do not just happen out of the blue, children may exhibit difficult or challenging behaviours for a range of reasons. For example;
- biological (pain, medication, the need for sensory stimulation),
- social (boredom, seeking social interaction, the need for an element of control, lack of knowledge of community norms, insensitivity of staff and services to the person’s wishes and needs),
- environmental (physical aspects such as noise and lighting, or gaining access to preferred objects or activities),
- psychological (feeling excluded, lonely, devalued, labelled, disempowered, living up to people’s negative expectations) or
- Simply a means of communication.
Most often these behaviours occur because the child’s needs are not being met or they are unable to clearly communicate their needs. As a result the child may experience consequent feelings of frustration that can quickly escalate into challenging behaviour. This includes self-injurious behaviour (such as hitting, head butting, biting), aggressive behaviour (such as hitting others, screaming, spitting, kicking), inappropriate sexualised behaviour (such as public masturbation or groping), behaviour directed at property (such as throwing objects and stealing) and stereotyped behaviours (such as repetitive rocking or echolalia). In a small number of cases the challenging behaviour can lead to a series of responses and actions that result in the use of restrictive practices that involve restraints (Hayward 2010). Jumping once again to the systemic window we could ask first about why the system needs to exhibit this behaviour, how is it adaptive for the system, or perhaps how is it adaptive or useful to each of the elements or people in the system?
Mechanical restraint
According to the Victorian Disability Act 2006, mechanical restraint means the use, for the primary purpose of the behavioural control of a person with a disability, of devices to prevent, restrict or subdue a person’s movement but does not include the use of devices—
(a) For therapeutic purposes [such as those recommend by a medical practitioner or therapist for use at identified times and places for therapeutic purposes (i.e., explicitly to enhance health and wellbeing) and an authorised mechanical restraint recommend by a medical practitioner or therapist to support a person participate in identified activities of daily living (e.g., at meal times)]; or
(b) To enable the safe transportation of the person;
Mechanical restraint involves the use of devices or objects, and can include actions such as strapping a child to a bed or a “restraint chair”. Mechanical restraints are commonly used in response to challenging behaviour and often associated with other restrictive responses to challenging behaviour including seclusion, multi and frequent ‘as required ‘psychotropic medication use. The associated actions and reactions surrounding mechanical restraint are associated with injury and harm to children and those who are implementing the restraint (Deveau and McDonnell 2009).
Concerns about restrictive practices
Experience of children who received restraint
According to researchers, disability can increase one’s vulnerability to abuse. For example children with any type of disability are 3.44 times more likely to be a victim of some type of abuse as compared to children without disabilities (Sullivan 2000). They also found that of all types of disability, children with behaviour disorders and children with intellectual disability were both at an increased risk for all three forms of abuse (neglect, physical and sexual abuse) compared to those children with other types of disabilities (speech/language, hearing impairments) (Sullivan 1998 ).
Children should be able to participate without fear of unnecessary and improper restraint (Marquez 2010). Restrictive practices often result in harm, mostly to clients but also to some staff who implement them. For example, (Deveau and McDonnell 2009) reported that both the physical and or emotional themes which emerged from interviews with people who received restraint were overwhelmingly negative, with pain, anxiety and mental distress, anger, and the perception that the staff were experiencing anger and hatred and feelings of enjoyment during the interventions expressed. Staff also reported experience similar negative thoughts and emotions- feeling guilty or upset following the use of restraint and that this use was always as the ‘last resort’. Although the long term impacts of restrictive practices in childhood is not well understood, some have argued that psychological trauma such as fears and phobias, impaired trust, and cumulative re traumatisation are among the consequences of restrictive practices (Kennedy and Mohr 2001; Selekman and Synder, 1996). Being restrained can be a frightening and traumatic experience. Restraints can negatively interfere with the relationship between the person being restrained and their care giver, they are reported to be:
a. Overwhelmingly traumatizing experiences and emotionally stressful for young people, staff, and families.
b. Injure young people and staff and cause a loss of self-respect and dignity.
c. Impact relationships and create a loss of trust between young people and staff.
d. Slow treatment progress for young people and result in longer treatment.
e. Make people scared and can trigger other young people.
f. Create an unsafe unit with unsafe behaviors.
(Crisis Prevention Insititure (CPI) 2005 and Massachusetts Department of Mental Health, (MDMH) 2009)
Risks
The inappropriate use of physical interventions is not a benign form of behaviour control, it is a high risk intervention that increases the risk of injury to both therapist, children and those implementing the program (Powell and Northfield 2002) and which may cause sudden death. A child may have health problems, and children have gone from a state of no distress to death in a matter of moments. There is limited Knowledge about the safety of specific restraint methods, although some types are thought to pose increased risk (Deveau and McDonnell 2009). Within the medical community, the current consensus is that restraints can cause death triggered by “positional asphyxia” which is a compromise of respiratory function. Such asphyxia can occur when the child is face down on the floor, as in a prone restraint, because the child must breathe against the weight of their own body, or when seated, if the restraint is restricting chest of abdominal movement. Research on healthy people who refrained from struggling found that “vital capacity was impaired and normal levels of blood pressure and heart rate significantly degraded” (Marquez 2010). To date no specific assessment tool exists which compares the risks or effectiveness of different physical interventions. However what is known is that the risks of injury and death increases when the child is suffering from a medical condition. For example:
- Asthma
- Obesity
- Down syndrome
- Disease that affect bone density
- Children on certain types of medications
- Special education setting on medications to address behavioural and cognitive issues.
The dangers posed by physical restraint are compounded when they are performed in ways that contravene acceptable methods. For example, any restraint where the adult’s body weight is placed upon the child’s back or chest is extremely dangerous (Marquez 2010).
According to (Marquez 2010) common themes of selected cases of restraint where there was a criminal conviction, finding of civil or administrative liability, or a large financial settlement were that they:
- Involved children with disabilities
- Often the children were not physically aggressive
- The child’s parent had not approved consent
- Involved restraint where the airways were blocked
- Most of the staff involved had not been trained in the use of restraint.
Manual and mechanical restraints
There is a rising demand and expectation on therapists, paediatricians, social workers, and educationalists to supply appropriate, high quality equipment for children living with a disability (Reading and Marpole 2000). Therapists may prescribe the use of aids, devices and equipment such as splints, modified clothing, harnesses, helmets or wheelchair to enhance a child’s functional ability and support their participation in meaningful activity. So too they may be expected to provide training in manual restraint for the purpose of protection of the child or others in its system.
However there are rare occasions when a therapist either prescribes or is asked to prescribe such items for the purpose of restraint. This may be in the form of modified clothing using methods of making clothing restrictive for the person with a disability wearing it, such as by reversing garments so that openings are on the back; placing arms or legs out of sleeves or pant legs but under the garment; and deliberately using fasteners that cannot be opened by the person.
Concerns
Different cultures and professional backgrounds of staff working at all levels within different agencies can create additional complexities and problems when prescribing equipment (Reading and Marpole 2000). Often there is a lack of agreement over common assessment and intervention procedures, such as:
- Less than high priority that children living with a disability have among agencies.
- Devolvement of budgets for equipment.
- Fragmentation of care between and within different agencies. For example, between and within different school, disability and accommodation settings.
- Where the prescription of modified clothing is concerned, while clothing items may work in stopping the behaviour of concern, they do not address why the behaviour is occurring and how the person may learn over time to change the behaviour. In these cases, the altered clothing items are ‘band-aid’ solutions that do not promote long-term change in the behaviour itself (without positive behaviour support) and the altered clothing more often than not will be used indefinitely (Hayward 2010).
- The prescription of such an item for the purpose of physical restraint should always be an option of last resort and carried out within a sound clinical, legal and ethical framework that sets out explicit safeguards for the child with an intellectual disability and for staff or family (and only after all other forms of therapeutic intervention have been tried and failed – or if immediate safety needs of the client or other outweigh non-restrictive intervention).
- There are occasions of reported misuse and unintended use of an item originally prescribed to increase function being inappropriately used as a method of restraint when responding to challenging behaviour.
- An appropriate therapist skilled in the prescription, modification and manufacture of such aides, devices and equipment is not always consulted to ensure proper fitting and use of an item prescribed as a mechanical restraint.
- Therapists have a duty of care to children living with an intellectual disability. Bidmeade, 2004 states that ‘someone working with a person with intellectual disability would be expected to take into account the vulnerabilities and idiosyncrasies of that person’. Consequently a disability professional may have a duty of care to children living with an intellectual disability that is higher than that which one could reasonably be expected to owe to a more able person in the community.
- As professionals we are expected to take into account the child’s vulnerabilities and idiosyncrasies and eliminate and minimise to the best of our ability any foreseeable risk that could result in harm.
- Duty of care also needs to be balanced with dignity of risk. For example, a child living with an intellectual disability needs to have support to discover their gifts and talents explore their interests and develop their capacities and skills. A duty of care cannot be used to automatically override these and other usual rights to take reasonable risks. If we did attempt to eliminate all possible situations of harm, we would also more than likely severely limit the child’s opportunity for many positive and rewarding experiences in addition to increasing the probability of challenging behaviour occurring. Legally or ethically we are unable to place unreasonable restrictions on a child’s freedom of movement and freedom to explore within safe boundaries.
- The absence of formal positive support plans, or documentation that would reasonably guide or justify the use of restrictive practices places both safety and legal risks not only to the child living with an intellectual disability, but also to the child’s family, carers and agencies that support the child. The use of any restraint on the child in a behavioural intervention process requires careful consideration of the least restrictive alternatives, and of, practical, legal, ethical issues. In terms of the legal and ethical considerations governing restraint, the use and continuation of inappropriate physical restraint or seclusions may under specific circumstances, constitute a criminal act of unreasonable force and wrongful imprisonment and an action requiring a notification to child welfare authorities.
General Considerations
Specific issues that therapists need to consider when working with children include:
- That practices derived from adult research needs to be implemented sensitively with young client group.
- To fully understand their legal obligations with regard to obtaining consent before providing any therapy service to children and adolescents.
- Whether clinical practices using evidence derived from adult research are appropriate for children and adolescent groups and whether the staff and health practitioners require specific training for working with those groups.
- Some of the unique aspects of restrictive practices that apply to minors. Although guardianship laws vary across states, guardian or parental consent needs to be obtained prior to any decision to implement a restrictive practice. More broadly, and consistent with family-centred and for that matter family systems approach, parents should be given the opportunity to participate fully in the planning and delivery of behaviour support services. Parents should also be provided with information about the restrictive practice (e.g., the location of restrictive practice, the maximum length of any restrictive period, and the number of times restraint would be used during a single day) and be notified of incidents requiring the use of restrictive practice. Parents have the right to refuse a restrictive intervention if they disagree with the method in which instance therapists should take further advice (APS) 2010)
Clinical Approaches
Positive Behaviour Support has a strong evidence base and is always the first and preferred approach for assessing and developing strategies to address challenging behaviour (APA 2010). The issue of prevention is particularly relevant for young children. There are several evidence based programs that have been developed in Australia and are available for clinicians to use in the preventative endeavour. These may be generic child management programs such as Triple P (Sanders, Markie-Dadds, & Turner 1999), or programs specifically designed for children with living with intellectual disabilities such as Stepping Stones (Roberts, Mazzucchelli, Studman, & Sanders, 2006), or Signposts for Building Better Behaviour (see Hudson, et al. 2003; Hudson et al., 2008 Hudson, Camerson, Reece, & Matthews, 2009). Family systems theory and practices gives a lens through which to see the behaviour in a way that takes focus off the individual to all members of the system, or the system itself and can strengthen the outcomes of therapeutic intervention.
What is needed is an approach that focuses on:
- Understanding the system’s and person’s learning and emotional needs
- Clearly knowing all the critical incidents or triggers that give rise to behaviours of concern
- Continually adapting the environment to the system’s or person’s needs to avoid triggers
- Therapy including specific skill development, cognitive training and counselling
- Medication and other therapies, if required, to treat mental illness
This approach requires:
- Intensive service provision over a long period of time
- Therapeutic engagement from all workers
- Therapeutic engagement from others involved to the child’s system, especially parents and siblings
- Buy in from all decision makers
- Non-aversive therapy from workers who show respect and concern.
Behaviours of concern, behaviours of protest and environments of concern, once understood and acted on, can lead to positive changes and better overall well-being for people with a disability who show these behaviours (Webber 2010).
Evaluating and revising interventions
Interventions outcomes should be evaluated regularly and treatment plans should be modified accordingly to ensure treatment effectiveness and to ascertain what aspects of the Behaviour Support Program need to be modified (APS) 2010).
- A direct and continuous measurement of the challenging behaviour targeted for change;
- A record of any restrictive procedures used;
- An assessment of the extent that the plan has been followed, i.e., treatment fidelity;
- An assessment of improvement in any skills targeting for intervention as part of the plan;
- An assessment of broader factors such as involvement in community activities or quality of life using an instrument such as the Personal Wellbeing Index 2006 for people with an intellectual disability:
- An assessment of any negative side effects; and
- An assessment of the social validity of the intervention, which typically includes assessment of the client’s satisfaction with both the intervention and procedures used and the outcome achieved.
In an effort reduce the use of restrictive practices the Massachusetts Department of Mental Health (MDMH 2009) report a range of proactive strategies that children and young people have themselves, expressed as useful, this includes:
- Using sensory strategies such as comfort rooms, music, coping skills, and blanket wraps
- Having the support and leadership of peers
- Creating comfortable environments that feel more like home
- Having more individual time with staff
- Allowing appropriate physical contact
- Conducting community meetings and encouraging participation in activities such as sports, art, and music can be helpful for youth
- Using strong communication skills and listening skills
- Encouraging young people to be active and fully engaged in their lives, programs and treatments
- Using nonjudgmental positive language and tone of voice and no threatening body language
- Respecting confidentiality
Least Restrictive Practice
In other states there is legislation that clearly aims to reduce or eliminate the need for the use of restrictive practices across the therapeutic and disability services sector and helps ensure transparency and accountability with adults. Although South Australia is yet to introduce such measures, it should not impede therapists to lead the way and ensure that any use of restrictive practices (for example, containment or seclusion) by a staff person has regard for the human rights not just for adults but for children also, and is the least restrictive way of safeguarding them and others from harm. In the Victorian Disability Services Act 2006 ‘least restrictive’ means:
Use of the restrictive practice —
(a) Ensures the safety of the adult or others; and
(b) Imposes the minimum limits on the freedom of the adult as is practicable in the circumstances.
Any use of mechanical restraints must be in the person’s best interest, ‘least restrictive’ and used as the last resort following preventative strategies. The last resort principle implies that services should be able to demonstrate support plans to prevent or reduce the frequency and or restrictiveness of mechanical restraints used in individual cases. Adopting explicit policies and practice to reduce mechanical restraints is likely to be more effective in improving quality of support as opposed to solely managing mechanical restraints use. Mechanical restraints should be as the last resort to prevent harm to people, even when used ‘proactively’. Practical policies and actions to develop and reward alternative non- restrictive responses by staff should be developed (CPI 2005). Reducing mechanical restraints use can apply to both frequency and or restrictiveness.
According to (Marquez 2010), strategies that should precede the use of restraint should focus on:
- Strict prohibition on the use of restraints in non-emergencies. Mechanical restraints should not be employed as a disciplinary measure or by untrained staff.
- Restraints may only be imposed in extreme, rare, emergency circumstances and only to ensure the immediate physical safety of others, and only until the emergency safety situation ends.
- The most readily accepted indication for the use of restraint and seclusion is the prevention of harm to oneself or others, usually when danger is imminent and after other measures have proven in effective.
- Last resort in an emergency situation to protect the safety of other the child and others. This will include the need to explicitly describe what an emergency situation is in the context of using a restraint and the restraint protocol.
Use of restraint and seclusion should be regarded as appropriate with children and young people only when all alternatives have been exhausted. Practice should be guided by the latest research about child and youth populations in Australia. Clinicians should be aware of the ethical issues associated with working with children and adolescents (APS) 2010).
Espousing statements such as ‘the last resort’? In reality will require changes in the expectations and focus of many different agencies and professionals. The minimum needed now is for services to develop, expect and monitor mechanical restraint reduction programmes for individuals and across services. This can include surveying whether the setting has and restrictive practice policy and whether it is reviewed and dated, what type of restraints have been used within the last year? Has this use increased for the service user and have they tried to reduce this? As minimum, services should be developing and implementing individualised restraint reduction programmes.
Staff Training Approaches
The APS 2010 and Marquez 2010 recommend specific education and training for staff to increase awareness of alternatives to restraint and seclusion should be provided to support workers and health and disability practitioners who work with children and adolescents living with a disability. Staff who are expected to implement and or advise on restrictive practices should be trained and certified in restraint prevention and de-escalation, crisis de-escalation with children and instruction in how mechanical restraint procedures may be safely employed as a last resort. Examples of types of training programs that can provide this are; Mandt System, Crisis Prevention Institute, Handle with Care and those developed by the British Institute of Learning Difficulties.
Prescribing orthotics, devices or equipment
Many pieces of equipment, devices or orthotics have the potential to be prescribed to be used as a restraint or misused as a restraint. Therefore the following guidelines have been developed to assist therapists undertake a considered processing in addressing the complexities surrounding theses issues:
- A thorough assessment of need must have been undertaken by a member of staff with relevant professional competence. This should include other equipment and strategies tried and the outcome.
- The intended location where with the equipment is to be used should be specified.
- When a buggy or other item of equipment is requested as a form of restraint, this should be part of a broader programme of behaviour management, ideally with other allied health professional support.
- Equipment requires an assessment from two professionals, ideally from different agencies, one of whom is usually an occupational therapist.
- Pieces of equipment are often lost; staff/carers are uncertain about which agency is responsible for equipment and what it is used for. For example, health, social or an educational need. A tracking, documentation, review and monitoring system will enable improved ability to respond and account for these issues. Therefore a system is needed to keep track of equipment and it needs to include the following:
- Equipment to be tagged with the name, contact and other relevant details of agency the equipment belongs to.
- Equipment and provide an efficient system for recycling unused equipment.
- Where pieces of equipment are and who is responsible.
- Request for equipment that is clearly the responsibility of a single agency can be redirected and processed more rapidly.
- Clear communication and documentation about the purposes and intended use of pieces of equipment. This should also include warnings, contraindications and risks associated with misuse. For example, the use of a weighted item as a restraint.
Mandatory reporting requirements
The major issues with the use physical restraint are the absence or lack of reporting requirements. While restraint can injure children and staff the full extent of the risk and deaths caused by restraint is not known or likely to be inaccurate because reporting is so fragmented (Marquez 2010). No agency has successfully determined the number of deaths and or injuries caused by mechanical restraints. Funding to services, including schools, must be on the condition that every child or student is safe while attending the program or school. There can be no assurance of safety unless documentation of every mechanical restraint and every resulting injury and death is required. Mandated reporting requirements include:
- Consent
- Use of restraint, the: type, frequency, and length of time
- Injuries they caused
- Notifying the parent and or guardian
Parents and guardians should know when mechanical restraints are used on their child. This is necessary for parents to adequately participate in Negotiated Education Plans. In addition some children with disabilities lack the ability to speak and therefore, cannot inform their parents and guardians about the use of mechanical restraints.
Increased documentation will assist parents who wish to challenge the use of mechanical restraint in court. Because of the strong presumption of validity given to professionals and staff within education settings, parents cannot challenge restraint successfully without information about how restraints were used on their children (Marquez 2010). A requirement of recordkeeping would level the playing fields in the courts. Mandating documentation would encourage professionals and educators to maintain sage and appropriate practices when using mechanical restraints because decisions made would be much more transparent.
Leadership and Commitment
Therapists are called by their professions to demonstrate leadership and commitment to improving organisational culture which actively promotes reducing restraint. The Six Core Strategies referred to by Deveau and McDonnell 2009 to help achieve this include:
- Leadership and organizational change
- Use of data to inform practice
- Restraint reduction strategies: Use of seclusion and restraint prevention tools
- Workforce development
- Consult roles in inpatient settings
- Debriefing
This strategy places an increased focus on:
- Self evaluation checklist to assist organizations to achieve restraint reduction- this includes assessing the readiness of organizations to achieve this through stages starting with inactions through to espoused action to sustained action and maintenance (Colton 2004).
- the role of leadership within any therapeutic organisation and the development of systems that include extensive evaluation and systematic approaches to reducing mechanical restraint that include focus on education of staff, families and carers on understanding aggression and prevention, reducing the number of mechanical restraint techniques taught, and monitoring the frequency and type of mechanical restraint employed.
- Staff surveys with questions regarding mechanical restraint such as whether services monitored the frequency and restrictiveness of mechanical restraint use and for opinions on whether they should be seeking to reduce mechanical restraint and how.
- For therapists ensuring exploration of each of the following areas are useful in assessing a restraint and its alternatives.
- Trailing alternative strategies and equipment
- Development of a positive behaviour support plan
- Historical trail of interventions
- System’s and child’s communication strategies and abilities
- Stressors in the child’s life
- Stressors across the system and within the system
- Child’s physical health (also other health issues across the system)
- Beliefs of each member of the system of restraint, disability and therapeutic intervention.
- Medical conditions
- Adverse effects of medication
- Collecting and recording baseline data
- Not using restraints that are known to increase the risk of Positional asphyxia.
- Using the least restrictive practice
- Obtaining consent
- Provide information to carers
- Prescribing equipment
- Documenting the when the restraint is used
- Creating and entering information into a centralized database
- Monitor and check equipment
- Supervising and monitoring the program
- Completion of equipment prescription form
Reference & Bibliography
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