Physical Restraint and Seclusion Procedures in School Settings

Principles

• Behavioral interventions for children must promote the right of all children to be treated with dignity.
• Educational settings should adopt a comprehensive approach that assures all children are screened and receive necessary educational and mental health supports and programming in a safe and least restrictive environment.
• Positive and preventive educational interventions, as well as mental health supports, should be provided routinely to all children who need them, school staff should be trained to employ these techniques, and the level of staffing should be adequate to provide such supports in an effective manner.
• Staff working with students with behavioral or mental health needs, and particularly students with emotional or behavioral disorders and autism, should have mandatory training in the use of positive behavior supports, trauma-informed care,  nd/or other effective strategies for understanding, preventing, and addressing student behavior challenges.
• All children whose pattern of behavior impedes their learning or the learning of others should receive appropriate educational assessment, including functional behavioral assessments accompanied by behavioral intervention plans that incorporate appropriate positive behavioral interventions (e.g., instruction in appropriate behavior and strategies to de-escalate their behavior).
• All educational settings should use federal guidelines specifying behavior that constitutes a crisis and staff working with students with emotional and behavioral problems should be trained to recognize and invoke crisis procedures only when the child presents an immediate imminent danger to him/ herself or others.
• All parents of school age children have the right to be informed about school, district, and state policies pertaining to the use of crisis procedures, as well as a right to be informed of each and every instance that these procedures are used with their children.
• 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.

Recommendations

1. Restraint used to control behavior should be used only under the following emergency circumstances and only if all four of these elements exist:
   • The student’s actions pose a clear, present, and imminent physical danger to him or her or to others;
   • Less restrictive measures have not effectively de-escalated the risk of injury;
   • The restraint should last only as long as necessary to resolve the actual risk of danger or harm;
   • The degree of force applied may not exceed what is necessary to protect the student or other persons from imminent bodily injury.
   • These four components define the circumstances and limits of the use of restraint. Restraint should never be used as a punishment, to force compliance, or as a substitute for appropriate educational support.
2. U.S. states and school districts should have specific regulations for the use of physical restraints within educational settings.
   • States and school districts that do not have specific regulations should create them to ensure that both educators and policy makers are informed about and receive training on the use of these procedures and their potential for misuse, and the liability that might result.
     • Guidelines or technical assistance documents are not adequate to regulate the use of restraint procedures and generally do not contain mechanisms for providing oversight or correction of abuses.
   • Regulations:
     • Should apply to all students, not just students eligible for special education.
     • Should apply to all educational settings, not just public schools.
     • Should operationally define actions that fall within and outside of the definition of physical restraint.
     • Should prohibit dangerous types of physical restraint.
     • Should define crisis situations and include measures to assure it is used only in situations of imminent risk of serious physical harm to self or others.
     • Should specifically identify how the use of crisis procedures will be monitored at the state or district level (e.g., inclusion in accreditation procedures and monitoring in each educational facility) to include reporting of accurate incident data to an outside agency on a regular basis, identifying responsibility for assessing the accuracy of data provided by schools, and analysis of data and oversight along with intervention when data indicate overuse or potential abuse of restraint.
3. The type of restraints schools are permitted to use should be regulated by policy.
   • Prone restraints (with the student face down on his or her stomach) or supine restraints (with the student face up on the back) or any maneuver that places pressure or weight on the chest, lungs, sternum, diaphragm, back, neck, or throat are the most dangerous and should be used with extreme caution. No restraint should be administered in such a manner that prevents a student from breathing or speaking. Training programs should specifically train how and why they must be avoided.
   • Mechanical restraints should never be used in school settings when their purpose is to manage or address student behavior, with the following two exceptions:
     • Vehicle safety restraints should be used according to local, state, provincial, and federal regulations as needed for student safety when in vehicles.
     • Mechanical restraints employed by law enforcement officers in school settings should be used in accord with their policies and acceptable professional standards.
4. Positive and preventive procedures should be in place to reduce the reliance on reactive procedures.
   • All school personnel should be trained on how to implement positive behavior supports.
   • Data should be collected to verify implementation of positive supports and procedures. Mental health supports should be available to students with a process to identify students in need.
5. Restraints should only be conducted by persons who are trained in the use of such procedures. Professional learning and ethical practice standards should be developed by each educational accreditation agency/organization.
   • Training must be relevant to the particular setting. For example,training designed for mental 60 Behavioral Disorders 46(1) health agencies may not translate well into educational settings. Likewise, procedures designed for self-defense may be inappropriate in educational settings.
   • Training should result in some form of certification or credential for each individual staff member and overall certification or credential for the school district, agency, or school.
   • Training should be recurrent with annual updates at a minimum and should be appropriate to the type of school setting and to the age and developmental level of students.
   • Training should include content and skills on the use of positive, instructional, preventive methods for addressing student behavior. Because restraints have a history of being used as punishment, staff training must include procedures to correct the perception that it is acceptable to use in this manner.
   • Training should include content and skill development on conflict prevention, de-escalation, conflict management, and evaluation of risks of challenging behavior.
   • Training should include potential psychological harm that the use of these procedures may have on children who have experienced trauma related to previous abuse.
   • Training should include information about how medications or health problems and might affect the physical well-being of the student during restraint procedures.
   • Training should include multiple methods for monitoring a student’s well-being during a restraint.
   • Given death and injury associated with restraint, training should minimally include certification in First Aid and cardiopulmonary resuscitation (CPR) in the event of an emergency related to restraint.
   • A pulse oximeter and a portable automatic electronic defibrillator, and related training for staff on their use, should be available and readily accessible in any school where the use of physical restraint is used.
6. Each incident of restraint should be immediately documented, including the student behavior that resulted in the restraint, de-escalation procedures used prior to the restraint, the type and length of the restraint.
   • A copy of this documentation should be placed in the student’s permanent record.
   • Parents or guardians should be informed as soon as possible after each and every incident of restraint and should be provided a copy of all documentation as soon as it is created.
   • The program supervisor or building administrator should be informed as soon as possible after each use of restraint. In addition, data should be provided to district- and state-level staff, as required, and federal agencies for documentation and planning.
   • Due to the risk of injury, shock, and potential delayed effects, the physical well-being of the student should be monitored for the remainder of the school day. Similarly, the physical wellbeing of the person(s) who conducted the restraints should be monitored.
   • A staff debriefing should occur as soon as possible after every incident of the use of restraint but no later than 48 hours after the incident.
     • This debriefing should include all of the participants in a restraint situation, an administrator, and at least one other staff member who has expertise in the use of behavioral techniques and who was not involved in the restraint procedure. For students with behavior support plans, team members should also attend to discuss revisions to the plan.
     • Parents or guardians should be invited to participate in this debriefing.
     • The student should also be invited to participate. If not, a special debriefing with the student should occur separately.
     • The debriefing should focus on antecedent conditions that preceded the behavior of concern, alternate interventions that were used and why they were unsuccessful in deescalating the behavior, how this situation could have been handled in such a way to prevent the need for the use of restraint, and how a similar event could be avoided in the future.
     • A report of the finding of this debriefing should be included in the student’s file with a copy provided to all of the student’s teachers and sent to the parents or guardians.
7. Schoolwide safety coupled with plans to avoid/reduce/eliminate use of restraint should be developed for every district/school.
   • Research indicates that state policies appear to have little correlation with frequency of restraint rates and despite an increase in the number of states adopting policies, state trends in use remain similar across school years (Gagnon et al., 2017); therefore, additional reductive plans are needed.
   • Regular, team-based reviews of policies should be conducted with school emergency plans updated and revised as indicated by crisis response data and other relevant information (e.g., changes in relevant legislation, other behavior data).
   • Repeated use of physical restraints for any one student or multiple physical restraints across different students should be viewed as the failure of educational programming and indicate the need to modify supports, educational  methodologies, and other interventions.
8. Restraint should not be included in individualized safety or emergency plans.
   • For students with disabilities, the use of restraint is an emergency procedure and should not be incorporated into the student’s Individual Educational Program (IEP) or Behavior Intervention Plan (BIP) and should not be considered a behavior change strategy. IEPs and BIPs reflect plans for educational programming. Physical restraint is regarded as an emergency procedure that should be a part of an emergency or safety plan, not routine programming. CCBD asserts that it is the obligation of educational staff to be fully apprised of medical needs and the health status of all students and the implications for use of restraint. Furthermore, employment of restraint outside indicates the need for comprehensive staff training to assure restraint is never unnecessarily, prematurely, or inappropriately used. More generally, inclusion in an IEP or BIP might legitimize physical restraint as part of educational programming, imply that it could be used routinely by educators, and may be interpreted by staff members (though wrongfully) that the parent or guardian has provided consent or support for its use by signing the IEP.
9. The U.S. Department of Education and its Institute of Education Sciences (IES) should develop and fund a series of studies to address the current lack of research on all aspects of physical restraint. Research should be conducted regarding the use of restraint with students across all settings, with the goal of reduction and/or elimination. Areas for future research include but are not limited to\
   • How often restraints are employed in various settings;
   • Which specific types of restraint are used;
   • The nature of the antecedents or behavior that precipitates restraint;
   • The Diagnostic and Statistical Manual diagnoses (American Psychiatric Association, 2013), special education category (if applicable), or other characteristics of students who receive restraint;
   • The intended purposes or goals of restraint;
     • The efficacy/lack of efficacy of restraint procedures in achieving these goals;
   • The potential outcomes or side effects including injuries and fatalities to student or staff as a result of the use of restraint in schools as well as other long-term psychological, emotional, behavioral, and other effects on students or staff;
   • The training level and certification of each staff members involved with the incident where restraint is employed;
   • The degree to which procedures for de-escalation of student behavior and positive behavior supports are used before, during, and after restraint;
   • The existence or lack thereof of policies and procedures related to restraint.
10. CEC, CCBD, and other divisions should collaborate with other appropriate professional organizations to create content and training standards, quality indicators, and accreditation procedures for crisis intervention training which includes physical restraint. This effort can be informed by the BILD model in Great Britain.