Historically, physical restraints have been used freely on children, developmentally disabled persons, and the mentally ill, as well as on persons convicted (or just accused) of crimes. After years of discussion at the end of the last century, Federal legislation, as part of the Children's Health Act of 2000, began to regulate the use of restraint and of seclusion in psychiatric facilities. This legislation (described by the Bazelon Center for Mental Health Law at www.bazelon.org/issues/restraintandseclusion/moreresources/childr...) guaranteed the rights of children and adolescents in psychiatric facilities to be free from the use of restraint or seclusion as means of coercion, discipline, convenience, or retaliation for misbehavior. The use of restraint as a necessary safety measure was recognized, but whatever the situation, the least possible effective restraint was to be used. The Department of Health and Human Services published in the Federal Register new guidelines for use of restraint and seclusion, including time limits for each episode and documentation of the event and the child's condition following it.

To repeat, however: the Children's Health Act established rules for children and adolescents in psychiatric facilities. These rules did not apply to children at school, in a therapist's office, or at home. Although some forms of restraint and seclusion may be considered as child abuse for research purposes, it would be unusual for their use to be considered a legal problem unless a child was injured. In fact, children in those situations are not considered to have a right to be free from restraint used for coercion, discipline, convenience, or retaliation. Paradoxically, children in some institutions have a right guaranteed to them, which is not guaranteed to the average child living at home.

We seem to be in a period of transition between an older view that vulnerable persons may be restrained by those in authority, at the will of the latter, to a possible future view that disapproves of the use of force for any reason other than safety. So far, we have only come to that future view with respect to children and adolescents in psychiatric care. The actions of the GAO and other groups show that discussion is beginning of an extension of the Children's Health Act protections to children in schools. Perhaps another ten years will be required before advocates of this change are successful.

Meanwhile, we have yet to begin a real discussion of the use of restraint either in a therapist's office or at home. There are a few unconventional therapists who claim, without evidence, that restraint has a therapeutic effect. If these therapists use restraint in their offices, and there are no injuries that need treatment and no complaints from parents, there is no statement of objection to their actions. There are also a number of parents who employ restraint for purposes of coercion, discipline, convenience, or retaliation, either because of their own attitudes or because of advice from unconventional therapists. Unless a child is injured and a court sees this behavior as wrong, parents may use restraint and seclusion freely.

The issue of use of restraint by parents is an especially complicated one because of developmental issues. In the United States, as well as in many other parts of the world, young children up to age 4 or 5 or often restrained by their parents for reasons other than safety. Parents of young children use restraint for coercion, discipline, convenience, and retaliation, and I certainly do not claim that they should never do this. When you have an unco-operative two-year-old, who does not want to come and have a bath, it may work very well for everyone to chase him, pick him up upside-down, tickle him a bit, and bear him off shrieking and giggling to where the bathwater waits. This is restraint, it's done for the purpose of coercion, but it's fun too. When you're trying to make your way to your gate at an airport with a toddler who wants to walk 20 feet behind you, you may pick her up for convenience, and what parent would argue with that?

The question thus becomes not whether restraint should ever be used by parents, but what circumstances are the wrong ones and what is the age at which restraint should no longer be used for purposes other than safety. At present, these issues need to be resolved by individual families. There is no national dialogue relevant to parental use of restraint, and only when a child is injured or killed (as in asphyxia from prone restraint) is any consideration given to these questions.

When restraint is used in psychiatric facilities for children and adolescents, staff members are carefully trained in restraint methods, and in addition they are subject to clear rules about the circumstances and timing of physical restraint and are required to document restraint events. While many school staff members may receive training, their guidelines may not be clear, and documentation is hazy. Therapists working in their offices, however well trained they may be, do not have to report or document their use of restraint, and of course parents are not required to be trained or anything else.

Without wanting to argue that all these adults should be subject to exactly the same rules, I would suggest that it is time to begin a discussion of how restraint should be regulated when used by any of the groups who are currently not covered by the Children's Health Act. Let's start by working out sensible guidelines for school staff and then go on to consider office practice and parental use of restraint.