Is restraint always abuse?
There is no place for abusive treatment of any person, especially children.
Posted Jun 03, 2010
After a fairly long hiatus in preparation for and attending the annual Association for Behavior Analysis conference I'm going to get back to work by stealing from some work I did in preparation for that meeting. One of the highlights for me at the conference was a panel discussion I chaired on Seclusion and Restraint. Among the panelists was, world famous author (with Nate Azrin) of "Toilet training in less than a day" Richard Foxx. In the US Senate there is currently a bill (HR4247/S2860; http://www.wrightslaw.com/info/restraint.bill.hr4247.pdf) that proposes federal regulations for seclusion and restraint in elementary and secondary schools. Though this blog focuses on autism (students with autism would clearly be impacted by this legislation) this legislation is relevant to all children. The "Keeping All Students Safe Act" was passed by the House of Representatives in March but is it a good bill? To figure that one out, we should take a look at what the bill states.
The bill would establish federal standards for the use of restraint and seclusion (R & S). Regulations across the country are quite variable. Some states have no regulations or reporting standards while others very tightly control R & S with certain procedures being banned outright. So, the primary goal of imposing federal standards is, in my opinion, important and necessary. There is no place for abusive treatment of any person, especially children. R or S used in an abusive manner is intolerable. The federal act would ban elementary and secondary school personnel from managing a student "by using any mechanical or chemical restraint, physical restraint or escort that restricts breathing, or aversive behavioral intervention that compromises student health and safety". This is a pretty complicated statement. No one should argue with banning procedures that restrict breathing or compromise health and safety. It should also be noted that no one should use any of these types of procedures without extensive training and close monitoring (the bill explicitly addresses this). However, as to the prohibiting of these procedures, an argument can be made that when some of these procedures are implemented in a manner that does not compromise health and safety, they are occasionally (and very infrequently) necessary.
Let's start with mechanical restraint. There are some applications of mechnical restraint that are very effective and humane interventions. Self-injury occurs somewhat frequently in persons with ASDs and has been estimated to occur in between 10 and 30% of individuals with developmental disabilities. The prevalence is thought to be on the higher end in persons with more severe impairments and autism. A smaller percentage of these folks produce significant injuries to themselves with some of the more common injuries consisting of lacerations, bruising, scarring, and injuries to the eye including retinal detachment. Death from self-injury has also been reported.
One type of mechinical restraint, arm limiters or arm splints (which limit flexion at the elbow), has sound evidence of it's effectiveness (see the Association of Professional Behavior Analysts or APBA statement of the support for the use of R & S; http://www.apbahome.net/Support%20for%20APBA%20Pos%20Stmt%20-%20Restraint%20&%20Seclusion.pdf). This research shows that these devices can reduce severe self-injury. Interestingly, there are three mechanisms through which this effective intervention can occur. The first involves continuous application of a rigid arm limiter that is then faded in its rigidity in a systematic manner (e.g., Fisher et al., 1997; Pace et al., 1986; Powers et al., 2007). Fading occurs by gradually reducing the rigidity of the arm restraints while maintaining low levels of self-injury (Fisher et al.,1997; Lerman et al., 1994; Pace et al., 1986). Some persons find the arm limiters to be unpleasant and when they are applied following an occurrence of self-injury that can make self-injury less likely to occur with contingent application of the arm limiters (Rapoff, Altman, & Christophersen, 1980). On the other hand, some people like the arm limiters and when the arm limiters are provided to the person when they do not engage in self-injury, this can increase appropriate behavior while self-injury decreases concomittantly (Favell, McGimsey, & Jones, 1978; Favell, McGimsey, Jones, & Cannon, 1981; see also Lindberg, Iwata, & Kahng, 1999).
I'm going to skip discussing chemical restraint because I do not view this as a behavioral intervention. However, there is some evidence to suggest that certain medications may, as part of a comprehensive behavior management plan, help diminish the severity of certain problem behavior. Function-based assessment of the problem behavior is a critically important part of developing effective behavioral programming (see my previous post on this topic; http://www.psychologytoday.com/blog/radical-behaviorist/201001/self-harm-or-request-help).
The next topic is aversive behavioral interventions. What is an aversive behavioral intervention? Many people will have differing opinions. Is any procedure that involves punishment an aversive procedure? (I've also heard people, including some Psychologists, say that negative reinforcement is not an aversive procedure but those people are incorrect.) In lay terms punishment involves retribution and though this is not part of the technical language of behavior analysis, one type of punishment is, by definition aversive. That would be positive punishment, the first technique described in the following sentence. Punishment involves either the addition of an event (like extra homework) or the removal of an event (like the loss of a scheduled event, like recess) that decreases the probability of a response class (like failure to complete one's homework or speaking rudely to a teacher or peer in class). I choose these examples to illustrate common consequences in schools that could be considered aversive behavioral interventions. The devil is in the details of what the language is in the law, should it pass, and in how it is implemented. I will write a post in the near future about aversive control and how it is involved in so many aspects of our daily lives (not that this is necessarily a good thing). That said, there are clear guidelines for the use of aversive interventions for behavior analysts (these can be found here; http://www.bacb.com/consum_frame.html). The fundamental tenet of behavioral intervention for severe problem behavior is to use the least intrusive, yet effective procedures.
There are a couple of other aspects to the HR4247 that I'd like to touch on. One is that each instance of the use of R & S must be reported to parents in a timely fashion. This is a critically important part of the legislation. Moreover, the general reporting of the use of procedures within each state will 1) help to provide critically important yet absent information about how often such procedures are used; and, 2) provide the necessary baseline for evaluating the effectiveness of a state's implementation of these guidelines in terms of decreasing the use of the procedures and tracking other relevant events (e.g., injuries to students and school personnel).
Last, but certainly not least. The bill would prohibit writing R or S into a child's IEP as a planned intervention. This is ass backwards. The only situation in which R or S should be regularly allowed is when developed as part of a systematic plan of action that is implemented and monitored by competent, qualified personnel. What a systematic plan of action for those rare instances in which R or S is warranted is nicely articulated in the APBA position statement on R & S (http://www.apbahome.net/Restraint_Seclusion%20.pdf).
APBA maintains that restraint and seclusion procedures should only be used to intervene with severe problem behaviors when
• the individual lives in an environment in which he or she is safe from harm, has access to experiences and interactions that promote his or her wellbeing and development, and is supported by caregivers who
have meaningful relationships with the individual;
• a problem behavior is extremely serious and clearly jeopardizes the safety, wellbeing, and quality of life of the individual or others;
• a medical evaluation has been conducted to assess and address medical conditions that may be contributing to the problem behavior;
• medical professionals have determined that there are no contraindications to the use of the planned intervention;
• less restrictive alternative interventions are clearly not feasible, safe,or effective;
• a functional behavioral assessment has been conducted to identify environmental conditions that trigger and/or maintain the severe problem behavior; and
• there is a written comprehensive intervention plan that
o is developed by the individual, his or her family, and his or her education or treatment team. The team must include a Board Certified Behavior Analyst or another properly credentialed professional with documented training in ABA and experience in treating severe problem behaviors, a physician, and other relevant professionals. The behavior analyst ensures that the intervention plan conforms to current best practices and ethical standards for the treatment of severe problem behavior, and is responsible for overseeing its implementation. The physician determines that there are no medical contraindications to the planned intervention, and that proper medical safeguards are in place when seclusion or restraint is employed. The entire team is responsible for monitoring the intervention plan and seeing that it is implemented correctly.
o is customized to the strengths, needs, preferences, and circumstances of the individual and his or her family.
o is agreed to voluntarily and in writing by the individual and his or her parents or legally authorized guardians or surrogates after they have been provided with complete, accurate, and understandable information about all intervention techniques that will be used with the individual. That information must
include evidence of the effectiveness of the techniques, their risks, and the risks and benefits of all alternative interventions and of no intervention for the problem behavior.
o includes procedures to prevent or reduce the occurrence of the severe problem behavior by modifying or removing the environmental causes of the behavior.
o includes safeguards to minimize risks of harm, especially when restraint or seclusion procedures are used.
o includes procedures to build appropriate skills that can serve as alternatives to the severe problem behavior and otherwise improve the individual's functioning and quality of life.
o is implemented by personnel who are trained to implement the entire intervention plan competently and ethically, and who receive frequent direct supervision from a properly credentialed behavior analyst with experience in treating severe problem behaviors. If the intervention plan includes restraint or
seclusion, the behavior analyst and all personnel must be explicitly trained to implement those procedures competently, safely, and ethically.
o is adjusted as needed based on frequent review by the behavior analyst of data representing objectively measured occurrences of the problem behavior, implementation of the intervention
procedures, and appropriate alternative behaviors.
So, in summary, this is an important bill geared towards protecting children, all children. But those with ASDs and developmental disabilities will be particularly affected by this legislation. It is my hope that a revised, reasoned, and informed version of the current bill passes.