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Policy Analysis of Child and Adolescent Physical Restraints

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Jillian Clark

on 27 April 2010

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Transcript of Policy Analysis of Child and Adolescent Physical Restraints

Policy Analysis of Child and Adolescent Physical Restraints Jillian Clark
Lisa Conner
Nicholas Haberek
Ashley Owens
Rilka Stefanov child welfare = a HOT topic! This topic has been on the agenda of many candidates running for public office (President Barack Obama and Senator Hilary Clinton)

1998- a series of newspaper articles reported OVER 142 fatalities that occured in past decade due to physical and mechanical restraints, psychotropic meds, isolation, and seclusion in ages 6 -78 yrs old KEY POLICY ISSUE The responsibility for law and policy-making governing the use of restraints on children and adolescents is given to individual states

There are many discrepancies in the treatment and safety of children/adolescents in schools, residential settings, and wilderness programs

States lack the following: (a) a clear definition of an acceptable physical restraint, (b) standardization of technique, (c) education and training for staff/personnel in positions where physical restraints are enforced, (d) sanctions for agencies that do not follow appropriate crisis intervention techniques, as well as (e) incentives for agencies to conform to evidence-based practices
1800s- private and religious organizations began caring for orphaned children (Murray & Gesiriech, 2010).

1900s- the first child welfare state laws were passed, the first national conference on child welfare was held, and the first Children’s Bureau was created.

SSA 1935- The very first funding for child services (Murray & Gesiriech, 2010). The SSA also created Aid to Dependent Children (ADC), which was later, renamed Aid to Families with Dependent Children in 1962, and then again renamed to Temporary Assistance for Needy Families (TANF) in 1996 (Murray & Gesiriech, 2010).

1974- Congress passed The Child Abuse Prevention and Treatment Act, which created a federal law requiring states to develop a system of reporting child abuse and allocating federal funds for such programs. a little history...

Recent Cases/ Injury &Death Butler's Study (2009)

Butler composed a chart of the states with laws, and the extent to which those laws regulated restraints.

21 of the 50 states had substantial restraint and seclusion laws

4 states reported some sort of law

23 states had no laws but some had policies

only 11 states banned the use of mechanical restraints while only 7 seven states banned the use of chemical restraints

even in the states that had laws or policies on physical restraints, the definition of a restraint and body parts allowed vary.

In only 16 states do the laws define which body parts apply in a restraint, and 15 states define restraint in terms of the entire body (Butler, 2009).

The Preventing Harmful Restraint and Seclusion in Schools Act(H.R. 4247): a bill aimed at preventing/ reducing the use of physical restraints and seclusions in school settings.

Purpose of the act is mainly to prevent and reduce the use of physical restraints in school settings, to provide school personnel with appropriate training, and to collect data and evaluate when restraints are performed.

Includes a minimum of standards that limits or restricts the use of certain restraint techniques and requires documentation and enforcement of the standards listed in the bill. requires a national assessment to analyze when restraints are performed and to identify programs that help reduce the number of restraints.

Passed the House of Representatives favorably in February of 2010. Current Legislation On Restraints
Children are more likely to be restrained and secluded than adults in similar environments (GAO report, 1999).

Children/adolescents are smaller in stature and weaker, and staff may overpower and injure them more easily than with adults.

While many programs may utilize some type of in-house training, the lack of universalized protocols, procedures and techniques lead to a wide variety of practices, some of which are very dangerous.

Programs are neither punished for inappropriate practices, nor rewarded for complying with the standards that do exist.

The lack of a universal definition for the term restraint may mean that even more fatalities have occurred without being reported as the result of a restraint.
MODEL Major contributing factors!
One industry standard seems to be that restraint is justified when a child or adolescent is putting themselves or others in danger of serious injury or death (Nunno, Holden, & Tollar, 2006).

Other programs may include, ‘attempting to flee the program’ and ‘attempting to destroy valuable program property’ within the boundaries of when restraints are appropriate. What situations justify physical restraint? There needs to be a concrete set of standard definitions regarding the usage of restraints from a “who, what, where, when, why, and how perspective”.

Specific issues that require attention include, but are not limited to the following:
(1) how is ‘restraint’ defined,
(2) who is eligible to perform a restraint,
(3) what the appropriate use of a restraint is,
(4) where restraints can occur,
(5) the place/environment where a restraint can take place,
(6) why the restraint is taking place, and
(7) how the restraint is done (i.e., the type of method).

In addition, this policy will address what will happen if treatment facilities and/or schools fail to comply with the proposed policy.d Description of Policy Recommendation 1. To determine what type of physical restraint is appropriate for children and adolescents.

2. To establish a standardization of the use of nonviolent crisis intervention in all programs that service children, adolescents, adults, and their families.

3. To create a mandatory concrete training/ educational program for any personnel who are working in an environment where a child or adolescent may need to be restrained due to issues of safety.

4. To develop and implement monetary sanctions to agencies that do not adhere to the techniques that are outlined in the nonviolent crisis intervention manuals.

5. Money incentives should be given to agencies that actively seek to improve their knowledge and use of nonviolent crisis intervention.

6. To develop a Physical Crisis Prevention Team for the state of New Hampshire that would serve to record and evaluate the state’s agencies.

7. To write a bill proposed at the national level in an effort to standardize physical restraint practices in the US Policy GOALS Advocacy Strategies To develop communication between the following parties:

(1) the US Department of Health and Human Services: Administration of Children and Families,

(2) the International Association of Nonviolent Crisis Intervention,

(3) the National Alliance on Mental Illness (NAMI),

(4) the Child & Adolescent Action Center,

(5) the Child Welfare League of America, and

(6) the Coalition Against Institutionalized Child Abuse (specifically support the bill H.R. 5876: Stop Child Abuse in Residential Programs for Teens Act of 2008).

As well as to spread awareness about the use of nonviolent crisis intervention; talk about and distribute literature describing the dangers of not standardizing physical restraint policies at the state level; discuss the implications for having personnel who are not trained in nonviolent crisis intervention work with children and adolescents ; and the need for a state law, eventually a federal law, to be passed that requires all agencies working with children and adolescents to adhere to the guidelines of nonviolent crisis intervention. Major Stakeholders
The major decision-makers who would need to be persuaded in order to endorse the proposed legislation are:

The Children’ Defense Fund
The Advocates Coalition for the Appropriate Use of Restraints
The Child Welfare League of America
The National Alliance on Mental Illness’s (NAMI)
The Federation for Families and Children for Mental Health (FFCMH) Mental Health America
U. S. Department of Health & Human Services’ Health Care Financing Administration (HCFA).
The Coalition Against Institutionalized Child Abuse (CAICA)
The Government Accounting Office (GAO)
National Down Syndrome Congress (NDSC)
Further research needs to be conducted to evaluate the efficacy and implications of restraints and seclusion on children and adolescents.

This research can be facilitated by incorporating a national database for reporting all cases of institutional abuse.

The recommended policy suggests the use of nonviolent crisis intervention and the philosophy that restraints are a failure to treat clients.

By standardizing state and federal policies, all personnel and programs serving children and adolescents will use appropriate de-escalation techniques, which will cultivate a safer environment and reduce the number of injuries and deaths as a result of restraints.

This proposed policy has addressed key issues surrounding the use of physical restraints with children and adolescents in residential and school settings.

Contingent upon the success of the Preventing Harmful Restraint and Seclusion in Schools Act (H.R. 4247), which has passed the House of Representatives with an overwhelming majority, the authors speculate that the recommended policy would fare well in Congress. Conclusions. Very few states currently have laws or policies on the physical restraint of children and adolescents.

In 1995 a 9-year-old boy from NH died while being restrained in a Massachusetts school for autistic students (New Hampshire Department of Education, 2005).

A 12-year-old boy suffocated at a residential school while being restrained face down with his arms crossed over his chest.

An 11-year-old boy died at a Connecticut psychiatric hospital while two aids restrained him by sitting on his back.

A disturbing finding Steel is that 26% of the deaths related to restraint populations are children (Steel, 2010).

A descriptive study compiled information from 45 fatalities that occurred during the use of restraints on children and adolescents (Nunno, 2005)

Approximately half of the restraints that led to fatalities were preceded by behaviors that could be categorized as dangerous to self or others, which means that approximately half of the restraints that took place followed situations that would not be considered appropriate to use physical intervention.

38 of the 45 fatalities were the result of prone restraints

25 of the 45 were caused by asphyxia.

Values underlying model. One of the ongoing debates within the issue of restraining children is the intent and necessity of this action.

For some the act of restraining an individual represents a failure to treat that client (LaFond, 2007).

Some programs have even removed restraints from their protocols, resulting in restraint free environments.

Other professionals see restraints as a measure of last resort, but as a necessary method to control crises; and may argue that it would be difficult or impossible to provide treatment, while keeping patients and staff safe without the use of restraints and seclusion techniques (GAO, 2009).

While the former philosophy is admirable, from the perspective of a policy addressing a multitude of environments, the latter perspective seems the most accurate and reasonable for this model.

Butler, J. (2009). State Laws (Statutes & Regulations) on Restraints/Seclusions. Retrieved from
www.wrightlaw.com .

Crisis Prevention Institute, Inc. (2010). Non-Violent Crisis Intervention History. Retrieved
from http://www.crisisprevention.com

Health and Human Services. (2010). Senate bill 396-FN: As amended by the senate. Retrieved from

LaFond, R. (2007). Reducing seclusion and restraint for improved patient and staff safety. Journal of Safe Management of Disruptive and Assaultive Behavior. Retrieved from: http://www.crisisprevention.com/research/pdf/Lafond-from-07-JSM-JOU-002.pdf

Murray, K. O & Gesiriech, S. (2010). A brief legislative history of the child welfare system. The Pew Commission on Children in Foster Care. Retrieved from www.pewfoster.org .

New Hampshire Department of Education. (2005). Guidance on considering the use of physical restraints in New Hampshire school settings. Bureau of Special Education.

Nunno, M., Holden, M., & Tollar, A. (2006). Learning from tragedy: A survey of child and adolescent restraint fatalities. Child Abuse & Neglect 30, 13331342

Peterson, R. (2002). Effective responses physical restraint. Retrieved from

Residential Child Care Project. (2010). Therapeutic crisis intervention system edition 6 information bulletin. Ithacy, NY: Family Life Development Center.

Singh, N., Lancioni, G., Winton, A., Singh, A., Adkins, A., & Singh, J. (2009). Mindful staff can reduce the use of physical restraints when providing care to individuals with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 22(2), 194-202. doi:10.1111/j.1468-3148.2008.00488.x.

Special Residential Services Board. (2006). Best practice guidelines in the use of physical
restraint. Retrieved from http://www.srsb.ie/getdoc/9246779b-835d-40f5-a4d6-dddc2c4aa3fc/Best-Practice-Guidelines-in-the-Use-of-Physical-Re.aspx

Steel, E. (2010). Seclusion and restraint practice standards: A review and analysis. Mental
Health America. Retrieved 3/23/2010. www.ncstac.org.

Stubbs, B., & Alderman, N. (2008). Physical interventions to manage patients with brain injury: An audit on its use and staff and patient injuries from the techniques. Brain Injury, 22(9), 691-696. doi:10.1080/02699050802270022.

Temple, R., Zgaljardic D., Yancy, S., & Jaffray, S. (2007). Crisis intervention training program: Influence on staff attitudes in a post acute residential brain injury rehabilitation setting. Rehabilitation Psychology, 52(4), 429434

U.S. Department of Health and Human Services. (2010). Retrieved from www.hhs.gov.

U.S. General Accounting Office, (1999). Extent of risk from improper restraint or seclusion is unknown (GAO/T-HEHS-00-026). Washington, DC: GAO

U.S. Government Accountability Office, (2009). Seclusions and restraints: selected cases of death and abuse at public and private schools and treatment centers (GAO-09-719T). Washington, DC: GAO.

Williams, D. (2009). Restraint safety: An analysis of injuries related to restraint of people with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 22(2), 135-139. doi:10.1111/j.1468-3148.2008.00480.x.
References Congress
HCFA The Children’ Defense Fund
The Advocates Coalition for the Appropriate Use of Restraints
The Child Welfare League of America
The National Alliance on Mental Illness’s (NAMI)
The Federation for Families and Children for Mental Health (FFCMH) Mental Health America
The Coalition Against Institutionalized Child Abuse (CAICA)
The Government Accounting Office (GAO)
Proponents Decision Makers
Opponents Taxpayers' Union
National Down Syndrome Congress
Grand Old Party

... A moment to discuss
Rural Poverty?! Organizational Analysis

HCFA & ASL (Assistant Secretary for Legislation
Extra Personnel for Nonviolent Crisit Intervention
Facility Expansion
Equipment (computers, internet access, SPSS)
School Settings
Loss of Funding
Pressure from Special Interests

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