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Children's Voice Article, September/October 2003

Practicing Restraint

By Scott Kirkwood

Restraint and seclusion were once considered acceptable, even valuable tools in maintaining control of unruly children in residential group homes. But the call for alternatives is growing louder.

The 11-year-old girl stood outside New York's Andrus Children's Center with a pile of rocks at her feet. She picked up one of those rocks and started carving words into the side of the agency's van--words that can't be printed here. When the staff tried to approach her, she threatened them, grabbed a rock from the pile at her feet, and took aim.

What would you do?

In the past, many supervisors at residential facilities would have found a way to physically restrain the child, bringing an end to the vandalism and the threat to the staff. But for some time now, Andrus staff have sought alternative approaches to restraint, recognizing the danger it poses to residents and staff alike, and the conflicting message it sends in what is ostensibly a therapeutic environment.

So the staff stood by and watched closely to make sure the girl was in no danger until her rage subsided, she put down the last rock, and she simply walked away. In the end, the child was spared any physical trauma, the workers were unharmed, and the agency had a memorable automobile insurance claim.

More Harm than Good

The negative effects of restraint have been well-publicized in recent years, most notably in a 1998 series in the Hartford (Connecticut) Courant implicating restraint in the death of dozens of children each year.

"Facilities that use seclusion and restraint have a much higher rate of injuries and sometimes deaths than institutions that don't use seclusion and restraint," says Kevin Ann Huckshorn, Director of the Office of Technical Assistance for the National Association of State Mental Health Directors in Virginia. "Before the Hartford Courant expose, many people thought, 'We use restraint because we have to--it's a serious intervention that must be done well,' but now we're starting to ask why we're using restraint at all."

If the Courant series revealed the lethal physical component of restraint, new research reveals the mental component is just as important.

"Children who are victims or witnesses to abuse experience significant changes in the way they regulate their emotions over time, creating all kinds of problems as they get older," Huckshorn says. And yet as these children escape violent, abusive surroundings, they are all too often subject to violence in a venue designed to protect them.

"I think we've confused what's therapeutic in terms of intervention," says Janice LeBel, Director of Program Management for the Child and Adolescent Division of Massachusetts's Department of Mental Health (DMH). "There was a tacit belief that containing children, setting harsh limits, and imposing a physical restraint or seclusion was somehow therapeutic. How we got the idea that meeting a child's history with violence was somehow going to be palliative and restorative, we don't know."

If a child's past is the powder keg that makes potential conflict so explosive, it's often the staff who provide the spark. "In reviewing restraint episodes involving children, we noticed a pattern," says Nan Stromberg, Director of Nursing and Licensing for Massachusetts DMH. "When kids were in trouble and in distress, the staff would set limits, and the kids would then become more agitated--a recipe for restraint."

"Research that looks at why restraint increases [stress] points to the phenomenon of counteraggression," says Paul Jones, Staff Development Coordinator at Home of the Innocents in Louisville, Kentucky. "When you feel like you're being attacked, there may be an [instinctive] reaction, and a staff member [may be contributing to that situation]. Counteraggression prevents people from being able to let those verbal assaults or other things go."

"Everyone [is vulnerable to counteraggression], whether they admit it or not," Jones warns, "but the extent to which it happens decreases with experience and training."

When Stromberg and LeBel decided to investigate the backgrounds of children involved in the most restraints, they found that more than 85% had significantly well-documented trauma histories.

"These kids weren't seeking out restraint, they were traumatized," Stromberg says, "and their needs were being expressed and being poorly met. Restraint was not only countertherapeutic, it was [repeating] the abuse they had already experienced. Once we understood that was a critical variable, we were forced to step back and do business in a different way."

At New York's Bellevue Hospital, where restraint is not used at all in the child unit, and only rarely in the adolescent unit, Stromberg and LeBel found a staff committed to doing whatever it took to see a child through a crisis by talking through the situation.

"In the adolescent unit, we saw a remarkable example where a girl was very out of control, pounding the wall," Stromberg says. "Instead of offering the usual 'You've got to lower your voice and get in control,' the nurse manager was validating her anger, saying, 'I know you're angry, and that makes sense--I'd be angry too.'" The staff were able to escort the other children from the room, and in that quieter setting, the situation was quickly diffused.

But to the DMH officials, it all seemed too simple. "We grilled the directors," LeBel says, "looking at numbers of staff and training and how much they paid their workers, figuring there had to be some big difference that allowed them to be restraint free, but there wasn't one. But there was crystal-clear, rock-solid leadership [committed to finding another way], and a group of people who understood they could negotiate any kind of crisis without resorting to restraint."

Stromberg and LeBel brought others to Bellevue and immersed them in the experience as well. And because they knew it was not enough to mandate the abolition of restraint, they set up training opportunities, connected agencies to one another so they could share best practices, brought in a consultant to answer questions, and supported the effort statewide. After just 2 1/2 years, the use of restraint and seclusion was down 78% in licensed child facilities across Massachusetts, 65% in agencies with a mix of child and adolescent services, and 44% in adolescent service agencies.

A Philosophical Change

Of course, the numbers aren't an end in and of themselves. Often, the numbers are just the beginning. Many agencies find the process of simply monitoring restraint more closely has a remarkable affect on its use.

"Once you start measuring something, it's a pretty powerful tool to get people to start looking at their actions," says Steve Karp, Chief Psychiatric Officer for the Pennsylvania Department of Public Welfare. "When we throw a graph up on the wall, [staff at one hospital] can recognize they're not doing as well as some of the other hospitals, and that really motivates them to bring their numbers down. There was a decent disparity among hospitals initially, but now they're all very successful because the ones that weren't doing so well communicated with the others and asked what they were doing to get their numbers down."

When a physical intervention raises a red flag, people think twice before choosing restraint. Karp and others say making people accountable for such decisions forces them to ask, "Is this really worth the trouble?" Of course, management needs to show the new approach is designed to help residents, not punish staff.

"In the past, a staff person got called on the carpet if they performed a hold and something went wrong--if a kid got hurt, or someone filed a complaint, or child protective services filed a report," says Brian Farragher, Director of Campus Programs for Julia Dyckman Andrus Memorial in Yonkers, New York. "But the idea of [reviewing these incidents] all the time diminishes that. It's not that you screwed up when you hurt a kid, it's that this is an intervention we prefer we not use. If you're doing it because you think you're trying to keep a kid safe, you need to justify that decision and be sure the child's behavior was more risky than the hold. That's a tough call to make."

If the issue turns into nothing more than a numbers game, agencies can find ways around it. Some agencies have manipulated medication levels to reduce restraint numbers. One agency called the police for every conflict, preventing the staff from resorting to restraint. That's why a complete philosophical change is a big part of the transition.

"Our belief now is that restraint is a treatment failure," Farragher says. "We end up physically holding kids when our program isn't holding them. To change that requires a team approach." Andrus's restraints went from 40 in one month to 20 the next, then slowly continued to decrease until only two holds were done in the month last tracked--and Farragher believes those could have been avoided as well.

A big part of that philosophical change must come from the leaders of the organization. Several people interviewed for this article have seen agencies try to make changes, only to have the leadership end the process. "If you don't have 100% buy-in from management, you're wasting your time," Jones says. "That's why senior managers, even CEOs, should get the same training as staff, so they know firsthand what's expected."

Many crisis-resolution training programs spend 90% of the allotted time focusing on restraint techniques, while others spend 90% on negotiation skills and only 10% on safe restraint. If the CEO doesn't understand the content, he or she can't choose the right training and can't help his or her staff by supporting and reinforcing their work after training.

Finding Better Ways

But if the leadership backs the new approach, the rewards can be handsome. When workers are forced to stop relying on restraint, they find different ways to negotiate the inevitable conflicts, and that often reveals deeper reasons for their causes.

Farragher tells of a young girl who was restrained on a regular basis. Once that option was removed, the root of the problem was exposed.

"Every night, [she] would get very agitated, and she would end up moving furniture around her room," Farragher says. "As soon as the staff heard noises, they would come into her room, correct her, and move the furniture back where it belonged. Inevitably this would escalate into a hold. But once we sat down and talked about [the situation], we learned she had a history of sexual abuse at bedtime--she was moving her furniture against her bed to make a barricade. The staff were getting agitated by all this activity when she should have been settling down to sleep, so it turned into this tragic reenactment--all of these provocative activities led the staff to respond by holding her down."

Two simple things ended the vicious cycle: The agency bought the girl a bunk bed, even though she was in a single room, thinking she might like having something above her, and they bought her a giant stuffed dog for her to sleep behind. She went from being restrained about eight times in a two-week period to not being restrained for six or seven weeks, and only rarely after that. "We put our heads together and figured out a different strategy," Farragher says. "If you have no motivation to do that, if you don't see restraint as a treatment failure, you have no motivation to change."

But motivation isn't always enough. It's easy to tell staff not to restrain residents, but unless you provide alternatives, you're unlikely to change their actions. As one supervisor noted, "If the only tool in your toolbox is a hammer, you'll treat everything like it's a nail." So how do you increase the selection of tools with a limited amount of time and an already overworked staff?

"These kids require your time one way or the other," Farragher says. "You can either give it, or they'll take it. Sure, [training new approaches] is labor-intensive, but restraints are too, and they usually happen when you least want to invest that time. These kids are complicated; they're not so easy to figure out. Restraint takes a lot of brawn, but not a lot of brains. Sometimes, it's easier to use restraint than to think through a situation and figure out how to avoid it."

The move away from physical restraint may have an unforeseen positive effect on workforce retention and turnover. "We recruit a lot of kids out of college ... who don't think of this work as rolling around on the floor wrestling with kids," Farragher says. "The work they want to do is more cognitive. Turnover is exacerbated by an environment with lots of restraints. Our retention has improved dramatically over the last couple of years, and the fact that staff aren't wrestling with kids every day is a contributing factor."

Stromberg agrees. "Instead of functioning as custodians and police, staff have been elevated to be teachers and role models."

Minimizing restraint goes beyond a single staff member dealing with a single child. That's where witnessing and debriefing come into play. Some agencies make sure that as soon as a potential conflict situation arises, at least one staff member is brought into the room to observe. When the debriefing occurs within 24 hours of the restraint, it's much easier for that individual to provide the most objective view of the event.

It's also a good idea to talk to the patient and speak to family members if possible to see if some deeper issues may be at work. Huckshorn recalls a case in a Florida mental hospital: A large young man in his mid-20s had entered the hospital's care; based on his record, the staff was very prepared for problems. He was surrounded by security guards and watched closely--staff were instructed to physically restrain him as soon as any conflict arose. The third day of his stay, the young man was put into restraint, and the process left him and three staff members with serious injuries.

When the staff analyzed the situation afterward, they learned the young man was manicdepressive and had entered a manic stage during group therapy, when he was expected to stay seated. When he tried to leave the room to watch television, three male guards told him to stay put, and the physical assault began. A debriefing with the patient's mother revealed the patient had been abused by his father for years and had grown leery of men; if he had been approached by a woman, he would have been more likely to talk through the situation. Once the staff accounted for the man's special needs, he was never again restrained in the two years Huckshorn remained at the hospital.

Relinquishing Control

Such situations point to potential problems that can occur when staff perceive the need to control residents. "[In] any residential environment where people are being treated in an institutional sense ... the traditional culture is characterized by control," Huckshorn says. "The mantra has been when you have a large group of people in [your care], you need to control them ... That's extremely conducive to using violence to make people do what they think they should do."

Mental hospitals may need to rely on physical interventions more than do children's residential centers, but if that field can make a commitment to lowering restraint, critics charge, then surely residential facilities for children can do the same.

"If you're looking at facilitating the growth or rehabilitation of kids who've already been traumatized and haven't had good role models, and you're trying to make them productive adults, you don't do that by forcing, coercing, controlling, and ruling them," Huckshorn says. "If you include the people in your facility in some of the decisions, give them some choices, and allow them to make some decisions, you have much less conflict."

When Andrus changed its approach, "there was an initial sense that we were giving away the store, the kids were going to walk all over us, and we were going to have terrible behavior management problems," Farragher says. "But all the ... major behavioral indicators, like AWOL, physical aggression, property damage, and assault, have gone down, and I think it's because aggression breeds aggression. The more you try to control, the more resistance you're going to encounter. Ultimately, we're not going to make these kids change [if they don't want to], so it's important they be in an environment where they understand they have some responsibility, some role in their own treatment."

"All models of recovery are based on empowerment, self-determination, collaboration, partnerships," Huckshorn adds. The more control an agency yields to its residents, the more opportunity for growth.

The notion of relinquishing control also applies in more systematic ways, too. Several hospitals and agencies have abandoned structured programs for some of their more challenged residents, adapting programs that allow for greater choice. For example, rather than require residents to attend group therapy or other activities based on a rigid schedule, some facilities provide four or five activities simultaneously and allow residents to choose.

Many agencies let their clients tell them what they need. The children at Pittsburgh's Bradley Center came up with 10 ways to cope with crisis and made posters that were distributed all over the units. "When Johnny is having trouble, the rest of the kids will say, 'Pick number eight, or pick number seven!'" says COO Dan Hunt. "Although leadership must drive the change, it can't be [forced on people]--your frontline staff, your kids, and families all have to get involved."

Odds are any approach to lowering restraint will also improve conditions on every level as children begin to see staff as supportive agents rather than potential adversaries. "Our agency is a kinder, gentler place--and these places have to be safe, because kids come here with multiple traumas, where people who were supposed to take care of them hurt them," Farragher says. "There's a real pull to use physical force because of the way some of the kids behave and some of the issues they bring in, but we've lost the sense that we need to control the kids--the kids are encouraged to control themselves."

"I was looking out the window of my office," he continues, "and saw two members of my staff with a kid who was storming the grounds, but they've just been shadowing her, making sure she's safe, and nobody's touching her. She'll blow off steam, then she'll be able to talk ... Ten years ago, we would've tackled her, and what would that do? She's not unsafe, she's not running into traffic, she's walking around a fairly pristine little campus here. Sure, it's frustrating for the people shadowing her, but at the end of the day, they'll all be OK."

Scott Kirkwood is Managing Editor of Children's Voice.

In Harm's Way

Those who cling to restraint as a valuable practice generally cite one potential problem with other approaches: What do you do if a child poses a serious danger to himself or others?

"Whoever is asking the question hasn't thought ahead," says Janice LeBel, Director of Program Management for the Child and Adolescent Division of Massachusetts's Department of Mental Health (DMH). "When you get to the point where somebody is self-harming, you've lost the chance to intercede early, to respond to the triggers that preceded that self-harming behavior."

"Behavior does not come out of the blue--it's triggered by something," adds Nan Stromberg, Director of Nursing and Licensing for DMH. "To work with a child and the parents to identify those triggers [beforehand], you need to plan and identify some actions that will help if the child gets upset--maybe coloring, maybe being in a rocking chair, being held, playing a game, telling jokes."

LeBel cites a push in Massachusetts for providers to adopt a public health approach. "The primary component is doing all your frontloading--thinking, planning how to avoid the use of physical intervention, and creating policies and procedures that can mitigate the need for restraint. The second component involves looking at the tools: Do we have the tools? Are they being used? Are they being incorporated into treatment plans? And lastly, if something untoward does happen, the third stage allows you to debrief: What happened? What went wrong? What can we learn? And it feeds right back into the process of retooling your whole system."

No matter how much planning one does, there's always a chance a youth will attempt to hurt herself or others. But even then, is restraint the only solution?

"If a kid is punching out windows, he could really be hurt, so we teach our staff to position themselves between the object and the kid, to reduce risk, and to try to talk them down," says Andrus Memorial's Brian Farragher. "But in reality, kids rarely do things like that--they may punch a window, but usually that's the end of it. They punch a window, it breaks, they're either scared by it, or they just stop. It's very rare for a kid to go from window to window. In the past, if a kid broke a window, we'd tackle him, but once the damage is done, it's done."

It's also rare for a youth to strike a staff member without warning or provocation. In general, Farragher says, if a resident hits a staff member, that means the staff member got too close. "Your first step is backwards," he says. "It's hard to train people to do something that counterintuitive, or to tell someone who just got punched in the nose that they made a mistake, but people are starting to get it--they realize there's a lot of risk involved in putting their hands on a child."

Silent Killer

Certain restraint positions can result in positional asphyxia, a condition that occurs when a person's body position interferes with respiration, resulting in suffocation. Any body position that obstructs the airway or interferes with the muscular or mechanical components of breathing may result in positional asphyxia.

For breathing to occur, the central nervous system must activate the respiratory muscles, causing the ribcage to expand and the diaphragm to descend into the abdomen, creating a larger internal chest space. This size change causes the internal chest air pressure to be less than the external air pressure. When the airway opens, this pressure difference causes air to flow into the lungs, producing inhalation.

Relaxing the diaphragm and ribcage muscles results in a smaller chest space, and internal air pressure becomes greater than external air pressure. When the airway opens, the pressure differences causes air to flow out of the lungs, producing expiration. If the internal chest air pressure cannot change because the size of the chest space cannot be changed, no air movement occurs.

When a patient is placed facedown, with forceful compression of the shoulders and chest, chest expansion is seriously restricted or prevented altogether. By forcefully compressing the patient's lower back or hips against a surface, the abdomen is compressed, preventing the diaphragm from descending into the abdomen and changing the size of the chest space. Thus, forceful prone restraint significantly restricts or prevents inhalation. Abdominal fat places overweight individuals at greater risk for interference in breathing and a more rapid onset of restraint asphyxia when forcefully prone restrained.

Often, a patient is restrained after aggressive or violent behavior and extreme physical exertion brought on by alcohol or drug use, traumatic head injury, psychiatric disorders, low blood sugar, or seizures--all of which can result in extreme total body exhaustion. The patient usually expends more energy wrestling with or avoiding intervenors.

Physical intervention at this point frequently involves forceful prone restraint--the patient is placed facedown, usually with one or more people kneeling on the patient's shoulders or back and lower back or hips. This position immediately impedes the exhausted patient's ability to breathe. The patient's body continues to expend extreme energy in a desperate struggle to breathe. This struggle is often misinterpreted as a continued threat to the patient and others, so the forceful prone restraint is maintained.

The energy required to fuel the patient's muscular ability to breathe can become completely exhausted within seconds. Once the patient cannot change the size of his or her chest space to move air in and out of the lungs, he or she rapidly enters respiratory arrest, followed swiftly by cardiac arrest.

In addition, during the extreme physical activity preceding and during the restraint, the patient's body produces abnormally large amounts of adrenalin and other body chemicals, creating a hypercatabolic state that weakens all muscles, but especially results in severe respiratory muscle fatigue, and stresses the heart by increasing its workload. When a patient with severe respiratory muscle fatigue, an increased heart workload, and an increased need for oxygen is placed in a body position that interferes with or prevents breathing, it's easy to understand why certain restraint positions can be dangerous.

Source: "Restraint Asphyxia: Silent Killer," by Charly D. Miller, published in the Summer 2001 issue of Residential Group Care Quarterly.

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