October 26, 1999

The Child Welfare League of America (CWLA) is grateful for the attention to the use of seclusion and restraints and strongly supports the establishment of national standards to care safely and appropriately for children and young people. These complex issues directly affect the safety of children in care and the safety of staff who provide care. It is essential that legislation be thoughtfully developed. Our response to abuses in the use of seclusion and restraints must not undermine sound practices critical to insuring the safety and well-being of children and staff.

CWLA is an 80-year-old association of more than 1,000 public and private nonprofit community-based agencies that serve more than three million children, youth, and families each year. Member agencies provide services for the prevention and treatment of child abuse and neglect, as well as child protective services, family preservation, family foster care, residential group care, adolescent pregnancy prevention, child day care, emergency shelter care, independent living, youth development, and adoption. Setting standards and improving practice in all child welfare services have been major goals of the Child Welfare League of America since its formation in 1920. Nearly 600 of our member agencies provide residential services.

The Children in Residential Care:

Children in residential group care today have complex problems. They often show violent behaviors, multiple diagnoses, severe learning disorders, and an increased frequency of alcohol and drug addiction. Typically, children and youth in these facilities have histories characterized by instability, abuse, neglect, and rejection.

Most of the children and young people we serve have had horribly sad lives. They are angry, they are depressed, and they act out. For many youths, their placement into residential facilities very often is their last chance at social services before a move into the juvenile justice system. For younger children, their successful placement in residential and group settings prevents them from being hospitalized in more institutional settings. The legislation as currently drafted will severely limit appropriate staff options needed to protect children, will sometimes jeopardize children’s safety, and may force young people into more restrictive settings.

Residential Care:

Unlike hospitals, residential group care is based on a non-medical model and very purposely so. On the whole, residential group care is meant to provide children with a safe, nurturing, protective, therapeutic environment while addressing their unique educational, social, behavioral, developmental, medical, and emotional needs. These facilities were developed as step-down, less intensive, non-medical means to keep children in their communities. Just as in private families, physicians are not a part of daily interaction and behavior management. Direct care workers are the primary care givers and have the day-by-day, hour-by-hour involvement in the lives of the children.

CWLA Concerns about Pending Legislation:

1) Need for definitions:

  • Pending legislation seeks to extend a provision for nursing homes to cover people with a range of conditions, from birth to death, in medical facilities as well as non-medical facilities that provide behavioral health care.
  • “Physical restraint” is defined broadly and fails to distinguish between physically holding a child and the use of mechanical restraints. There is no way to distinguish a reassuring hug from a restraint.
  • Seclusion is defined broadly to include locked isolation and time-out. Time-out is the separation from the group, in a non-locked setting, for the purpose of calming.
  • There is no explanation of when a standard medication becomes a chemical restraint. It presumes that there is a clear line between a medication used for disciplinary purposes and when it is related to a patient’s medical condition. The line between is very vague and a potential area of abuse.

2) The requirement that a “physician or other licensed independent practitioner” order the use of seclusion or restraint fails to insure that the responsible person will have the necessary and appropriate skills, knowledge and expertise. Standards should designate the responsible person not by title but rather by a mastery of experience and knowledge in matters including behavior management, de-escalation, health concerns, restraint techniques, and use of seclusion and restraints.

CWLA Practice and Policy Recommendations to Protect Children in Care:

  • Restraints and seclusion must only be used to ensure the physical safety of the child and all others and should never be used for purposes of discipline and convenience.
  • The use of chemical restraints, mechanical restraints, and locked, isolated seclusion for children and youths must be prohibited.
  • There should be mandatory reporting of behavioral interventions, such as seclusion and restraints, within 24 hours.
  • All staff must receive appropriate initial and ongoing training in behavior management, de-escalation, and the use of seclusion and restraints, including less intrusive interventions and emphasis on the medical, legal and other implications of the use of restraints.
  • Any legislation must support the development of national guidelines and standards on the quality, quantity, orientation and training, as well as the certification of those staff responsible for the implementation of behavioral intervention concepts and techniques.
  • Proposed remedies must include a plan to address the workforce crisis confronting children’s service organizations throughout the country in the recruitment and retention of qualified direct care practitioners. The goal of establishing a licensing, certification, and credentialing standard for direct care workers is of primary importance.
  • States should be required in their licensing, contracting, and regulation to include reporting and analysis of restraints on a regular basis, to set minimum expectations about staff development, and to make expectations consistent between public and privately operated facilities that serve the same children and youths.