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Running head: Therapeutic Physical Management

An Analysis of Therapeutic Physical Management

Kathleen Wiejaczka

Ferris State University

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An Analysis of Therapeutic Physical Restraint

My Educational Setting

New Campus School is a K - 12 center based special education program for

students with severe emotional or behavioral impairments. Enrollment on average is 50 to

70 students. These students are bussed in from five surrounding counties with the

following most common diagnoses: attention deficit hyperactivity disorder, bipolar

depression, schizophrenia, post traumatic stress disorder, anxiety disorder, obsessive

compulsive disorder, oppositional defiant disorder, seizure disorder, reactive airway

disorder, and conduct disorder. Twenty-five percent of the student population is

diagnosed with autism spectrum disorder. The educational program at New Campus

School combines academics, behavior instruction, community based instruction with

counseling services from school social workers.

My primary responsibilities at New Campus as the school nurse is to assist and

monitor the health concerns of students and staff including medication consultation,

development of health care plans, and injury assessment, treatment and prevention. My

major emphasis is monitoring the correct administration of medications by classroom

staff and assessing the safety, health and welfare of our students in crisis.

The students at New Campus School tend to be very aggressive with emotions

that are unpredictable and volatile. Due to these factors each classroom is comprised of

no more than ten students with a teacher and teacher assistant. In addition usually there

are 1 – 2 students school-wide who are assigned a one-on-one teacher assistant due to

extreme aggression and violence.

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Issues of relevance

The safety of each student and staff is of the utmost importance at any school but

especially at a school like New Campus. Dignity, respect, and the student’s right to an

appropriate education in a least restrictive setting are hallmarks at New Campus School.

To accomplish this goal, behavior intervention techniques are used to help the student

learn appropriate responses to staff, other students, and to follow school rules.

Kutz (2009) through the U.S. Government Accountability Office (GAO) testified

before the committee on Education and Labor, House of Representatives regarding

allegations of deaths, abuse, injury, and trauma at residential and school programs related

to restraints of vulnerable students. The GAO reviewed the data from the past 20 years

but they did not evaluate the beneficial effect of using restraints. They found no federal

laws restricting the use of restraints in public or private schools and very divergent laws

at the state level. Hundreds of cases of alleged death and abuse were found in the past 20

years. They also found 10 physical restraint cases where there was a criminal conviction,

civil or administrative liability, or a large financial settlement.

Kutz (2009) found that the following themes were common in the restraint cases

that caused death or injury:

a) They mostly involved children with disabilities that often times the

student was not physically aggressive and there was no consent from

parents.

b) The restraint blocked air into the lungs due to physical struggling of

the student, pressure on the chest, or other interruptions in breathing.

c) Staff was not often trained in the use of physical restraint.

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d) Staff from at least 5 out of the 10 cases continued to be employed as

educators.

Kutz (2009) found 19 states have no laws or regulations related to the use of

restraints in schools, 17 states require training before being allowed to restrain students, 7

states place some restriction or restraints but none for seclusion (Michigan), 19 states

require parents to be notified after restraints are used, 8 states prohibit the use of prone

restraints, and 4 states are collecting and reporting data to Michigan Department of

Education (MDE).

The National Disability Rights Network (NDRN) (2009) reported because there is

no mandate to report or collect data, the scope of the problem is unknown. Their findings

show 41% of the schools have no laws, policies or guidelines relative to restraints in

schools, 90% still allow prone restraints, and only 45% require or recommend that

schools notify parents of restraint use. The NDRN favors a ban on the use of restraints in

school.

The NDRN (2009) reported the Protection and Advocacy (P & A) system

established by Congress in the mid 1970’s has helped states establish new policies to

protect children from restraint abuses. The Michigan P & A helped the Michigan

Department of Education (MDE) to establish new standards on restraint and seclusion in

2006. According to the Michigan Developmental Disabilities Council (2007) these

standards will help to eliminate dangerous restraint practice in schools. The committee

that formulated these guidelines recommended drafting them into law but this

recommendation was not instituted. However each school district must have a system of

school wide positive behavior support strategies. These strategies will support
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appropriate behaviors and promote safety by encouraging adherence to a student code of

conduct.

In addition the NDRN (2009) asserted the government findings from the

Presidents New Freedom Commission on Mental Health states the “use of restraints

cause significant risks for children, including serious injury or death, retraumatization of

students with a history of trauma, loss of dignity, and other psychological harm.” NDRN

reported the 1998 Harvard Center for Risk Analysis estimated deaths due to such

practices at 150 per year across the U.S.

One of the most lethal school practices is restraint according to NDRN (2009).

Sudden fatal cardiac arrhythmias or respiratory arrest can occur through the prone

restraint. In fact they assert prone restraint may predispose a person to suffocation. An

example of a death resulting from restraint in Michigan is a 15-year-old boy with autism

who died in 2003 after being restrained by four public school employees who held him in

the prone position. He became unresponsive after 45 minutes but restraint continued until

he stopped breathing. This was the second child in Michigan who died from restraint

according to NDRN.

The first step in decreasing the incidence of behavior problems is to identify why

the student is engaging in this negative behavior. Ayres & Hedeen (2003) identified four

categories that behavior falls into:

a) Attention seeking

b) Escape

c) Avoidance

d) Power and control

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They assert the most effective way to address difficult behaviors is to prevent them from

occurring. Common ways to accomplish this is by changing the physical, instructional,

and/or social environment of the child. They cited teaching new skills to replace the

challenging behavior. Therefore it is necessary to understand the purpose of the behavior

so a replacement skill can be determined. A positive behavior support plan (PBSP)

emphasizes prevention and teaching rather than focusing on how to handle the behavior

once it occurs. PBSP uses a functional assessment to understand the behaviors purpose.

These authors remind us that we must acknowledge that behavior serves a purpose for the

students and is an indication of a learning need. The ultimate goal is to teach new

strategies to the student so they can learn new communication, social, and self-regulating

behaviors.

Physical restraints is defined by the State Board of Education (SBE) Standards for

Emergency Use of Seclusion and Restraint (2006) as involving direct physical contact

that prevents or restricts a student’s movement. Restraint is seen as an opportunity for the

student to regain self-control. Examples of appropriate use of physical restraint are:

a) Breaking up a fight.

b) Taking a weapon away from a student.

c) Briefly holding a student by staff to calm a student.

d) Minimum contact to transport a student to a safer place.

e) Holding a student for a brief time to prevent an impulsive behavior

that threatens student’s safety.

SBE (2006) has determined that certain restrictions exist for physical restraint.

The following are prohibited:

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a) Restraints for the convenience of staff.

b) Substitute for an educational program.

c) A form of discipline or punishment.

d) Substitute for less restrictive alternatives.

e) Substitute for adequate staffing.

f) Substitute for staff training in positive behavior supports and crisis

prevention.

The recommendations from SBE Standards (2006) are that the restraint will cease

once the child has regained control of his behavior, usually no longer than 10 minutes. If

the restraint’s duration exceeds 10 minutes, staff is required to obtain additional support

such as a school nurse, behavior specialist, or other expertise, and document the reason

for the extension on the time limit.

The SBE Standards (2006) state while using restraint staff must:

a) Be properly trained to protect the safety of the child.

b) Continually observe the student in restraint for signs of physical

distress.

c) Document all observations of the incident in writing to the supervisor

and parent/guardian within 24 hours.

d) Debrief after the restraint episode to determine further actions.

e) Collect data regarding the use of restraint and report it to the MDE.

Additionally SBE Standards (2006) require if a pattern of behavior reoccurs

requiring use of emergency restraint staff must conduct a functional behavior assessment

(FBA), which is defined as a systematic process to identify triggers that caused the
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behavior problem This is done whenever behavior negatively impacts student’s ability to

learn. It is the first step in evaluating a child’s behavior.

Prohibitive practices are delineated by the SBE Standards (2006) as:

a) Mechanical restraint – the use of any device, article or material

attached or adjacent to the student which is difficult for the student to

remove and restricts freedom of movement.

b) Chemical restraint – the administration of medicine for the purpose of

reducing or restricting the child’s freedom of movement.

c) Corporal punishment.

d) Deprivation of basic needs.

e) Child abuse.

f) Any restraint that negatively affects breathing.

g) Prone position.

h) Intentional application of a substance or stimuli which causes physical

pain or extreme discomfort.

My position on this issue

I support the use of physical restraints to uphold the care, welfare, safety and

security of our students as a last resort when less restrictive strategies have failed. I do

not feel it is in the student’s best interests to ban physical restraints. How would we

protect a child who is out of control head banging or running out into traffic? We have

been successful at New Campus School diminishing the number of physical

managements each year. During the 2008-2009 school year we had 16 incidents of

restraint. Compare this to 23 the previous year and 31 in the 2006-2007 school year.
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According to Luiselli (2008) research has shown that physical restraint that is planned

prior to the incident can be effective in deceasing problem behavior. He also states

physical restraint should only be used if it decreases and ultimately eliminates the

behavior that leads up to it. Additionally he supports restraint as a therapeutic option

when dealing with dangerous behavior.

Luiselli (2008) supports assessing antecedent conditions and determining what

effects on behavior they may have. He stated this leads to an effective strategy toward

preventive behavior interventions. This is the purpose of the FBA, formulation of the

PBSP, and a Behavior Intervention Plan (BIP). These occur on every student at New

Campus School. I support this practice and all of our staff work diligently as a team to

identify these triggers, reasons for the behavior, and changes that need to occur in the

classroom to improve the student’s behavior. In addition Luiselli asserts the more precise

these assessments are, the more likely restraint provoking behavior can be curtailed or

eliminated. Weekly at New Campus School staff meet as a school-wide team to problem-

solve new approaches for resistant negative behaviors in students. This is our

commitment to diminish hands-on with students and try to get inside their mind to

determine why are they acting out.

Matson & Boisjoli (2009) cited the Association for the Behavior Analysis and the

National Institute of Health’s support for the physical restraint and that it is unethical not

to use restraint if it is likely to be effective especially where the possibility of harm is

eminent. However, they reported that the behavior-based strategies are at least partially

effective for most cases of challenging behavior. I agree that BIP’s are a very useful

document that are flexible and fluid with input from many professionals both within our
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facility and community agencies. The authors contend the goal of the behavior plan is to

build adaptive skills thus decrease the student’s need to resort to aggression. The authors

remind us that these behaviors remain powerful ways for the student to communicate and

provide some form of control in their lives. Therefore it can be very difficult to abolish

these behaviors.

Institutional Position and Examples

Crisis management training is mandatory for all staff at New Campus School on

an annual basis. The main focus of this training is the prevention of situations that lead to

nonviolent physical crisis intervention or physical management. The policy at New

Campus is explicit that staff will not carry any students and physical management will

only be used when a student is a danger to himself or others. This should only be done as

a last resort in an emergency situation. In addition according to Traverse Bay Area

Intermediate School District (TBAISD) policy book (2007) this intervention will only be

done according to guidelines developed by the Superintendent based on standards

adopted by the State Board of Education regarding student restraint.

At New Campus School all students have a BIP. There are three levels of BIP’s.

As referenced in the TBAISD Proactive Behavior Intervention Training Manual (2007)

level one BIP focuses on changing challenging behavior through the adjustment of

classroom management procedures. A level two BIP uses proactive and reactive

procedures. The most intense BIP is a level three that has to have approval by the

Behavior Support Committee. The level three BIP may include exclusionary time-out,

restraint devices such as a bus harness, and restraint holds.

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Practical Implications

As the school nurse I am often called to a physical management episode to

monitor the student’s health and safety. This is in direct alignment with the MDE

guidelines for staff to be sensitive to student health needs. Student may have

polypharmocology issues affecting their ability to regulate their internal temperature

during highly aggressive episodes leading to hyperthermia. In addition the prevalence of

students with seizure disorders and asthma heightens the concern that during a restraint

any of these comorbidites may contribute to an unsafe situation. I make judgment calls to

end the physical management, or remove outer clothing to cool a student, or to observe

for correct and safe physical restraint technique.

Due to the increased incidence of self-injurious behavior, restraint becomes

necessary to keep the student safe from harm. Certainly we weigh our options if the

student is mildly hitting himself versus full hard blows to his body before we engage in

physical restraint.

Our policy at New Campus School has been modified to align with the new state

standards. For instance we have purchased many full size firm mats to shield the students

from harming themselves or staff and also to prevent acting out for attention. We have a

computer software program to document all physical restraints, time-outs and aggressive

episodes. This report is sent home to parents the same day of the episode.

If the physical restraint continues past 10 minutes I am always asked to observe

and consult about the child’s health and safety. On occasion if a student’s behavior

cannot be calmed and physical restraints continue past 15 minutes, law enforcement

officers are called to assist. On two occasions EMS was notified and the student was
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admitted to a psychiatric facility for evaluation.

As a team member alongside special education teachers, teacher assistants, social

workers, school psychologists, and behavior specialists I am an integral part of the

student’s behavior plan formulation. I assist in brainstorming new strategies to assist the

child to maintain control at school. With my medical background and knowledge of

medication side effects and dosing, I contribute to decreasing the incidence of physical

restraints at New Campus School.

References

Ayres, B. J. & Hedeen, D. L. (2003). Creating positive behavior support plans for
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students with significant behavioral challenges. In M.S. Fishbaugh, T.R. Berkeley

& G. Schroth (Eds.), Ensuing Safe School Environments (pp. 89-105). Mahawah,

N.J.: Lawrence Erlbaum Associates.

Kutz, G. D. (2009). Seclusions and restraints. Selected cases of death and abuse at

public and private schools and treatment centers. Testimony before the committee

on Education and Labor, House of Representatives. United States Government

Accountability Office. Retrieved from:

http://www.gao.gov/docsearch/locate?
searched=1&o=0&order_by=rel&search_type=publications&keyword=restraints+in+sch
ools&Submit=Search

Luiselli, J. K. (2009). Physical restraint of people with intellectual disability: a review of

implementation reduction and elimination procedures. Journal of Applied

Research in Intellectual Disabilities, 22 (2), pp. 126 – 134. DOI:

10.1111/j.1468-

3148.2008.00479.x Retrieved from: http://dx.doi.org/10.1111/j.1468-3148.2008.00479.x

Matson, J. L. & Boisjoli, J. A. (2009). Restraint procedures and challenging behaviors in

intellectual disability: an analysis of causative factors. Journal of Applied

Research in Intellectual Disabilities, 22 (2), pp. 111 – 117. DOI: 10.1111/j.1468-

3148.2008.00477.x

Retrieved from: http://dx.doi.org/10.1111/j.1468-3148.2008.00477.x

Michigan Developmental Disabilities Council. (2007). Restraint and seclusion in school:

are state guidelines enough? Lansing, MI. Retrieved from:

http://www.michigan.gov/ddcouncil
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National Disability Rights Network. (2009). School is not supposed to hurt: Investigative

Report on abusive restraint and seclusion in schools. Washington, DC. Retrieved

from: http://www.ndrn.org/issues/an/rs.htm

State Board of Education (2006). Supporting student behavior: standards for the

emergency use of seclusion and restraint. Retrieved from:

http://www.michigan.gov/documents/mde/StandardsforSeclusion_Restraint_247533_7.p

df

Traverse Bay Intermediate School District. (2006). Proactive behavior intervention

training manual. Traverse City, MI.