Clinical Case Studies-Autism

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Effects of Fixed-Time Release Fading on Frequency and Duration of

Aggression-Contingent Physical Restraint (Protective Holding) in a Child With Autism
Serra R. Langone, James K. Luiselli, Denise Galvin and Jessica Hamill
Clinical Case Studies 2014 13: 313 originally published online 30 October 2013
DOI: 10.1177/1534650113509305
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CCS13410.1177/1534650113509305Clinical Case StudiesLangone et al.
Article
Effects of Fixed-Time Release

Fading on Frequency and Duration
of Aggression-Contingent Physical
Restraint (Protective Holding) in a
Child With Autism
Clinical Case Studies

2014, Vol. 13(4) 313321
The Author(s) 2013
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DOI: 10.1177/1534650113509305
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Serra R. Langone1, James K. Luiselli1, Denise Galvin1,

and Jessica Hamill1
Abstract
We report the case of an 11-year-old boy with autism who displayed aggressive behavior and
required aggression-contingent physical restraint (protective holding) to protect peers and
teachers from injury. During a baseline phase, teachers implemented the boys behavior support
plan and applied protective holding according to a behavior-contingent release (BCR) criterion
in which they maintained physical contact with him until he was calm for a minimum of 30
consecutive seconds. In the intervention phase, baseline procedures remained in effect, but the
teachers terminated protective holding with the boy according to a fixed-time release (FTR)
criterion that was independent of his behavior during protective holding and faded (decreased)
systematically over time. In contrast to BCR, FTR fading was associated with less exposure to
and fewer applications of protective holding. Post-intervention and follow-up results revealed
that protective holding was no longer required. We discuss the clinical implications of these
findings.
Keywords
physical restraint, autism, aggression, restraint reduction, fixed-time release fading
1 Theoretical and Research Basis for Treatment

Physical restraint is sometimes required with children and adults who have developmental disabilities; display challenging behaviors such as aggression, self-injury, and property destruction; and are
unresponsive to less restrictive intervention procedures (Harris, 1996; Luiselli, 2011; Reed, Luiselli,
Miller, & Kaplan, 2013). Concerning the acceptable use of physical restraint, virtually all regulatory agencies and professional organizations specify that it be reserved solely for behaviors that are
harmful to self, others, and the environment (American Psychological Association, 1994;
Association of Professional Behavior Analysts, 2010; Ryan, Robbins, Peterson, & Rozalski, 2009).
As for the focus of intervention, physical restraint is frequently applied to manage crisis situations
1May
Institute, Randolph, MA, USA
Corresponding Author:
James K. Luiselli, May Institute, 41 Pacella Park Drive, Randolph, MA 02368, USA.
Email: jluiselli@mayinstitute.org
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Clinical Case Studies 13(4)
and behavior emergencies (Reed, DiGennaro Reed, & Luiselli, 2013). In addition, physical
restraint can be a planned method of behavior support that is combined with antecedent control,
positive reinforcement, skill building, and other function-based procedures (Federal Statutes,
Regulations, and Policies Governing the ICF/MR Program, 2003).
It is important to acknowledge that physical restraint has several limitations. For example, the
procedure can be difficult to implement and easily misapplied. Improper implementation of
physical restraint is particularly concerning due to the risk of injury (Hill & Spreat, 1987; Spreat,
Lipinski, Hill, & Halpin, 1986; Williams, 2009). Furthermore, physical restraint is sometimes
positively reinforcing (Favell, McGimsey, & Jones, 1978; Magee & Ellis, 1988), thereby increasing the behavior it follows. Another factor is that many care-providers do not approve of physical
restraint (Cunningham, McDonnell, Easton, & Sturmey, 2003). Among staff who must implement physical restraint, poor acceptability can negatively impact procedural fidelity which, in
turn, compromises intervention effectiveness. Finally, some service settings may not have the
personnel and financial resources needed to provide extensive physical restraint training with
staff (Lennox, Geren, & Rourke, 2011).
Acknowledging the preceding limitations, several strategies can reduce and eliminate physical restraint (Luiselli, 2009; Sturmey & McGlynn, 2003; Williams, 2010). For example, Luiselli,
Kane, Treml, and Young (2000) and Luiselli, Dunn, and Pace (2005) introduced antecedent control procedures that prevented or greatly curtailed challenging behaviors, which had required
physical restraint as a planned intervention. Restraint fading has also been successful by changing from a continuous to intermittent schedule of application (Lerman, Iwata, Shore, & DeLeon,
1997). From an organizational or systems-level perspective, decreased physical restraint has
been reported through mandatory behavioral consultation (Donat, 1998), administrative policychange (Singh, Singh, Davis, Latham, & Ayers, 1999), and performance improvement initiatives
that included intensified staff training, alternatives to restraint, increased clinical supervision,
and systematic utilization review (Sanders, 2009).
Another approach to reducing and eliminating physical restraint is termed fixed-time release
or FTR (Luiselli, 2008; Luiselli, Pace, & Dunn, 2006; Luiselli, Treml, Kane, & Young, 2004).
Typically, care-providers implement physical restraint according to a behavior-contingent release
(BCR) criterion in which restraint is terminated when a person is calm (e.g., absence of struggling and resisting) for a predetermined length of time (e.g., 2 min). Unfortunately, the duration
of physical restraint can be prolonged if the BCR criterion is not rapidly achieved. By contrast,
FTR has care-providers stop physical restraint as soon as a set duration elapses independent of a
persons behavior during restraint. In Luiselli et al. (2004), the average duration of physical
restraint applications with a 12-year-old girl decreased from 5.6 min with BCR to 3.1 min with
FTR. Targeting three children (11-14 years old), Luiselli et al. (2006) reduced physical restraint
from averages of 14.2, 5.1, and 11.2 min with BCR to 3.8, 1.4, and 3.0 min with FTR, respectively. These studies also revealed that when compared to BCR, the frequency of physical restraint
either remained the same or decreased with FTR. Thus, FTR reduces the total amount of time a
person experiences physical restraint and may have the corresponding reductive effect on how
frequently the procedure is applied.
Fixed-time release from protective holding has also been effective by gradually reducing the
FTR criterion. In treating a 13-year-old boy with autism, Luiselli (2008) had classroom teachers
initially apply physical restraint contingent on the boys aggression and at a FTR criterion of 60
s. Fading was then introduced by reducing the FTR criterion to 30 s, 15 s, and 7 s. Upon achieving FTR-7 s, physical restraint was eliminated by having the teachers stand behind the boy as if
to implement restraint, touch his shoulders, and instruct him to sit down. In addition to replicating previous studies that decreased total time exposed to physical restraint (Luiselli, 2008;
Luiselli et al., 2006; Luiselli et al., 2004), the results of Luiselli (2008) showed that FTR fading
can further reduce restraint duration as well as eliminate restraint entirely.
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Langone et al.
In the present case study, we evaluated the effects of FTR fading on frequency and duration of
physical restraint with a child who had autism and aggressive behavior. Our therapeutic objectives were to reduce physical restraint applications to the lowest duration possible while monitoring collateral changes in restraint frequency. Hence, we report another potentially effective
strategy for reducing and eliminating physical restraint of people who have developmental disabilities and require intensive interventions for treating high-risk challenging behaviors (Luiselli,
2011; Reed, Luiselli, Miller, & Kaplan, 2013).
2 Case Introduction
Danny was an 11-year-old boy who had been diagnosed with autism at two years of age. He
spoke in 2-4 word phrases and receptively could follow most 1-2 step instructions. Danny was
able to read many words and short sentences as well as match the corresponding pictures to sentences, identify numbers 1-100, and tell time on a digital clock. He had not received formal intellectual testing.
Danny lived at home with his parents. He attended a specialized school for children and youth
with developmental disabilities each weekday from 8:30 a.m. to 3:00 p.m. His classroom at the
school was comprised of five other students, a primary teacher, and two teacher assistants. All of
the teachers conducted instruction with Danny according to his Individualized Educational
Program (IEP). He had a daily schedule of instructional activities that addressed communication,
pre-academic, self-help, and leisure skills.
3 Presenting Complaints
Danny presented with aggressive behavior that included hitting, kicking, head-butting, grabbing,
hair-pulling, and biting. His aggression was primarily directed toward classroom staff, but sometimes against peers as well. His aggressive behavior had injured teachers, disrupted instructional
activities, and made it difficult to promote social interactions between Danny and classmates.
4 History
Danny had been displaying aggression at variable frequency several years preceding the study.
At times, his aggressive behavior consisted of a single response such as hitting or kicking a
teacher who was sitting beside him. On other occasions, aggression occurred as an episode in
which he exhibited several consecutive responses in rapid succession. Many times, Danny exhibited repeated aggression while actively pursuing one or more teachers.
Before the study, teachers reacted to aggressive behavior by physically blocking Dannys
responses and redirecting him back to the ongoing activity. The teachers also followed a behavior
support plan (described below) comprised of antecedent and consequence procedures.
Unfortunately, the behavior support plan was only marginally effective as Danny continued to
aggress toward peers and teachers several times daily.
5 Assessment
Direct Measurement
Throughout the study, teachers implemented protective holding when Danny exhibited an aggressive episode by (a) walking or running toward them or a peer and (b) making physical contact in
the form of a hit, kick, head-butt, grab, hair pull, or bite. Teachers recorded frequency of aggressive episodes and the corresponding protective holds on an incident report form that traveled
316
with Danny to and from his scheduled activities. These data were summed as the total frequency
of protective holds each day.
The teachers also documented the duration (minutes) of each protective hold by recording the
time (to the nearest minute) that they initiated and terminated physical contact with Danny. These
data were summed as the average minutes per protective hold each day (cumulative daily duration of protective holds/frequency of protective holds).
For 21% of protective holds that were implemented during the study, two teachers assessed
interobserver agreement (IOA) by independently completing an incident report form. Using the
protocol reported by Kleinmann et al. (2009), an agreement between teachers was recorded when
they documented the same date, time, and duration (+/ 10 s) of the protective holds. There was
100% agreement between the teachers.
Functional Behavioral Assessment

Preceding the study, the clinical director at the school and the primary classroom teacher conducted
functional behavioral assessment (FBA; Cipani & Schock, 2011) to identify antecedent and consequence influences on aggressive episodes. The FBA entailed first observing Danny during classroom activities, noting interactions and situations that were associated with aggressive episodes.
Next, the clinical director interviewed the teachers to solicit their opinions about behavior function.
The third component of FBA was reviewing antecedent-behavior-consequence (A-B-C) data
(Bijou, Peterson, & Ault, 1968) that had been recorded for several weeks in the classroom.
6 Case Conceptualization
The results of FBA suggested that Danny frequently displayed an aggressive episode when he was
required to complete non-preferred activities and at times when he requested objects that could not
be given to him or they had to be temporarily removed. Accordingly, aggressive episodes were
determined to be both tangible and escape motivated. That is, we hypothesized that Danny had a
learning history in which his aggressive behavior had been reinforced by care-providers providing
him access to preferred objects and withdrawing non-preferred activities contingently.
On the basis of FBA, the clinical director and teachers developed a multi-procedure behavior
support plan. First, the teachers provided Danny with differential positive reinforcement when he
participated in and completed instructional activities without displaying aggression. Positive
reinforcement consisted of verbal praise (e.g., Good, Danny, you opened your book.) and
access to objects such as playing with toys. The behavior support plan also specified that teachers
control antecedent conditions that appeared to be associated with aggressive episodes.
Specifically, they ensured that Danny was not in close proximity to peers, presented low
demand instructional activities as often as possible, and delayed activity termination if he displayed aggression and other disruptive behavior. As indicated previously, the teachers blocked
and redirected aggressive responses.
With the behavior support plan in effect several months preceding the study, aggressive episodes continued at an unacceptable level. The schools clinical team then determined that protective holding should be evaluated with the purpose of immediately stopping Danny from repeated
aggressive responses that were causing injuries, disrupting activities, and posing a safety risk to
teachers and other students (Luiselli, 2011; Reed, Luiselli, Miller, & Kaplan, 2013 ).
7 Course of Treatment and Assessment of Progress

The study conformed to a quasi-experimental design with an initial baseline phase in which
teachers followed a BCR criterion and an intervention phase in which the teachers followed a
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Langone et al.
FTR criterion and a FTR fading protocol. The behavior support plan described earlier was in
effect during baseline and intervention phases. Within intervention, the only manipulation was
decreasing the FTR criterion, thereby controlling external factors that might have influenced
outcome.
Baseline (28 Days)

The teachers had been taught to implement protective holding following a rigorous program in
physical management (see Lennox et al., 2011, for a description of such training). The clinical
team at the school approved application of protective holding with Danny and routinely supervised the teachers. Dannys parents also provided informed, written consent. When implementing protective holding, two teachers simultaneously stood to Dannys side, grasped his arms, and
gently guided him to the floor. The teachers then maintained their side-to-side position while
extending their other hand against Dannys leg to stabilize any movement.
During the baseline phase, teachers stopped holding Danny when he achieved a BCR criterion
of 30 consecutive seconds without struggling, moving his body, and vocalizing. In effect, the
BCR criterion was an indication that Danny was calm before teachers withdrew their physical
contact with him. Under this condition, the minimum duration of time Danny could spend in a
protective hold was 30 s. A protective hold could continue for as much time as it required Danny
to achieve the 30 s criterion.
Intervention (208 Days)

Baseline conditions remained in effect during the intervention phase, except that teachers followed a FTR criterion instead of the BCR criterion. Now, they terminated protective holding with
Danny when a set-duration of time elapsed independent of his behavior during the hold. The
initial FTR criterion was 2 min-30 s, which was the average protective hold duration in baseline.
Subsequently, the FTR criterion was reduced over consecutive days to 2 min-10 s (18 days), 1
min-50 s (18 days), 1 min-30 s (19 days), 1 min-10 s (23 days), 50 s (20 days), 30 s (9 days), 10 s
(35 days), and 5 s (36 days). The protocol for lowering the FTR criterion was based on visual
inspection of the protective holding frequency data and trend analysis showing less than 1 protective hold per week during 2 to 3 consecutive weeks.
Figure 1 shows that in the baseline phase, there was an average of 1.1 protective holds each
day lasting an average of 2.3 min per hold. Protective hold duration in baseline ranged from 30 s
to 15.1 min. The daily frequency of protective holding decreased contemporaneously during
intervention with the systematic reduction in duration of protective holding through FTR fading.
The data in Figure 1 reveal further that by conclusion of the study, Danny no longer required
protective holding (Weeks 1-5). In total, Danny was exposed to 1 hr and 19 min of protective
holding with the BCR criterion in effect during the baseline phase. In the final condition of the
intervention phase with a FTR-5 s criterion, his total exposure to protective holding was 15 s.
8 Complicating Factors
As explained earlier, implementing physical restraint is a complicated process that must consider
potential negative effects such as misapplication, injury, and procedurally induced problem
behavior. In the present case, the classroom teachers had been thoroughly trained in protective
holding, were closely supervised, and demonstrated exemplary intervention integrity (DiGennaro
Reed & Codding, 2011). Neither the teachers nor Danny sustained bodily harm and there were
no imminent safety risks. In addition, we did not witness unanticipated behavioral concerns that
were associated with protective holding during application or other situations in the school day.
318
2.5
BL
Intervention: Fixed-Time Release Fading
Frequency and Duration
1.5
Protective Holds: Average Daily Frequency

Protective Holds: Average Duration Per Hold
5 Weeks
4 Weeks
3 Weeks
2 Weeks
1 Week
FTR-:05
FTR-:10
FTR-:30
FTR-:50
FTR-1:10
FTR-1:30
FTR-1:50
FTR-2:10
FTR-2:30
BCR-:30
0.5
Phase Conditions
Figure 1. Average frequency of protective holds per day and average duration (minutes) per protective
hold during baseline (BCR) and intervention (FTR fading) phases.
Note. BCR = behavior-contingent release; FTR = fixed-time release.
9 Access and Barriers to Care

Danny had regular attendance at school which enabled intervention to progress without interruption. The consistency of intervention likely contributed to the positive results and durable maintenance effects. There were no managed care considerations or third-party financial constraints
because the study was conducted in a special education setting. Notably, Dannys parents supported his intervention plan and consented to protective holding as a necessary behavior management procedure. Certainly, some parents may not approve similar methods of physical
intervention, thereby curtailing implementation in high-risk clinical cases.
10 Follow-Up
Protective holding frequency and duration were reported for 4 consecutive months approximately
6 months following the study. During this period, teachers implemented four protective holds
with Danny, an average of one protective hold per month. The FTR criterion had been maintained
at 5 sthus, Dannys total exposure to protective holding at follow-up amounted to 20 s. As a
result of less frequent aggression and physical restraint, teachers reported that Danny was more
compliant during instructional activities and interacted more positively with peers.
11 Treatment Implications of the Case

We found that protective holding of a child with autism gradually decreased and was eventually eliminated subsequent to fixed-time release fading. In that these results support previous
clinical studies (Luiselli, 2008; Luiselli et al., 2006; Luiselli et al., 2004), it appears that FTR
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Langone et al.
is an empirically supported procedure for reducing the total time a person experiences physical restraint. As well, frequency of protective holding may also decrease with FTR although
the mechanism responsible for this effect is unclear. For example, manipulating duration
should not influence the frequency of behavior that produces protective holding, unless
restraint is positively reinforcing (Favell et al., 1978; Magee & Ellis, 1988). At this time,
further research is needed to clarify the relationship between protective holding frequency
and duration.
Fixed-time release fading is a deliberate process that must be carefully monitored to ensure
that practitioners adhere to the gradually decreasing release criteria. We reiterate that when compared to BCR, slowly reducing the duration of protective holding will expose a person to less
physical intervention and risk of injury. It is possible, of course, that frequency of protective
holding could increase with FTR fading, in which case the strategy may have to be abandoned in
favor of other restraint-reduction methods (Reed, Luiselli, Miller, & Kaplan, 2013 ; Sturmey &
McGlynn, 2003).
As a clinical case study, these results cannot be attributed unequivocally to FTR fading. For
example, frequency of protective holding may have decreased with lengthier implementation of
the BCR criterion or possibly the FTR criterion could have been lowered abruptly without fading
it systematically. In terms of research tactics, the relative effectiveness of BCR and FTR could
have been compared by introducing and withdrawing the two release criteria in a reversal-type
design (Kazdin, 2011). However, such an analysis was contraindicated because we wanted to
prevent long-duration protective holds that had been recorded with Danny during the initial baseline (BCR) phase.
12 Recommendations to Clinicians and Students

Clinicians and students alike should be fully appraised about physical restraint practices, training
requirements, regulatory guidelines, and evaluative methodologies (Lennox et al., 2011; Luiselli,
2011; Reed, Luiselli, Miller, & Kaplan, 2013 ; Ryan et al., 2009). Whenever possible, protective
holding procedures should be avoided and only considered when challenging behaviors are
harmful, non-responsive to less restrictive interventions, and likely to continue without additional treatment. If protective holding is clinically justified, it should be implemented as one
component of a comprehensive behavior support plan like the one illustrated in this study. Careproviders must also contemplate restraint-reduction and elimination strategies early in the treatment process.
In summary, we recommend FTR fading as one of several procedures that can effectively
decrease frequency and duration of protective holding with people who have developmental disabilities. Ultimately, the therapeutic objective should be to eliminate physical restraint and in
doing so, improve a persons social adjustment and quality of life.
Authors Note
This study was conducted at the May Center for Child Development, Woburn, Massachusetts. The authors
acknowledge the classroom teachers for participating in the study.
Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
320
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Author Biographies
Serra R. Langone, MS, BCBA, MEd, is a Clinical Director at the May Center for Child Development,
Woburn, Massachusetts.
James K. Luiselli, EdD, ABPP, BCBA-D, is a Senior Vice President of Applied Research, Clinical
Training, and Peer Review at May Institute, Randolph, Massachusetts. He also serves as a director of training for the institutes predoctoral internship and postdoctoral fellowship programs in clinical psychology.
Denise Galvin, BS, is a Senior Teacher at the May Center for Child Development, Woburn, Massachusetts.
Jessica Hamill, MEd, is a Director of Education and Educational Administrator at the May Center for Child
Development, Woburn, Massachusetts.

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CCS13410.1177/1534650113509305Clinical Case StudiesLangone et al.

Effects of Fixed-Time Release