Kathryn Green, Training Specialist
There are more than 37 million people in the United States living with a disability.
Prior to 1990, businesses could refuse service to individuals with a disability, and it was common for children with a developmental disability to be denied school admission (Norlian, 2020) with little reasoning. A recent interview shows us that children were being labeled by their principals as fire hazards (Clark et al., 2020). Based on data from the Congressional Research Service, approximately “one million children with disabilities were excluded entirely from the public school system in the 1970s” (Norlian, 2020).
The 1990 Americans with Disabilities Act (ADA) made it illegal to discriminate based on disability and has since made tremendous progress elevating the “human” element within the field of human services. (Clark, et al., 2020). The ADA improved the quality of life for millions of Americans by guaranteeing equal opportunity and increasing access to all areas of public life including transportation, employment, and education (ADA National Network, n.d.). The ADA has been monumental in protecting civil rights for individuals with disabilities and yet the work to protect their wellbeing is far from done.
Lawsuits across the U.S. highlight how children with developmental disabilities are harmed within the services and settings intended to educate and empower them.
Unfortunately, there are multiple examples of how physical interventions such as restraints are often misused within schools. A physical restraint is “any manual method that immobilizes or reduces the ability of a person to move freely” (Matte-Landry & Collin-Vezina, 2024).
- A recent Californian lawsuit settled in favor of four students with developmental disabilities after charges were filed against the State of California, the Contra Costa Office of Education, and the staff at the Floyd I. Marchus School (Lambert, 2019). The class-action lawsuit claimed that staff at the Floyd I. Marchus special education school physically and emotionally harmed students by routinely and illegally placing them in physical restraints for non-emergency situations. School records revealed that on multiple occasions, one student was physically restrained as often as up to five times per day, and for a total of “45 times within two semesters” (Lambert, 2019).
- In October 2021, NBC news reported the story of a Virginia mom, who arrived at her 5-year-old son’s school to pick him up for a dental appointment and found him in the school’s office being held in a chokehold for “singing too loudly in Spanish class” (Adams, 2021).
- One of the most tragic incidents to occur in recent years involving the improper use of physical restraints is one that resulted in the death of Max Benson in 2018. Max, a 13-year-old boy with Autism, was held face down in a restraint at school for almost 2 hours when he died (Lin, 2022).
Children and adolescents with intellectual and developmental disabilities experience a disproportionately high number of physical interventions and restraints.
80% of the over 100,000 students who are restrained or secluded every year in U.S. public schools are students with disabilities. (Bell & Craig, 2023).
For those unfamiliar with the fields of social services, residential care, and special education, it may be unsettling to learn about incidents in which children and adolescents with developmental disabilities are being placed in physical restraints. Historically, physical interventions such as restraints “have been used to manage challenging and/or aggressive behavior” (Kelly et al., 2023). Individuals with developmental disability, and particularly those with Autism, are at greater risk of “externalizing behaviors” compared to their neurotypical peers (Vasa et al., 2024). Higher rates of “irritability, physical and verbal aggression, non-compliance, property destruction, hyperactivity/impulsivity, self-injury, and elopement” are present in about 50% of the neurodivergent population (Vasa et al., 2024). These externalizing behaviors can escalate into a “mental health crisis” involving “loss of control” and behavior that poses significant and “imminent danger to oneself and others” (Vasa et al., 2024).
The current Developmental Disabilities Administration (DDA) policy limits the use of physical interventions, such as restraints, to situations that are “harmful or dangerous” to the client or others (DDA, 2023). Yet, according to information in the book Clinical Systems and Programming in Human Services Organizations, the use of “restrictive procedures” within human services settings are “easily misapplied” (Bird, et al., 2023). An article published by The Seattle Times stated that physical interventions are, “sometimes used to control behavior” despite laws that limit their use to situations in which there is an “imminent likelihood of serious harm” (Ramadan & Withycombe, 2023).
The overreliance on restrictive practices as a form of behavior management negatively impacts children and individuals with developmental disability, their parents and families, staff, and organizations.
- CHILDREN: There is a growing body of evidence that “coercive practices” such as physical restraints have been linked with “negative psychological consequences” (Kelly et al., 2023). The use of physical restraints can be traumatizing for children and retraumatizing for those who have “experienced adversity” in the past (Kelly et al., 2023; Matte-Landry & Collin-Vezina, 2024). The use of physical restraints can increase feelings of fear and alarm, further escalating the individual’s aggressive behavior (Kelly et al., 2023). Additional negative impacts include the distress, hypervigilance, and feelings of fear that have been observed in those witnessing their peers being restrained (Kelly et al., 2023; Matte-Landry & Collin-Vezina, 2024).
- PARENTS AND FAMILIES: A 2023 study interviewed 50 parents of children with intellectual and developmental disabilities were interviewed. According to the parents, “school officials suspended, restrained, and secluded their children between 1 and 30 times.” The parents also disclosed that “the trauma associated with their child’s school punishment led them to develop physiological and psychosomatic health challenges.” (Bell & Craig, 2023) “Forty-two parents stated they developed depression, anxiety, hypertension,” along with other health conditions, “due to the stress associated with their child’s suspension, seclusion, and restraint” (Bell & Craig, 2023).
- STAFF: Staff who are implementing restraints also often experience negative effects, including “secondary trauma and burnout” (Kelly et al., 2023).
- ORGANIZATIONS: Organizations experience higher costs associated with increased rates of staff turnover, staff injuries, and worker’s compensation claims (Kelly et al., 2023).
The over-use and misuse of coercive and restrictive practices in schools causes ongoing and unnecessary harm to students. Positive alternatives must replace outdated and unproductive methods of managing challenging behavior (Bird, et al. 2023).
Numerous studies reveal that a systems-wide, trauma-informed approach is the most promising strategy for significantly reducing the use of coercive interventions (Bird, et al., 2023; Matte-Landry & Collin-Vezina, 2024; Kelly et al., 2023).
A systems-wide approach involves changes on an organizational level in which leadership commits to a vision with clear expectations, provides ongoing knowledge and skills training to staff, and performance feedback (Bird, et al., 2023; Matte-Landry & Collin-Vezina, 2024).
A trauma-informed approach is based on the philosophy that “behind all behaviors that challenge is an unmet need” (Kelly et al., 2023). This humanistic approach “seeks to actively resist re-traumatization” through increasing staff’s trauma awareness and training staff how to sensitively respond to the individual’s needs (Matte-Landry & Collin-Vezina, 2024). This approach emphasizes relationship-building, communication, and a focus on “comfort versus control” (Bird, et al. 2023).
Researchers in the field of human services, Alexandra Matte-Landry and Delphine Collin-Vezina, discuss a study in which a trauma-informed staff training “was associated with changes in staff knowledge, attitudes, behaviors, practices, and stress” that accompanied “improvements in youth’s well-being,” and “reductions in the use of restrictive measures among children and youth” (Matte-Landry & Collin-Vezina, 2024). In another study in which a trauma-informed program was implemented at two residential care units, researchers “found an average 54% reduction in restraints over the intervention period” of 21 months (Matte-Landry & Collin-Vezina, 2024). Trauma-informed programs utilize a “strength-based approach” designed to “build staff effectiveness,” and incorporate a “debriefing and problem-solving” process for both staff and service-users (Kelly et al., 2023). Users of trauma-informed strategies have had a positive mental health change, reporting a decrease in post-traumatic stress disorder symptoms and an increase in feelings of safety (Kelly et al., 2023).
Trauma-informed practices are a form of primary prevention in managing challenging behavior and preventing crisis situations. De-escalation is recognized as a secondary prevention to be used when an individual’s behavior becomes aggressive (Hallet & Dickens, 2017). De-escalation includes the use of communication skills, “self-regulation, assessment, and actions” to reduce the likelihood of further aggression, and “maintain the safety” of the individuals involved (Hallett & Dickens, 2017).
Many human services organizations, residential care facilities, healthcare settings, and school districts have implemented significant changes in their approach to managing challenging behavior with the intent to reduce the use of physical interventions and restraints on their service users.
Service Alternatives has been a leader in adopting non-aversive prevention methodologies since 1994, when our organization walked away from a restraint-based model of crisis management and began the development of a proactive, person-centered approach to crisis prevention and de-escalation.
In addition to training participants in self-awareness, de-escalation skills, and positive behavior support, the RIGHT RESPONSE curriculum is in alignment with current trauma-informed practices. The guiding principles of RIGHT RESPONSE focus on respectfully addressing client needs while prioritizing the safety of all individuals involved. Topics covered in the training include self-awareness, self-regulation, the development of effective verbal and non-verbal communication skills, assessment skills, and the ability to adapt and make changes to the surrounding environment to reduce stimulus-related client agitation.
Even with a primary focus on proactive crisis prevention, there are occasions in which “tertiary” prevention methods, such as physical interventions, are necessary to prevent serious injury and harm (Hallet & Dickens, 2017). Children and adolescents with developmental disabilities, especially those with Autism, experience higher rates of “preventable injuries” and are “40 times more likely to die from an injury” than their neurotypical peers (Scutti, 2017). Approximately “50% of children with autism” elope or “wander” in an effort to cope with common symptoms such as anxiety (Scutti, 2017).
Wandering and elopement can lead to emergency situations in which it would be crucial to use a physical intervention to prevent injury. For example, if an individual with a developmental disability wandered towards a busy street and was unresponsive or in a state of crisis, an intervention such as a physical escort would be essential in preventing the individual from being hit by a car. Equally, if an individual was in a crisis state during a building fire and was unable to exit independently, a physical intervention would be imperative to safely move the individual out of the building and away from danger.
A third example is if an escalated individual became physically aggressive and was attempting to assault another person, a physical intervention to prevent the assault would be necessary to ensure the safety of all those involved. These are a few examples of when a physical intervention would be required to prevent the “imminent likelihood of serious harm” (Ramadan & Withycombe, 2023).
Service Alternatives has developed non-aversive physical intervention techniques, effective in keeping individuals safe while minimizing injury and discomfort to the person in crisis.
Physical intervention techniques are only ever to be used in situations in which safety is threatened, in the same way that CPR, first aid, and lifeguard training skills are used in emergency situations to preserve life (Bird et al., 2023).) When untrained staff attempt to physically intervene during a crisis, the attempt may result in over-response or under-response due to a lack of training. Untrained staff may respond in a manner that injures the person in crisis or results in inappropriate contact, which can traumatize or re-traumatize the individual, and create the potential for a lawsuit or litigation.
Service providers, teachers, and direct support staff may work with individuals who, on occasion, experience escalated behavior and moments of crises. Training in the correct use and application of physical intervention techniques, for service providers and staff, is in the best interest of all parties involved. Proper training ensures that staff fully understand that physical interventions techniques must only ever be used as a last resort response to a crisis in which a lack of action would result in significant harm, injury, and/or death of the individual(s) involved.
The modular-style curriculum of RIGHT RESPONSE allows organizations to choose the level of training and certification that is appropriate for their needs. Training certifications start with trauma-informed primary and secondary prevention methods in which the focus is on proactive, person-centered prevention and de-escalation techniques. The most advanced level of the RIGHT RESPONSE workshop adds training and certification in the physical intervention techniques necessary to maintain safety during moments of crisis. During advanced level training, attendees are guided to examine the risks, guidelines, and ethical standards that must be considered and upheld whenever the use of physical intervention techniques are deemed necessary. Advanced certification enables staff to be confident, prepared, and appropriately responsive in the event of an emergency in which safety is at risk.
References
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