As a professional term, restraint is defined as any physical method of restricting an individual's freedom of movement, physical activity, or normal access to his or her body (International Society of Psychiatric and Mental Health Nurses, 1999). The term is sometimes used to address three different types of restraint procedures: mechanical, ambulatory, and chemical. Mechanical restraint entails the use of any device or object (e.g., tape, tiedowns, calming blanket, body carrier) to limit an individual's body movement to prevent or manage out-of-control behavior. Ambulatory restraint is also known as manual restraint or "therapeutic holding" (American Academy of Pediatrics Committee on Pediatric Emergency Medicine, 1997). It involves one or more people using their bodies to restrict another individual's body movement as a means for reestablishing behavioral control and establishing and maintaining safety for the out-of-control client, other clients, and staff (American Academy of Child and Adolescent Psychiatry, 2000). Finally, chemical restraint uses medication to control behavior or restrict a patient's freedom of movement. This type of restraint is typically used only in institutional or hospital programs; it has evolved only in the past 40 years as a result of developments in psychotropic medications.
Today, physical restraint is used in numerous professional settings including medical and psychiatric facilities, law enforcement and correctional facilities, and schools. These different types of restraint can be used with both adults and children in the event of emergency situations stemming from aggressive, violent, or dangerous behavior or as a precaution against such behavior.
The use of physical restraint originated in the psychiatric hospitals of France during the late 18th century. Restraint procedures were developed by Philippe Pinel and his assistant Jean Baptiste Pussin for the same intent it is used today, as a means of preventing patients from injuring themselves or others (American Academy of Child and Adolescent Psychiatry, 2000; Fisher, 1994; Weiner, 1992).
From their initial usage, mechanical and manual restraint have been controversial procedures. Almost immediately after the procedures became popular, a nonrestraint movement was started in England in an attempt to prevent physical and often brutally aversive mechanical restraint from being used on psychiatric patients in hospitals (Jones, 1972; Masters et al., 2002; Scull, 1979). In response, a Lunacy Commission was established in 1854 to monitor and regulate the use of seclusion and restraint in asylums. In contrast to England's decreased use of restraint during this time frame, the United States viewed physical restraint as a form of therapeutic treatment and adopted it as an accepted practice for dealing with violent patients (Masters et al., 2002; Tomes, 1988).
For many years, law enforcement and correctional agencies have employed physical restraint and related conflict deescalation procedures as tools in apprehending and managing prisoners. Physical restraint also has a long history in hospitals and psychiatric institutions, particularly in the clinical treatment of violent persons (Romoff, 1985). The use of physical restraint has been applied to children with emotional disturbance since the 1950s, and it was included in a list of "techniques for the antiseptic manipulation of surface behavior" compiled by Redl and Wineman (1952). Redl and Wineman stated explicitly that physical restraint should not be used as, nor should it be associated with, physical punishment. They stated that a child's loss of control should be viewed as an emergency situation in which the educator or clinician should either remove the child from the scene or prevent the child from doing physical damage to himself or herself or others. The person performing the restraint should remain calm, friendly, and affectionate while attempting to maintain a positive relationship with the child, thereby providing the opportunity for therapeutic progress once the child's crisis subsides.
Standards and Guidelines for Using Restraint
In most medical, psychiatric, and law enforcement applications, strict guidelines govern the use of physical restraint. Often these standards include accreditation requirements from governing bodies such as the Joint Commission on Accreditation of Healthcare Organizations or other agencies such as the National Association of Psychiatric Treatment Centers for Children (Cribari, 1996) and the American Academy of Pediatrics (1997). These requirements have resulted in widespread training and certification for staff in these programs.
Unfortunately, there has been no such accreditation requirement for schools or many other child care agencies. The lack of these commonly accepted guidelines or accreditation standards in schools makes those who use physical restraint more susceptible to misunderstanding and abuse, let alone improper implementation. To make matters worse, school staff may lack training in effective behavioral interventions necessary for the prevention of emotional outbursts that are typically associated with children who have severe behavioral problems (Moses, 2000). Such interventions are critical in preventing student behavior from escalating to potentially dangerous levels, where restraint may be needed.
Use of Restraint in Education
Once thought of as an exclusive tool of psychiatric institutions, physical restraint has been thrust into the mainstream of public education. This is, in part, due to the Individuals with Disabilities Education Act (IDEA), which established the principle of serving children with special needs in the least restrictive environment. Many students with emotional or behavioral problems, regardless of disability label, are now being included in public school environments, frequently in general education schools and classes.
Prevalence of the Use of Physical Restraint
After an extensive search, we were unable to identify any research indicating how widespread the use of restraint in schools has become. Anecdotal information based on court cases and legislation seems to indicate that it has become common at least for larger school systems to have some staff performing physical restraint in public school settings.
Researchers also reported that restraint was more common among younger children, perhaps because they possess fewer mechanisms for coping with frustration.
Physical restraint has long been considered to be a behavior management technique appropriate for teachers when crisis behavior occurs (Fagen, 1996; Rizzo & Zabel, 1988), and it may be used for a much wider set of student behaviors such as preventing children from leaving a classroom or school grounds or from destroying private or school property. One study conducted with teachers of students with emotional or behavioral disorders (E/BD) in public schools found that many had used restraint either as part of a planned behavioral intervention or as a spontaneous reaction to aggressive behavior (Ruhl & Hughes, 1985). The study reported that 71% of these teachers used physical restraint with their students if they displayed aggression toward others, 40% to prevent self-abuse, and 34% to prevent destruction of property.
Efficacy of Restraint Procedures
Despite the belief that physical restraint is a commonly used procedure in schools serving children with E/BD, little is known about its efficacy, due to a lack of research (Persi & Pasquali, 1999). Few of the proponents of physical restraint have claimed that the procedure has any therapeutic value in and of itself. However, proponents of therapeutic holding justify restraint procedures through the attachment theory developed during the early to mid 1970s (Bowlby, 1973; Cline, 1979; Zaslow & Menta, 1975). Day (2002) reviewed these theories and for the most part concluded that there was very little empirical support for therapeutic benefits to children receiving restraint. Most of the studies located were of poor quality and relied upon "unverifiable, and hence questionable, anecdotal evidence and case reports" (Day, 2002, p. 272). There was also no evidence for any potential side effects of restraint. While some might believe that children diagnosed with E/BD who are exposed to restraint on a daily basis could be humiliated by such highly aversive procedures, there is no scientific evidence of psychological damage or harm beyond the clear physical danger of injury or death. Instead, restraint is usually viewed as a physical safety mechanism that may permit continuation of other therapeutic interventions once the restraint is completed. Most educational textbooks dealing with aggressive or violent behavior of students with E/BD suggest that physical restraint might be warranted for purposes of safety despite a lack of empirical research supporting such claims.
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Summary of Research
Very little research has been conducted on the prevalence, appropriate applications, or efficacy of physical restraint. Almost no research has been conducted on the use of restraint in school settings. We do not know how widely physical restraint is used in the schools, the extent or nature of injuries occurring when it has been used in the schools, or its effectiveness in achieving the desired outcomes.
The passage of the Children's Health Act of 2000 established national standards regarding the use of physical restraint with children in psychiatric facilities. Unfortunately, this legislation did not affect schools. Five states-Massachusetts, Colorado, Illinois, Connecticut, and Texas-have passed legislation over the past several years addressing the use of physical restraint with children in the school environment. Texas is the most recent state to do so (Amendments to 19 TAC Chapter 89, 2002), while one additional state, Maryland, has proposed legislation on this topic. Although state guidelines differ, the legislation typically contains many similar elements including (a) definitions of terms common to physical restraint, (b) required procedures and training for staff, (c) conditions when physical restraint can and cannot be used, (d) guidelines for the proper administration of physical restraint, and (e) reporting requirements when restraint is employed.
Summary of Federal Court and OCR Rulings on Individual Rights
Parents and advocacy groups have argued for the outright banishment of physical restraint, claiming its usage unfit for man, woman, or beast (Williams & Finch, 1997). Many nationally recognized advocacy groups have posted position statements regarding the use of physical restraint on their Web sites. The National Alliance for the Mentally III recently posted a position statement supporting the Children's Health Act of 2000 regarding the use of physical restraint and proposed similar standards be established for schools (National Alliance for the Mentally III, 2001). Another group, the Child Welfare League of America, called for a minimum national standard of training in behavior management techniques, especially in the area of deescalation. In addition, it called for future research to develop a better understanding of what crisis prevention models work best for specific situations (Child Welfare League of America, 2002). More recently, the Autism National Committee has called upon Congress and state legislatures to limit the use of restraint on children with disabilities to brief, emergency situations involving serious threat of injury to the person with disabilities or to others. They are also asking for standardized reporting procedures following a restraint, with an investigation of circumstances leading to the incident to develop supports and accommodations for the prevention of future restraint (Autism National Committee, 2000).
Due to the current risk of student injuries and the mortality rates associated with the use of physical restraint, immediate action is required to ensure that schools employing restraint do not jeopardize student safety. Based on the review of case law, legislation, and recommended procedures from both professional organizations and advocacy groups, there is a need for clear standards regarding the use of restraint procedures in schools, as well as mandatory training of staff before they use restraint. Improved and standardized record keeping and notification of administrators and parents of incidents in which restraint occurs are also important. Additional research is needed to define situations in which restraint is appropriate in schools, as well as its effectiveness in containing or preventing violent or destructive behavior. Unless these recommendations are heeded and action is taken, headlines will continue to appear across our nation describing these preventable fatalities.
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Death by Teacher
Federal figures reveal close to 1,000 injuries and 13 deaths were caused by physical restraint in public schools, last year.
One in ten (9%) said the last time they were involved in physically restraining someone they did not feel they knew what they were doing.
On December 18, 2013 the Antioch School Board (California) approved a eight million dollar settlement because one of their teachers abused a number of children in her special education class. Click here for our webpage about that case, newspaper clippings and a copy of the Complaint filed in the U. S. District Court. In January 2014, a second $8 million settlement with the Brentwood Union School District. Two Contra Costa, CA School Districts will pay nearly $17 million to local families in one year.
By Joseph B. Ryan, Doctoral Student, and Reece L. Peterson, Professor, Department of Special Education and Communication Disorders, University of Nebraska-Lincoln
The current emphasis on educating children in the least restrictive environment has resulted in the use of physical restraint procedures across all educational placement settings, including public schools. Since its initial use, restraint has been controversial. Professionals who use physical restraint claim that it is necessary to safely manage dangerous behaviors. Child advocates, however, argue that far too many children suffer injury and death from the very staff charged with helping them.
The use of physical restraints against a persons will, is a serious intrusion of basic human rights and, as such, an act of violence against the person. The improper use of physical restraints can cause injuries of varying severity, which can sometimes be fatal.
A headline of the Austin, Texas, American-Statesman Staff stated that a 14-year-old boy died after being restrained in a classroom by his teachers. According to a preliminary autopsy, the child succumbed to an intense amount of pressure to his chest (Rodriguez, 2002). Unfortunately, newspapers across the nation carry similar stories. The exact number of deaths caused by physical restraint remains in dispute. The Hartford Courant, a Connecticut newspaper, reported that 142 restraint-related deaths, 33% of which were caused by asphyxia, occurred in the United States over a 10-year period (Weiss, 1998). The U.S. Government Accounting Office (GAO) stated in 1998 that an accurate estimate was impossible because only 15 states had established reporting procedures for such incidents. Based on the information available, the GAO estimated that there were 24 restraint-related deaths in the United States among children and adults in 1998 (U.S. Government Accounting Office, 1999). More recently, the Child Welfare League of America (CWLA) estimated that between 8 and 10 children in the United States die each year due to restraint, while numerous others suffer injuries such as bites, damaged joints, broken bones, and friction burns (CWLA, 2002). There is no precise way to measure the number or extent of the injuries to children and also to staff as a result of the use of restraint.
On May 19, 2009, the U.S. Government Accountability Office (GAO) testified before the Education and Labor Committee in the U.S. House of Representatives regarding allegations of death and abuse at residential programs for troubled teens. Recent reports indicate that vulnerable children are being abused in other settings. For example, one report on the use of restraints and seclusions in schools documented cases where students were pinned to the floor for hours at a time, handcuffed, locked in closets, and subjected to other acts of violence. In some of these cases, this type of abuse resulted in death.
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A reasonable diagnosis of restraint asphyxia can usually be made after ruling out other causes and collecting supportive participant and witness statements in a timely fashion. Common elements in this syndrome include prone restraint with pressure on the upper torso; handcuffing, leg restraint, or hogtying; acute psychosis and agitation, often stimulant drug induced; physical exertion and struggle; and obesity. Establishing a temporal association between the restraint and the sudden loss of consciousness/death is critical to making a correct determination of cause of death.
Dangerous Use of Seclusion and Restraints in Schools Remains Widespread and Difficult to Remedy: A Review of Ten Cases from Tom Harkin, Chairman, Senate Health, Education, Labor, and Pensions Committee.
The Cost of Waiting from TASH (The Association for Persons with Severe Handicaps). This Report chronicles the implications of inaction from Congress, as children across the country continue to be subjected to abusive practices that result in serious emotional trauma, physical pain and injury, and even death.
Achieving Better Outcomes for Children and Families - The Child Welfare League of America (CWLA) and the Federation of Families for Children's Mental Health (FFCMH) serve as the Coordinating Center for the three-year Best Practices in Behavior Support and Intervention Project. The project is designed to reduce the use of restraint and seclusion by improving the training and supervision of staff who work directly with children and youth.
Parents of Teen Who Died While Restrained at Yonkers School Speak Out
GAO report on death by teacher
ABC Death at School by restraint
Students recall harsh punishments by teachers
Mom sues after son dies at school
Death at School: Parents Fight Back Against Deadly Discipline
Students forced into closets "isolation rooms" at school
Death at School: Parents Protest Dangerous Discipline for Autistic, Disabled Kids