Restraint & Seclusion Legislation/Hearing Feb 4, 2010

News ● U.S. House of Representatives

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EDUCATION & LABOR COMMITTEE

Congressman George Miller, Chairman

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ADVISORY FOR Thursday, February 4, 2010

Press Office, 202-226-0853

Advisory: House Education Committee to Consider Legislation to Protect Children From Abuse in Schools

WASHINGTON, D.C. – On Thursday, February 4^th, the House Education and Labor Committee will consider legislation that will protect schoolchildren from harmful uses of restraint and seclusion in their classrooms.

A recent investigation by the U.S. Government Accountability Office found hundreds of allegations that children have been abused, and some even died, as a result of misuses of restraint and seclusion in public and private schools, often at the hands of untrained staff. Unlike in hospitals and other medical and community-based facilities that receive federal health funding, there are currently no federal laws addressing restraint and seclusion in schools.

The Preventing Harmful Restraint and Seclusion in Schools Act (H.R. 4247) is the first national effort to address this troubling problem and ensure the safety of everyone involved – both students and school staff. It would establish minimum safety standards in schools and increase transparency, oversight and enforcement to prevent future abuse, among other things. Learn more here: http://edlabor.house.gov/blog/2009/12/preventing-harmful-restraint-a.shtml.

WHAT: Full Committee Mark-Up of H.R. 4247 “The Preventing Harmful Restraint and Seclusion in Schools Act”

WHEN: Thursday, February 4, 2009

11:00 a.m. ET

WHERE: House Education and Labor Committee Hearing Room

2175 Rayburn House Office Building, Washington, D.C.

Note: This hearing will be webcast live from the Education and Labor Committee website. You can access the webcast when the hearing begins at 11:00 am Eastern here.

GA: Clayton State University's Hollowell Publishes 'The Forgotten Room': Legislation Introduced to Protect Children from Misuse of Seclusion

http://www.prnewswire.com/news-releases/clayton-state-universitys-hollowell-publishes-the-forgotten-room-legislation-introduced-to-protect-children-from-misuse-of-seclusion-78956627.html

MORROW, Ga., Dec. 10 /PRNewswire/ -- Dr. Mary Hollowell, an associate professor of Teacher Education at Clayton State University, recently published "The Forgotten Room," a book covering an ethnographic case study of a public alternative school which highlights solitary confinement.

"I've tried to write the kind of education book that I've always liked to read -- a chronology of a school year from start to finish that sucks you in, sweeps you along, and spits you out," explains Hollowell. "'The Forgotten Room' is a unique and somber story of students on parole, and it reveals what happens to them and their hardworking teachers when they are put in crumbling school buildings and overcrowded conditions. It's dark and gritty. I saw students threaten and assault teachers. We had lockdowns, SWAT team visits, gang fighting, drug dealing, and students on rampages, but we also had oases of peace in the classrooms of exemplary teachers."

During her study of this school she discovered the "forgotten room" used for solitary confinement. She noted and photographed the graffiti written in blood covering the walls of this room.

"I have been an advocate against 'school seclusion,' as it is called, ever since. Seclusion rooms are allowed in Georgia public schools provided they are big enough for children to lie down, have good visibility, and have locks that spring open in case of an emergency such as a fire. The small, dark solitary confinement cells that I have seen, though, are double-bolted on the outside and do not meet these criteria," Hollowell expresses. "This week I learned that U.S. Reps. George Miller (D-CA) and Cathy McMorris Rodgers (R-WA) will introduce new legislation to protect all children in schools from misuse of restraint and seclusion. If my book 'The Forgotten Room' can play any part in the process, I will be satisfied."

For her book Hollowell used her own black and white images to accompany the text. Each chapter opens with a provocative photo of the deteriorating facility or neighborhood. Her work is featured as the cover image as well.

The 2009 Laura Ingalls Wilder Award winner from the American Library Association for lifetime contributions to children's literature, Ashley Bryan, wrote the foreword for Hollowell's book.

A unit of the University System of Georgia, Clayton State University is an outstanding comprehensive metropolitan university located 15 miles southeast of downtown Atlanta.

Contact:  Erin Fender Communications - Photojournalist University Relations Clayton State University (678) 466 4462 http://news.clayton.edu/

Physical Restraint - Minimisation in Acute and Residential Care Facilities

From the Joanna Briggs Institute:

Volume 6, Issue 4, 2002 ISSN 1329 - 1874

http://bf.jbiconnect.org/connect/docs/jbi/pdf/BPISEng_6_4.pdf

There is a growing concern surrounding the use of physical restraint in health care institutions and many facilities have investigated ways in which the use of restraint can be reduced.

However, the information reported in the literature is at times inconsistent and a number of different approaches to restraint minimisation have been proposed. A systematic review focusing on physical restraint was conducted by The Joanna Briggs Institute.

This systematic review addressed a number of different issues, including:

• Restraint Minimisation Programs
• Components of Restraint Minimisation Programs
• Restraint Alternatives

This Information Sheet Covers the Following Concepts:

1. Restraint-free Care
2. Restraint Minimisation
3. Programs
4. Restraint Education
5. Restraint Alternatives
6. Management of Specific
7. Populations
8. Multiple Support
9. Activities

A List of Questions You Can and Should Ask Your Child's School District about the "Training" Their Staff May Have Had on Restraint and Seclusion

December 7, 2009
By Jennifer Searcy
Founder/Director of Public Policy & Affairs

The Coalition for Positive Behavioral Interventions & Supports

Many times school districts will tell the parents of a special needs child that there may be a time when their child will "need to be restrained or put into seclusion."

Depending on the laws and policies of your state, it may be a legal requirement that restraints and seclusions may only be used in an emergency or if used in accordance with the child's individualized education plan (IEP) or behavior intervention plan (BIP). In other words, a district may be required to have your signature on file before restraint/seclusion may be used.

Parents wonder (as they should) how safe these techniques are; oftentimes, parents are reassured when districts inform parents the district's staff "is appropriately trained."

Unfortunately, this may or may not be the case.

A district may have received training in the past, but may not be up to date on their training. A district may have sent individuals to a professional "crisis management training" program offered by one of the many professional organizations which "train" non-violent, non-physical and/or physical forms of intervention, but those individuals may disregard all but the "how to restrain/seclude" aspects of their training.

"Certified instructors/trainers," who have been trained by a professional organization to provide training to others within a school district, also have the leeway of "customizing training to meet the needs of their district" - which means a certified instructor/trainer has the option of training nothing BUT restraint/seclusion use.

And finally, some of the professional training organizations do not even train in seclusion use!!

Yet the school districts claim to be following "professional protocols" and insist their staff are or have been "appropriately trained" and are only using techniques learned in training. How is this possible if the district is using seclusion yet has had staff trained by a company which does not offer training in seclusion!?

Bottom line: While it may be true that a district has sent employees to a professional training session, that doesn't mean that district employees are using the training they'd received appropriately or that the district puts into practice the philosophy of the professional training company.

So....

If your school district wants you to agree to the use of restraint and/or seclusion for your child, especially if they want to include these aversive measures in your child's individualized education plan (IEP) or behavior intervention plan (BIP), you may want to first ask the district to respond to any or all of the questions listed below:

1. What is the name of the training company they use?

2. How long have they used this training organization?

3. Can they provide you with the name of their contact at the organization, so you can contact the training organization directly to address any questions/concerns you may have?

4. Will they provide you with the name and contact information for the trainer/instructor who "trained" the district's staff?

5. Are they willing to provide you with the names and "trainer identification cards" for any/all employees who are "trained" to restrain/seclude your child. (Please note: Many of the training companies provide those who have trained under them ID cards which contain a date of completion of training, which is generally good for 12 months after the date of issue. If the training date on their ID is more than a year old, then you know that that individual's training has "expired" and that they need to be "re-certified." Please contact us at tcfpbis@gmail.com or the training organization directly for more information.)

6. Are they willing to invite (or you could invite them yourself) any/all "trained" employees to the next IEP meeting so you can discuss their training program and methods.

7. Are they willing to ask/permit you to ask each "trained employee" if they have ever placed a child in a restraint/seclusion and to describe the circumstances surrounding its use. (Please note: Due to confidentiality laws, they may not disclose a child's name, or may be reluctant to share a specific incident, but they should be willing to discuss circumstances when they may use restraint/seclusion in "general.")

8. Does the IEP team know what training philosophy the district and/or the professional training company follows. (Hint: Some districts claim to be using a specific training organizations' techniques, such as those offered by The Crisis Prevention Institute (CPI), but instead are restraining children for discipline or placing children in seclusion. CPI does not train restraint as discipline or anything about seclusion. It's against the company's "training philosophy.")

9. Are they willing to allow you to see a copy of the training manual and a copy of the trainer's manual. (Please note: I've personally spoken to some training organizations and they insist this information IS available to parents. So if the district says they can't share this info with you, tell them point blank, "That's funny, because the training organization insists that you can." And then call the training organization to report the district. OR, you could take the list of training companies with you, along with their contact information, whip out a cell phone during the meeting (or ask to use their phone) and call the training company IN FRONT OF the IEP team and explain to the training co. exactly what the district told you about access to the training manual. (That's only if you've got the moxie to do it, though :) ))

10. Are they willing to set up an appointment with a trainer who can go through a "Parent/Advocate" training module with you, as most companies are willing to explain their program to parents. (Makes it easier for the training companies to earn $$ if parents are on board - especially in states which require parental signatures along with "trained staff.")

11. Can they tell you how many times the district has used restraint and/or seclusion in their schools in the past year, and in the past 5 years, so you have a better idea how the district is really using restraint/seclusion?

12. Are they willing to provide you with the reasons why/situations when YOUR child would be placed in a restraint and/or secluded, and are they willing to commit in writing that those are the only times when restraint/seclusion will be used, short of a true "emergency?" (Please note: This way you have a better idea whether a district only uses restraints/seclusions for true emergencies, or if your child is in a situation where abuse is ripe for the taking. Please also note, that the newly proposed federal legislation, if passed as written, would prohibit schools from including restraint/seclusion in the child's IEP.)

13. Have they always used their current "trainers" and if not, are they willing to provide you with the names of the organizations used previously and the reason why they no longer use them? (Please note: You want to know what other "philosophies" and methods staff may have been exposed to, as they may pull from another "training program" in an "emergency.")

14. Can they tell you the maximum amount of time a child has been placed in a restraint and in seclusion? (Hint: If a restraint/seclusion is used at all, it should only last as long as the child poses an imminent/immediate danger of serious injury to himself/herself or others. As soon as the child is no longer a "danger," restraints (and seclusion) are to END.)

Finally, please, please, please! If you are considering agreeing to restraint and/or seclusion use for your child, ask the district to first respond to the above questions in writing before you sign on the dotted line. Once a district has your signature, if abusive practices do occur, it becomes so much harder to prove to an attorney or to a due process hearing officer because you gave your permission for the use of those techniques.

If you have any questions or concerns, please email me at tcfpbis@gmail.com.

List of Materials to Ask Your District for re “CPI-Certified/Trained Staff”

December 6, 2009

By Jennifer Searcy
Founder/Director of Public Policy & Affairs
The Coalition for Positive Behavioral Interventions & Supports

The following is a list of resources and materials which CPI provides to the districts/personnel/individuals CPI has trained, as evidence of what CPI teaches. This information is to be made available from school districts to parents/advocates upon request:

1. A Participant Workbook: This work book includes both pictorial and narrative descriptions of the different types of de-escalation and restraint techniques CPI trains.

Although this workbook is copyrighted and your district may not personally reproduce any portion of the workbook, you can ask the district to either give you access to their copy OR you could ask them to order a copy for you.

Please note: If you are ever in doubt about a technique personnel may have used on your child, ask them to show you the photograph of the technique they used, as outlined in CPI's Participant Workbook. If they cannot, or if you cannot find either a photographic or narrative description of a technique described to you, then personnel may have used a technique which is not “CPI-approved.” This needs to be reported to CPI at info@crisisprevention.com and/or us at tcfpbis@gmail.com immediately. Additionally, if the district refuses to provide you access to the CPI Participant Workbook, please contact CPI at info@crisisprevention.com and/or us at tcfpbis@gmail.com immediately.

2. An Instructor Manual: Every CPI-Certified Instructor is provided with a trainer’s manual which provides them with everything he/she needs to effectively conduct and customize training sessions, including a module which is used to educate parents/advocates on CPI’s philosophy and techniques.

Please note: If the district cannot produce the instructor's manual, or refuses you access to the manual, or if the district refuses to schedule an appointment with a trainer who could review the parent/advocate training module with you, please contact CPI at info@crisisprevention.com and/or us at tcfpbis@gmail.com immediately.

3. Identification Cards with Annual Training Date: Individuals who have completed CPI training are issued identification cards, which contains the date the individual was certified.

Please note: CPI requires annual recertification, so this “certification date” is very important. If identification cards cannot be presented, or if the certification date is more than one year ago, then the personnel may not be/may no longer be certified. If you are concerned about an individual’s certification, please contact CPI at info@crisisprevention.com and/or us at tcfpbis@gmail.com immediately.

Some additional things to know/consider:

CPI does not train in seclusion! So if your district is using/has used seclusion and/or seclusion rooms, and if they are claiming to be following “CPI training” for seclusion/seclusion rooms, then they are lying to you and should be reported to CPI at info@crisisprevention.com and/or us at tcfpbis@gmail.com immediately!

CPI also does not train restraint as discipline, punishment, nor convenience of staff; CPI is about avoiding restraint and seclusion! So if your district is using/has used restraint as discipline, punishment, or for staff’s convenience, please contact CPI at info@crisisprevention.com and/or us at tcfpbis@gmail.com immediately!

MD: Parents worried about ‘seclusion rooms

Seven Frederick County schools have rooms intended to help calm violent or over-agitated students

by Margarita Raycheva | Staff Writer

http://www.gazette.net/stories/12032009/newmnew161747_32541.php

A confined space with bare walls, linoleum floor, no furniture and a window for observation.

That is how educators describe "seclusion rooms" used to subdue violent or over-agitated special education students in seven Frederick County schools.

And Carla Papaioannou cringes at that thought.

Papaioannou had no idea until this year that Carroll Manor Elementary, at which she has two children, has a seclusion room.

When she discovered it — just down the hallway from her daughter's colorful and cozy classroom — it wasn't only the tiny space and the bare, unfinished walls that troubled her.

"It's like this big secret that is going on," said Papaioannou, who also has a kindergartner with autism. "Aesthetically, it is a very scary place. ... It is not a clinical setting."

Papaioannou told the Frederick County Board of Education about her concerns on Nov. 23 after finding out that the board was thinking about building one in Oakdale Elementary School.

"I am concerned about the training of the staff at the school," Papaioannou said. "Who decides to put the kids in that room?"

Teachers, according to county educators, decide when a student needs to be secluded, and they do not take the decision lightly.

"Only a very small percentage of students need this kind of intervention," Pam Pencola, the school system's director for special education and psychological services, told the school board. "It is a very serious step."

Seclusion can be used for any student, but is typically used on students who have special needs, Pencola told the board.

In fact, all seven Frederick County schools that have a seclusion room also have the Challenges or Pyramid programs, which serve students with severe autism and sensory issues and extreme behavior problems.

School system staff follows strict regulations for the use of seclusion rooms and are required to record every instance when they are used, Pencola said.

She did not specify how often schools use seclusion rooms because The Gazette had already requested that information through the Freedom of Information Act.

A Maryland law enacted in 2003 governs the use of seclusion, and local school systems have regulations based on that law.

For example, educators can only place a student in seclusion if the child becomes a safety threat or if seclusion is written in that child's individual education plan. Destruction of school property is not considered sufficient grounds for the use of seclusion.

Educators can seclude a child only after other interventions fail, and for no longer than 30 minutes straight. They must also constantly monitor a child in seclusion, and inform the child's parents.

But state law does not require school systems to systematically report the use of seclusion rooms to the Maryland State Department of Education.

The department, however, does investigate complaints about that practice, said Donna Riley, branch chief at the Maryland State Department's Division for Special Education and Early Intervention Services. Riley does not recall receiving complaints from Frederick County.

Riley said research has shown the seclusion does not help students in the long term, and the state department discourages the practice.

Instead, the state trains educators to look for the cause of outbursts and behavior problems. A fluorescent light or a noisy air conditioner can trigger aggressive behaviors, especially in students with autism and sensory issues.

If teachers can identify those triggers in individual students, they can avoid the need for seclusion. "It is much better to use that positive model," she said.

Riley encourages school systems not to build seclusion rooms. "I tell them: ‘Don't even go there.' There is a much better way," she said.

Still, Frederick County educators defended the practice, and said they use seclusion rooms as a last resort. Seclusion, educators say, is a necessity today when public schools educate much more students with severe problems, rather than institutionalizing them.

"This room is not used for normal bad behavior," said schools Superintendent Linda Burgee, the Frederick County Schools Superintendent, who encouraged parents to turn to their individual schools if they have other concerns.

"We would welcome the possibility to follow up on your comments," she told parents, who spoke to the board on Nov. 23.

But parents who attended the meeting were not satisfied.

They urged the school board to check if schools use of seclusion rooms according to regulations, and questioned the effect that the use of seclusion rooms can have on other students.

Seclusion rooms go against the efforts to mainstream special education students, and only prevent students from learning and being in the classroom, said Michele Clune, a parent with students at Tuscarora Elementary and the Monocacy Valley Montessori Charter School.

They are not a solution to behavioral problems and cannot help educators find the real reasons causing students to act out. Special education teachers have other strategies to calm down over-agitated students, and should not need to shut students in a confined space, Clune said.

"Seclusion rooms do not have a place in our schools," she said. "They could just deal with them without a quiet room."

Leslie Seid Margolis, a managing attorney at the Maryland Disability Law Center, concurred. She said seclusion is an "archaic" method of working with students, which has proven to be ineffective, and could be potentially traumatic and dangerous for students.

"Ideally, we don't think there should be seclusion rooms," Margolis said. "It's a potentially dangerous procedure that has no place in a school setting."

She said the law center has investigated a number of cases in which students were hurt or traumatized because of improper use of seclusion rooms.

Just recently, Margolis closed a case on a student who was restrained three times in one day and then sent to an emergency room covered in bruises. Margolis would not specify where the incident happened, but it was not in Frederick County, she said.

In another older case, teachers forgot about a student placed in seclusion. The child was found at the end of the school day because a bus driver asked about the student. The law center used the case as evidence when they testified for the need to create a statewide legislation governing the use of seclusion in 2003, Margolis said.

Since then Maryland has started moving in the right direction and county school systems must follow.

"It's not just a money issue, it's a training issue," Margolis said. "The state has just begun to recognize that there is a significant lack of qualified training. That is the piece that has been missing."

E-mail Margarita Raycheva at mraycheva@gazette.net.

The following Frederick County Public Schools have a seclusion room:

Carroll Manor Elementary

Lewistown Elementary

Middletown Elementary

Middletown Primary

Oakdale Middle

Rock Creek

Gov. Thomas Johnson High

Parents who have concerns or complaints about the use of seclusion in their schools can call the Maryland Disability Law Center at 410-727-6352 between 10 a.m. and noon.

MD: School seclusion rooms come out of the dark

By Marge Neal
News-Post Staff
http://www.fredericknewspost.com/sections/news/display.htm?storyID=98306

Originally published November 27, 2009

A planned addition to Oakdale Elementary School will include classrooms, restrooms, a faculty room -- and a seclusion room.

Seclusion rooms are used to isolate a child -- most often a special-education student -- who poses a physical threat to himself or others, or is disrupting the educational process, Pam Pencola told the Frederick County Board of Education this week.

After looking over the Oakdale plans, board members recently asked school officials to explain the use of seclusion rooms, which are seldom acknowledged or discussed in public.

"A very small percentage" of students need this kind of intervention on a regular basis, said Pencola, the school system's director of special education and psychological services.

She described the use of a seclusion room as a "very serious step" and said staff members employ many other strategies before isolating a student.

The school system already has seclusion rooms at Carroll Manor, Lewistown and Middletown elementary schools, Oakdale Middle, Gov. Thomas Johnson High and Rock Creek School. One is being built at Middletown Primary School.

At Rock Creek, the room is used for students with severe cognitive impairments who may also have behavior disorders, according to the report to board members.

At the other schools, the seclusion room is used for students in the Challenges or Pyramid programs. Challenges serves students ages 3 to 21 who have autism or severe communicative disorders, Pencola said. Pyramid is a K-12 program for students with significant emotional and behavioral needs.

At Lewistown Elementary, which houses the county's only elementary Pyramid program, parental consent is required to use the seclusion room as a behavior modification tool, principal Amy Schwiegerath said.

"A parent must sign the permission slip or be a part of the team decision-making process for the seclusion room to be used," she said.

The principal is notified every time the room is used, Schwiegerath said. A log is kept of all uses, and an incident report is filled out each time seclusion or restraint is used. Parents are to be notified within 24 hours of these techniques being used on their children. Lewistown also holds a staff debriefing after each use.

The seclusion room at Lewistown is about six feet square with a ceiling about eight feet high. The walls are covered with carpet from floor to ceiling. The floor is tiled with linoleum. In the ceiling is a light fixture, as well as a camera that allows constant observation of the student. The light switch is outside the room. The room is free of electrical outlets or anything else that could harm a student.

A calming place

Frederick County Public Schools use seclusion rooms in accordance with the Code of Maryland Regulations, which provides the legal definition and authority for their use. The FCPS policy on the rooms mirrors the state's parameters.

At Lewistown, students in the Pyramid program benefit from a team approach that includes general educators, special educators, administrators and clinical social workers, Schwiegerath said.

"The kids who come here come through the county's (individualized education plan) process," she said. "It's a highly structured program."

Thirty-three students are in Pyramid. Lewistown has another 160 students in its general education program.

Karen Williams, a licensed clinical social worker at Lewistown, said the seclusion room is used once or twice a day for "true seclusion events." The room might also be used at the request of a child.

"Our students know how to self-advocate," she said. "A student will ask for five or 10 minutes in the room to calm themselves down.

"A student might ask to have five minutes in the room with the door open and the lights out."

When a child with psychiatric or behavioral disorders is out of control, the cause is often sensory overload, Williams said. Putting a child in the room takes away the stimulation that has the child worked up and allows him or her to decompress.

The school system uses the Crisis Prevention Institute's techniques for de-escalation, Williams said.

The institute is an international training organization that specializes in the safe management of disruptive and assaultive behavior, according to its website.

Williams is a CPI-certified trainer and provides training to her colleagues.

"We must be annually trained and annually refreshed," she said. "And that's according to COMAR and FCPS."

Parents, when they first come to visit the Lewistown Pyramid program, are hesitant about the restraint and seclusion techniques, Schwiegerath said.

"But it is a last resort and is safety-oriented. We use this room for the safety of the child and the safety of others around him."

"The concept of seclusion and restraint always makes people nervous -- and it should," Williams said. "It's a very serious intervention, and should only be used to match the level of seriousness of the behavior being disciplined.

"We employ this tool in a professional, appropriate and positive manner. It's a necessary thing at times."

Article: 6 Things That Special Education Personnel Can Do to Decrease Restraint and Seclusion in Their School

From: http://www.spring-tides.org/294/6-things-that-special-education-personnel-can-do-to-decrease-restraint-and-seclusion-in-their-school

Are you the parent of a child with autism or another disability that is very concerned about your child’s safety at school, due to negative behavior? Has your child been physically or emotionally injured by restraint and seclusion, by special education personnel? This article will discuss 6 ways that school districts can deal with behavior rather than relying on restraint and seclusion!

Restraint is defined as any manual method, physical, material, equipment that immobilizes or reduces the ability of an individual. In school districts they mainly use holding techniques. Prone restraints (where the child is held face down) are the most dangerous and cause the most incidence of injury and death!

Seclusion is defined as the placing of a person involuntarily in a room or area alone and prevent them from leaving. Some schools have started relying on time out rooms to seclude children with disabilities when they misbehave.

Below are 6 things that special education personnel in your district can do to decrease or eliminate the use of restraint and seclusion in their schools:

1. They can have school wide policies in place with specific instructions on when restraint and seclusion will be used; and also policies developed on releasing the information to the public. By keeping written charts on when it is used, and releasing the information to the public on when it is used, will actually cause restraint and seclusion to be used less. The danger comes when special education personnel keep the information secret, and refuse to share it with the public; ask your district for accountability!

2. Stop relying on punishment, restraint and seclusion to deal with children’s negative behavior. One of the important things to know is that a lot of children with disabilities have behavior that is related to their disability. Also, it is proven in research that punishment, restraint and seclusion do not work in the long term to change a child’s behavior!

3. Have good attitudes that include all children in the school; including children with disabilities! Personnel that take a positive proactive approach to school order and behavior can absolutely have a wonderful affect, on all of the children in the school. Positive attitudes encourage learning, negative attitudes discourage learning!

4. Teachers and other special education personnel need to be taught not to overreact to behavior. By appropriately dealing with negative behavior the child’s behavior may decrease, but on the other hand overreacting to the behavior, can escalate the behavior. I have seen this many times over the years; a child with autism gets upset and the teacher jumps in; gets in the child’s face and escalates (makes worse) the child’s behavior! Teachers must learn to step back and give the child time to calm themselves down!

5. Understand the huge connection between behavioral difficulty and academic difficulty. Many parents call me when their child has negative school behavior, and ask for help. I ask them: how is your child’s academics? In 100% of the cases the child is below average in all areas of academics. The child is telling the people around them: I cannot do this work, so I am going to misbehave so that I can avoid the work! Avoidance of hard academics is the cause of a lot of negative school behavior!

6. Use research based processes; positive behavioral supports and plans to deal with a child’s negative school behavior. The process starts with a Functional Behavioral Analysis (FBA) to determine what the child is getting from the negative behavior. Is it to avoid hard academics? Is it to access attention? Then a properly conducted FBA is used to develop a positive behavioral plan. This is not a punishment plan, but a plan to increase positive school behavior which then decreases negative school behavior.

Bring these 6 things to your school district and ask them to implement them for your child and other children. This will ensure that all children have a positive environment to learn; even children with disabilities!

Article: Seclusion to inclusion

NOTE: Although this article references techniques that were used in a psychiatric facility, some of the same techniques can be adapted for use in other locations, such as public schools...

Friday, 20 November 2009

Genevieve Costigan

http://www.sciencealert.com.au/features/20092011-20269.html

A School of Nursing and Social Work pilot project in an inner city Melbourne hospital has seen the practice of locking up extremely unwell psychiatric patients in isolation reduced by more than 50 per cent.

The practice, commonly called seclusion, involves placing acutely unwell psychiatric patients in a confined space to prevent immediate harm to the patient and other people and is considered a measure of last resort.

It is, however, a relatively common practice in acute psychiatric settings in Australia with thousands of people being secluded each year.

The project, Translating Evidence to Practice: Seclusion Reduction in Acute Psychiatry, was led by Dr Bridget Hamilton, Director of Nursing for Mental Health at St Vincent’s and senior lecturer in the School of Nursing and Social Work.

“Seclusion is an issue that people often won’t want to think about or address, without significant support to do so – in some ways it’s treated like a dirty work practice and this is part of what stigmatises mental health practices,” Dr Hamilton says.

Involuntary psychiatric patients often come through the emergency departments of hospitals and are commonly people who are having a psychotic episode as a result of schizophrenia, hypermania or drug-induced psychosis and sometimes they are people in crisis with borderline personality disorder.

“It is challenging for even highly skilled staff to communicate effectively with people when they are acutely unwell,” Dr Hamilton says.

“Patients may express their fear and frustration being surrounded by unfamiliar people and places, they may be given directives they do not understand or may argue with, and the rising sense of injustice and distress can all lead to conflict situations where patients are manhandled into a seclusion room.

“Nurses don’t want to initiate physical restraint but as they are usually working within a constrained space in a psychiatric unit, they experience chaos, noise and verbal abuse and they work hard to meet the needs of the distressed patient but they are also trying to keep the other patients and staff safe,” she says.

International focus on seclusion policies began in the United States in the early 1990s following a newspaper expose of a series of deaths in seclusion rooms in US mental health facilities. Enquiries into seclusion rates went to Congress which led to changes to legislation and practice.

Yet, Dr Hamilton says, in 2006 when this project was planned the idea of seclusion reduction wasn’t on the radar in clinical settings in Victoria.

“We need to think about seclusion from the point of view of the unintended harm it can do to the patients and not just from the perspective of safety,” she says.

Dr Hamilton established a partnership with St Vincent’s Mental Health and sought support from the National Institute of Clinical Studies (NICS) and the Victorian State government to undertake the project.

Based on the US research Dr Hamilton used six core strategies to reduce the use of seclusion and restraint. The US strategies were adapted for the different mental health service structures and laws in Victoria.

Changes were made in St Vincent’s organisation and practice to reduce reliance on seclusion, including getting senior managers engaged in the goal of seclusion reduction, revising policy, focusing on available seclusion data and surveying staff attitudes to seclusion. Clinicians participated in training and senior clinicians reviewed all seclusion events.

Dr Hamilton believes examining the data was essential as it confronted clinicians and managers with the detail of seclusion, for example how some patients had been secluded many times and it raised the question of why this was so and how it could be changed.

“It was a difficult project for any organisation to take on and needed leadership but with the backing of the University, NICS, many colleagues at the hospital and state government we managed to get it going.

“Patients who are secluded often experience terrible shame, a sense of a loss of control and dignity and it can also re-traumatise people who have been abused, neglected and isolated and putting them in a confined space can reignite memories of abuse,” Dr Hamilton says.

“At the coalface we need nurses to be thinking hard and differently about what you can do in these situations, what you can do earlier, what you can do to address patients’ needs, concerns and fears which may help avert seclusion.

“We need to look at how we can orientate people to the ward, explain what the different spaces are and we need to expect that people are going to find it very difficult and so spend more time with them on admission to the unit.”

Dr Hamilton says some of the things wards can do to support patients are to directly address patients’ concerns which may revolve around their domestic situations, for example they may need to make phone calls to check on family members or arrange for the care of their pets.

“If you see a patient getting upset, behaving erratically, you can speak to the patient and try to find out why they are upset; it may be something you can deal with and can be a better way of handling a situation rather than waiting until the situation escalates,” she says.

Changes in attitudes can be crucial in reducing seclusion rates and Dr Hamilton suggests that the tendency to think that the person who is behaving badly does not deserve more attention needs to change to the idea that intensive work actually needs to be done with this person.p>

Child Abuse at Schools and Institutions Linked to Improper Use of Restraints

May 20th, 2009
http://www.aboutlawsuits.com/child-abuse-at-schools-and-institutions-linked-to-restraint-3985/

A new report from the U.S. Government Accountability Office (GAO) describes hundreds disturbing reports involving serious injuries and even deaths related to child abuse at schools and institutions where children were improperly restrained and secluded.

Gregory D. Kutz, Managing Director of Forensic Audits and Special Investigations for the GAO, testified before the U.S. House Committee on Education and Labor on May 19, detailing cases of child abuse caused by the improper use of restraint techniques. The agency also found that special needs children were particularly vulnerable.

The GAO looked at cases over the past 20 years, identifying instances of institutional or school abuse involving restraint injuries. There are currently no federal guidelines on the use of restraint techniques on children, and the report points to a large disparity between existing policies among different states.

The report was conducted at the behest of U.S. Rep George Miller (D-CA), chairman of the committee, and focused specifically on ten incidents of child abuse; four of them leading to fatalities. [NOTE: The Coalition Against Institutionalized Child Abuse has a more comprehensive Death Toll, which includes numerous deaths, here: http://www.caica.org/RESTRAINTS%20Death%20List.htm]

In one case, a 14-year old student was killed at a Texas public middle school after the boy was physically held down until he suffocated. The report indicates that he had also been denied food for several hours before the incident.

Although the death was ruled a homicide and the teacher was placed on a Texas state list for child abusers, the teacher was able to move to Virginia and continue teaching K-12 special needs children until her involvement came to light as a result of the GAO investigation. The teacher has now been placed on [PAID] leave.

In all four of the fatality cases investigated, teachers or staff members used restraining techniques on children that restricted the flow of air to their lungs.

Miller said the report showed that federal legislation needs to be enacted, regulating the use of such procedures, and the Obama administration pledged to meet with stakeholders to address the abuses.

“GAO’s report shows that in too many cases, a child’s life wound up being threatened even though that child was not a threat to others,” Miller said in a statement released by the committee. “This behavior, in some instances, looks like torture. The current situation is unacceptable and cannot continue.”

There have been several successful child abuse lawsuits against schools and other institutions in relation to the improper use of restraint, according to the GAO report.

In 2003, the mother of a 15-year old autistic student reached a $1.3 million settlement with a Michigan public school after her son died while being restrained in a prone position on his stomach. The incident occurred while the school staff was punishing the student, who had suffered a seizure and lost control of his extremities.

Another case involving an incident that occurred at a West Virginia public school, resulted in a $460,000 jury award after a 4-year old student with cerebral palsy was bound to a chair with leather straps. The girl suffered bruising and post traumatic stress disorder. Although the school district and teachers were found to be negligent in the incident, at least one of the teachers continued to work at the school at the time the GAO report was prepared.

COPAA Report - Unsafe in the School House: Abuse of Children with Disabilities

In March and April 2009, the Council of Parent Attorneys and Advocates conducted a survey which identified 155 cases in which children were tied, taped to chairs, forced into locked seclusion rooms, deprived of basic necessities, and subjected to a variety of abusive techniques. 

The survey findings concluded:

71% of cases, children did not have a positive behavior intervention plan

71% of parents did not consent to restraint, seclusion, or aversive use

68% of children abused had been diagnosed with an autism spectrum disorder

58% of abuse occurred in self-contained classroom with no other children with disabilities

53% of children aged between 6-10 years old

The report also includes summarized parent accounts of aversive use.

A copy of the full report can be found here:

http://www.copaa.org/pdf/UnsafeSchoolhouseCOPAAwithAppendixMay09.pdf

SPECIAL REPORT: NDRN to publish NATIONAL REPORT of Restraint/Seclusion in Schools!!

From Colorado's P&A:
http://randychapman.wordpress.com/2009/01/08/ndrn-to-issue-report-on-seclusion-and-restraint-in-schools/

On Tuesday January 13th the National Disability Rights Network (NDRN) will conduct a media briefing and will release a disturbing national report on seclusion and restraint in U.S. schools. Additionally, NDRN will call on the Obama Administration and the new Congress to introduce a national ban on seclusion and prone restraint practices in schools nationwide.

The report is a compilation of cases from NDRN's 57 member network of protection and advocacy (P&A) systems nationwide. This report will detail deaths and physical and emotional injuries inflicted on students ranging from kindergarten to high school from schools throughout the country. Moreover, the report will outline inconsistant state laws, lack of training for teachers, and virtually no government oversight or investigation of this issue.

Speakers who will attend the media briefing include U.S. Senator Chris Dodd (D-Ct.), NDRN Executive Director Curt Decker, and families of children who were physically restrained or placed in seclusion while attending school.

My office, The Legal Center for People with Disabilities and Older People, is Colorado's Protection and Advocacy System and part of NDRN's network of P&A Systems. We have been actively involved in investigating the inappropriate use of seclusion and restraint in
Colorado schools. The Legal Center has raised this issue in Colorado (Please see Defending the Rights of Children Report Sparks Controversy and The Legal Center Investigates Aurora Elementary Schools) and contributed to this upcoming report. I will follow up on this posting next week when NDRN's report becomes available.

Learning from Each Other - Success Stories and Ideas for Reducing R&S

A 42 page guide produced by the American Psychiatric Association, American Psychiatric Nurses Association, and National Association for Psychiatric Health Systems (with support from the American Hospital Association) which shares practical tips for reducing restraint and seclusion use:

http://www.naphs.org/rscampaign/Learning.pdf

Restraint and Seclusion - A Risk Management Guide (2006)

Below is a link to a Risk Management Guide for Restraint and Seclusion. This information primarily concerns mental health facilities, but the principles could also apply to other settings:

http://www.power2u.org/downloads/R-S%20Risk%20Manag%20Guide%20Oct%2006.pdf

Topics in this guide include:

* Restraint and Seclusion Use in Mental Health Facilities is Under Intense Focus

* Many Factors Contribute to the Substantial Legal Risks Associated with the Use of Restraint and Seclusion

* Overview of Legal Claims and Liability Risks Associated with the Use of Restraint and Seclusion

*Effective Tools to Reduce Restraint and Seclusion are Well-Established and Inexpensive

*Action Steps for Attorneys as Risk Managers

Following is an excerpt:

Over the past decade, however, a clear consensus has emerged that restraint and seclusion are safety interventions of last resort and that the use of these interventions can and should be reduced significantly. In evaluating the potential legal risks associated with the use of restraint and seclusion, risk managers should understand this emerging consensus as critical to a determination about whether a particular use of these interventions reflects “the exercise of professional judgment.” This should be considered in the context of the following factors:

(1) Each use of restraint or seclusion poses an inherent danger, both physical and psychological, to the individual who is subject to the interventions and, frequently, to the staff who administer them.

(2) The decision to use restraint or seclusion nearly always is arbitrary, idiosyncratic, and generally avoidable.

(3) Many inexpensive and effective alternatives to restraint and seclusion have been developed and successfully implemented across a broad range of mental health facility types.

The legal consequences of inappropriate use of restraint and seclusion can include civil damages, administrative sanctions (including the loss of Medicaid and Medicare certification), and criminal prosecution. Moreover, litigation about these practices invariably consumes the facility’s attention and resources, no matter what the ultimate outcome, with significant negative implications for the facility’s reputation and staff morale.

Federal Standards For Use Of Restraint And Seclusion

SPECIAL NOTE: Public Schools who receive Medicaid reimbursement would be covered under this statute because they provide medical services under the direction of a child's physician (i.e. Physical Therapy, Occupational Therapy, etc.) with funds that are "federally and/or state appropriated."

The new protections establish two sets of standards, depending on the type of facility. One applies to "non-medical community-based facilities for children and youth." The facilities will be defined in regulations and will include group homes and the like. The other set applies to any health care facility that receives federal appropriated funds, such as a public or private general hospital, an intermediate-care facility or other health care facility. All must comply with the general principle of protecting and promoting the right to be free from restraints and seclusion for purposes of discipline or convenience.

The statute requires that seclusion and restraint be used only:

* to ensure the physical safety of the individual or others; and
* subject to a written order by a physician or other licensed practitioner permitted by the facility and state law. In most cases, the written order will be obtained soon after the restraint or seclusion is initiated by staff.

Medications and drugs that are used to control behavior and are not a standard treatment for the individual's condition are considered a form of restraint. Accordingly, they are subject to the same requirements.

Deaths Must Be Reported Promptly

Facilities must also report, to agencies designated by the Secretary of the Department of Health and Human Services each death that occurs while a resident is restrained or in seclusion and each death that occurs within 24 hours after the person has been released from the restraints and seclusion or where it is reasonable to assume the death was the result of the restraints and seclusion. The designated agencies are likely to include protection and advocacy systems, which have unique federal authority to investigate and legally pursue instances of abuse and neglect in facilities. The notification must be provided within 7 days of the death of the resident.
In addition, the Secretary, within one year of enactment, must issue rules on appropriate training in the use of restraints and seclusion, in alternatives to their use and in adequate facility staffing.

Special Restrictions in Facilities for Children

Use of restraints and seclusion in "non-medical, community-based facilities for children and youth" is:

* limited to emergency situations to protect the immediate physical safety of the person or others; and
* imposed only by individuals trained and certified by a state-recognized body in a list of competencies, including the physiological and psychological impact of restraint and seclusion, in monitoring physical signs of distress and in the prevention of restraint and seclusion use.

However, an interim requirement was included to provide protections until a state develops a certification process for the competency areas. During this period, a supervisory or senior staff person, trained in restraint and seclusion and competent to make a face-to-face evaluation, will make a patient assessment within one hour of the initiation of restraint or seclusion and continue to monitor the use for its duration.

In these facilities, time-out and physical escorts are not defined as seclusion or restraint.

Accordingly, the new requirements do not apply to these procedures. However, for this limited group of youth-serving facilities, mechanical restraints and drugs are prohibited as a form of restraint and seclusion can only be used when a staff member is continuously monitoring face-to-face.

Reporting of deaths that occur must be made by each facility to the appropriate state licensing or regulatory agency, determined by the Secretary of the Department of Health and Human Services. The notification must be made within 24 hours of the death.

Furthermore, within six months of enactment, the Secretary must release regulations regarding national training standards and within a year states that license these facilities are required to develop a set of monitoring requirements on behavior management.

Reference: Public Law 106-310, Children’s Health Act of 2000 (Section 3207 and 3208)
These restraint and seclusion requirements amend Title V of the Public Health Service Act (42 USC 290aa et seq.) by adding Section 591 and 595. You may access the new law online.

Practicing Restraint

By Scott Kirkwood
For Full Article: http://www.cwla.org/articles/cv0309restraint.htm

Restraint and seclusion were once considered acceptable, even valuable tools in maintaining control of unruly children in residential group homes. But the call for alternatives is growing louder.

The negative effects of restraint have been well-publicized in recent years, most notably in a 1998 series in the Hartford (Connecticut) Courant implicating restraint in the death of dozens of children each year.

"Facilities that use seclusion and restraint have a much higher rate of injuries and sometimes deaths than institutions that don't use seclusion and restraint," says Kevin Ann Huckshorn, Director of the Office of Technical Assistance for the National Association of State Mental Health Directors in Virginia. "Before the Hartford Courant expose, many people thought, 'We use restraint because we have to--it's a serious intervention that must be done well,' but now we're starting to ask why we're using restraint at all."

Seclusion & Restraint - Rethinking the MO of the Status Quo

From: http://www.aacap.org/cs/root/member_information/practice_information/nov/dec_2005_aacap_news_seclusion_restraint_some_surprising_findings

November/December 2005

By now it should be apparent to those of us in the psychiatric professions that restraints and seclusion are not benign procedures. To date there is no precise way to measure the number or extent of the injuries to children and injuries also to staff as a result of restraint use. Most recently, the Child Welfare League of America (CWLA) estimated that between eight and ten children in the U.S. die each year due to restraints, while numerous others suffer injuries (CWLA, 2002). As caregivers who have chosen to work for the well-being of children, we can all agree that even one of these deaths is unacceptable.

Psychiatrists and psychiatric nurses have called for more staff training in de-escalation techniques and they have issued numerous position papers and guidelines asserting that restraints and seclusion are interventions of last resort. There is little to disagree with in any of these well-meaning pronouncements. However, the position papers and statements fail to convey the complexity of the factors involved in patient aggression, its management, alternatives to, and death and injury proximal to the use of physical or mechanical restraints. Nor do they address the key elements that should be foundational with respect to the consideration of any intervention that we include in our therapeutic armament. Such interventions should be informed by a solid knowledge enterprise that deals with questions of: 1) How much do we know? 2) How well do we know it? and 3) With whom are we knowing it?

Three areas beg for attention in our knowing enterprise with respect to the above questions: education, research, and practice. In the area of education, our professions have failed to educate our students and residents adequately with respect to the multi-factorial reasons for aggression and violence, how to de-escalate potentially violent situations, what risks are inherent in their use, and how to apply restraints safely. In the area of practice, health care professionals have been remiss in failing to identify patients who, because of potential risk factors, might be at high risk for death and injury. In the research arena, the situation is even more dismal. Research is urgently needed to address risk factors associated with death proximal to physical restraint of patients. Studies should be conducted on independent, interactive, and cumulative effects of these risk factors on death and injury rates (Mohr, Petti, & Mohr, 2003). Multidisciplinary research is also needed in determining what programming actually constitutes a best practices approach with respect to primary and secondary prevention of violence, and which constitutes the safest approaches in the unavoidable event that a restraint becomes necessary. In sum, our knowing enterprise needs serious focus before our positions can be fully realized.

Although the above areas do not exhaust what needs to be known or done, their daunting challenges suggest that an effective agenda and strategic approach cannot be developed by professionals in isolation from each other. It must be collaborative. The principle of collaboration underscores the importance of forging dynamic and workable partnerships between physicians, nurses, and patients. Nurses assess patients; physicians assess them as well and write the orders for their restraint; nurses and other caregivers implement the orders and evaluate the outcomes. Patients endure the procedure. It is clear that the knowing enterprise involves more than one group of participants.

Unfortunately, wide gaps separate us from each other as professionals and from our patients (Mohr, 2000). These gaps are the source of mistrust and tension that too often impede or block the implementation and use of research findings by members and nonmembers of the scientific community. For example, how many physicians read nursing research journals? This reality is most acute where members of a profession and our society feel alienated and not adequately regarded as participants in the mainstream decision-making or research process. Unfortunately, professionals and patients can feel this way in today’s legally challenged and over-regulated health care environment that spawns feelings of political disenfranchisement and disempowerment.

But, the very realities of the health care environment and the complexities and exigencies of what we must do in the area of aggression, violence, and their safe containment beg for the establishment of a multi-directional flow of effort that will help professional and patient groups to co-construct, research, and assess effective and safe intervention strategies. Such an effort must involve breaking out of the status quo of our narrow professional categories. It means that we must first honestly share fears, expectations, and mistrust of prospective collaboration, and agree to a sharing of power.

Out of this dialogue should come a recognition of the strengths that each partner brings to the collaboration and a commitment to cultivate these strengths. Second, there must be a genuine flow of information to enable partners to learn the value of each other’s unique perspective and knowledge related to their joint ventures. Finally, partners must together translate their trust and information exchange into useful assessment, intervention, and evaluation strategies. Establishing and maintaining effective partnerships on behalf of children and families must be an end in and of itself, before it can be a means to an end that results in therapeutic and safe interventions that will benefit them.

Dr. Masters is Chief Medical Officer of ABS New Hope Treatment Centers and Assistant Clinical Professor of Health and Behavior at the Medical College of Georgia.

Dr. Mohr is Associate Professor of Psychiatric Mental Health Nursing at the UMDNJ School of Nursing in Newark, NJ.

References
Mohr, W.K. Re-thinking professional attitudes in mental health settings. Qualitative Health Research. 2000; 10(5): 595-611.

Child Welfare League of America. Advocacy: Seclusion and restraints: Fact sheet, 1-2. 2002. http:// cwla.org/ advocacy/seclusionrestraints.htm. Retrieved March 23, 2002.

Mohr, WK, Petti, TA, & Mohr, BD. Adverse effects associated with the use of physical restraints. Canadian Journal of Psychiatry. 2003; 48, 330-337.

Seclusion and restraint of children: A literature review

For full article: http://findarticles.com/p/articles/mi_qa3892/is_200010/ai_n8915784/pg_1?tag=artBody;col1

The seclusion and restraint of children in psychiatric care represent extreme forms of intervention that are commonly used by nurses to provide containment and safety. There is widespread concern and ethical debate about the use of these controversial, untested, and questionably effective interventions with such a vulnerable population, especially when several more adaptive alternatives are available.

Nurses often are the key players in the decision to use and implement seclusion and restraint.

The concern of this paper, therefore, is nurses' beliefs about the rationale for and efficiency of the continued use of seclusion and restraint with children, and what alternatives are available. Mayton and Fontanez (1991) define seclusion as "the sequestration by placement of a recipient alone in a room which he has no means of leaving" (p. 33), and restraint as "direct restriction through mechanical means or personal force of the limbs, head or body of a recipient" (p. 33).

Guidelines to maintain safety of both yourself and others during situations of potential violence include

1. Take a position just outside the individual's personal reach (out of arm's reach) on the nondominant side.
2. Maintain an open posture.
3. Keep the individual in visual range.
4. Make certain the room's door is readily accessible; avoid letting the individual get between you and the door.
5. Summon help if the individual's aggression escalates to violence.
6. If other patients are in the vicinity, ask them to leave the room to decrease distractions and protect the person's dignity.

From: Alternatives to Restraint and Seclusion in Mental Health Settings: Questions and Answers From Psychiatric Nurse Experts

Partial List of De-escalation Techniques

From the The American Psychiatric Nurses Association
http://www.medscape.com/viewarticle/555686

Here is a partial list of de-escalation techniques that experienced mental health nurses find to be helpful in a crisis (These can also be applied in a public school/classroom setting):

1. Assess the situation promptly. If you see signs and symptoms of a person entering into crisis, intervene early.
2. Maintain a calm demeanor and voice.
3. Use problem solving with the individual -- ask "What will help now?"
4. Be empathetic.
5. Reassure individual that no harm will come to him or to others.
6. Avoid an argumentative stance.
7. Offer to help.
8. Engage the individual.
9. Use stress management or relaxation techniques such as breathing exercises.
10. Don't crowd the individual; give him or her space.
11. Be aware of yourself -- your look, your tone.
12. Offer choices.
13. Use open-ended questions.
14. Give the individual time to think.
15. Decrease the tension with relaxation techniques.
16. Ignore challenges; redirect challenging questions.
17. Tell them what you can do to help them.
18. Allow venting.
19. Allow pacing.
20. Don't say "you must."
21. Avoid power struggles.
22. Set limits and tell them what the expectation is.
23. Be careful with your nonverbal behaviors.
24. Be aware of the individual's nonverbal behaviors.
25. Be clear; use simple language.
26. Language -- follow the rule of 5 (no more than 5 words in sentence, 5 letters in a word -- eg, "Would you like a chair?")
27. Use reflective technique -- "Am I hearing you?"
28. Agree to disagree.
29. Be willing to break the rules.
30. Consider using sensory modalities such as weighted blankets or calming rooms with stress reduction tools.