Restraint and Seclusion

The majority of parents that commented on my last blog (see Cherry Hill's Chokey) were horrified when they learned that physical restraint and aversives, such as seclusion were being used on children in the Cherry Hill public school district. I received over 100 responses to that one blog! That is the highest ever on the Autism Blog, so it was obviously a great concern to many parents.


I was pleased that so many weighed in on this issue. We saw comments from parents of both special needs children and typical children, as well as a few teachers and other staff members that were able to offer their insight. It is my hope that through these public discussions, we can improve the situation for all of our children.


The issues of morality and legalities involved in this matter may seem complex. While we can all come to our own opinions on issues of morality, some parents may have been at a disadvantage since they may not be familiar with the laws related to special education. For the parents of typical children, without an IEP, I wanted to provide the legal information regarding the Individuals with Disabilities Education Act (IDEA) and the Free and Appropriate Public Education (FAPE) provisions. Obviously, IDEA is rather extensive, so I am just going to supply the basic information and that which relates to restraint and seclusion.


Every child in our school district that is "classified" as having a disability has an Individualized Education Plan (IEP). IEP's must follow the IDEA, which is a matter of Federal Law. There are also state laws that come into play, but for now I will focus on the requirements of IDEA as it relates to behavioral interventions.


IDEA supports positive approaches for all students.
The Individuals with Disabilities Education Act (IDEA) creates a presumption in favor of positive methods. IDEA requires that an IEP team consider positive behavioral interventions and strategies when it comes to a child's behavioral concerns.


A Functional Behavioral Assessment (FBA) is the type of evaluation used to determine a child's behavior support needs. This evaluation typically results in the development of a Behavioral Intervention Plan (BIP). The BIP will list the strategies to improve the child's behavior and determine the appropriate goals. All of this becomes part of the child's IEP.


The behavior plan is a very important aspect of the IEP because it tells staff how best to handle the behaviors of the individual child. Keep in mind it is an "Individualized" education plan. Special education is never a "one size fits all" approach and behavioral interventions must be individualized for the particular child.


Maladaptive Behaviors:
For parents of typical children and for teachers not specifically trained to work with children that display explosive behaviors, it is often hard to imagine why a child would "explode" in the classroom. There are many things that can lead to these maladaptive behaviors.


For children with neurological disorders, the behaviors are often triggered by skill deficits. Some of the common skill deficits are in the areas of social and communication skills. Perhaps the child has communication skill deficits that hamper his/her ability to express his needs verbally. Combine that with a low tolerance for frustration and this could easily trigger a meltdown. If the child's social skills are deficient, s/he may not understand what behaviors are socially appropriate. Effective teaching strategies could help the child learn what behaviors are appropriate in various social situations and curtail the maladaptive behaviors.


Some children have such severe Sensory Integrative Dysfunction that certain noises or lighting conditions become intolerable. This too, may manifest as inappropriate behavior. This is another thing that the behaviorist would need to consider in developing an "individualized" plan.


For some children, they may need to follow a very strict routine, so interuptions in their schedule (for assemblies, class parties, etc) may be triggering the inappropraite behaviors. Keep in mind that for most autistic children the inability to transition and extreme rigidness are part of the overall disorder. Just going from the classroom to the playground is a huge transition.


Some children may have simply learned that a certain behavior helps them to achieve a certain goal. The behaviorist then needs to consider what the child is accomplishing by displaying certain behaviors. Maybe the child becomes overwhelmed in the classroom and is actually acting out to get a "time out." In which case, the child can be trained to ask for a break when needed, rather than acting out in class. In this case, punishing the child would not teach them the appropriate way to ask for a break, it would just frustrate the child even more.


With so many pieces to the puzzle, the behaviorist needs to consider all of the possible antecedents in order to put together an effective behavioral intervention plan that is truly based on the individual child's needs.


Behavioral Interventions:
According to the IDEA, positive behavioral interventions and strategies must be considered first. Emphasis on the development of new, positive skills is different from the use of aversive techniques, restraint or seclusion, which are applied solely to control or reduce unwanted behaviors.


Some states have clarified the language in IDEA even further, specifying in state law or regulations that all methods used to support children with disabilities in the schools must be positive. At the present time, NJ continues to allow the use of physical restraint and aversive techniques in some situations, but requires advanced parental knowledge and consent before using any of these negative techniques. Basically, if it is not in the Behavioral Intervention Plan and it is not in the IEP -- it is not permitted.


A parent must sign a consent form BEFORE physical restraint or aversive techniques, such as seclusion may be utilized on their child. This is what led to the concerns in the last blog because the parent(s) were not notified in advance and did not give parental consent.


Restraint and Aversives:
Physical restraint refers to a broad category of restraints in which a person's movements are restricted by the use of physical force. Physical andor mechanical restraint has been used in the past as a means of behavioral intervention in a variety of programs for special needs children. If a child did not respond in the fashion that the adult felt was appropriate, staff was permitted to restrain the child to teach them a lesson.


An aversive would describe a type of punishment for displaying an inappropriate behavior. It refers to the deliberate infliction of physical and/or emotional pain and suffering, for the purpose of controlling or conditioning behaviors deemed unacceptable (like hand flapping or refusal to sit in a chair) by teachers or behaviorists. In general, aversive techniques include direct physical or corporal punishment: things like, spraying water at the person, Tabasco sauce in the mouth, slaps, pinches, blindfolds, hair pulls and rubber band snaps and isolation or confinement. The temporary but significant loss of movement, perceptual, or sensory ability; the disruption of basic emotional equilibrium and sense of safety; and the ongoing loss of freedom or of pleasure.


Some of the aversive techniques used were quite severe and in some cases resulted in injury and even death to a child. As sickening as this sounds, many special needs children were actually subjected to this type of treatment.


We have evolved enough as a society to recognize that aversive techniques ignore the neurological context of behavior and frequently target aspects of the disability that are not under the individual's control. We also realized that we were teaching our children that the bigger stronger person wins. We were not teaching them effective or appropriate ways to regulate their behaviors and were not teaching the skills necessary to resolve conflicts or solve problems without becoming combative.


Fortunately for our children, we also realized that there were better methods for teaching appropriate behaviors. This is where the "Best Practice" methods came into play in dealing with restraint, seclusion and aversive techniques.


The use of aversive techniques, restraint, and seclusion can lead to violations of the "free and appropriate public education" (FAPE) provision of IDEA. *
Under IDEA, an appropriate special education program must be designed to provide the student with meaningful educational benefit. However, students do not learn meaningful lessons about alternative ways of communicating and interacting when teachers and program staff respond to their challenging behaviors with aversive interventions, restraint, or seclusion. Often the frustration and anxiety caused by these negative procedures cause the child's original behavior to worsen, or to be replaced by other equally undesirable activities. When children suffer a high degree of anxiety and stress, their ability to process, retain, and act on new information is severely compromised, further undermining their ability to access the Free and Appropriate Public Education (FAPE) for which they are entitled.


The implementation of aversive techniques, restraint, and seclusion takes time and attention away from the child's IEP goals, so that educational progress is hampered. The use of these techniques, or even a request from the child's program for permission to use them, should immediately suggest that the student's program or services are not effective.


Parents can exercise their right to a new IEP meeting, at which time all aspects of the student's IEP and behavior support plan should be re-evaluated. Because of the dangers involved in using aversive techniques, restraint, and seclusion; programs wishing to use them must require the child's parents or guardians to give "informed consent" and parents have the right to deny consent.


Some parents may pre-emptively deny permission for their child's school or program to use these methods on him or her by using a letter stating "No Consent for Physical Restraint or Aversive Techniques." But even in the absence of such a letter, a special education program developed without parental input is in violation of the procedural requirements of IDEA.


In summary: No informed consent = No physical restraint, aversives or seclusion.


I hope this information is helpful to those that did not quite grasp some of the legalities involved in the use of restraint and seclusion. All readers are welcome to comment. My next blog will focus on the Best Practice methods that the Child Welfare League of America has established.


Please note: This information is in no way provided to be construed as legal advice. If you require legal advice, please contact a qualified attorney.


*Portions of the above text have been copied with permission from The Alliance to Prevent Restraint, Aversive Interventions, and Seclusion (APRAIS). Reproduction of this publication all or in part is authorized for noncommercial advocacy or educational purposes with full attribution to APRAIS.


*Originally published in the Courier Post, Autism Blog, Kathi Magee: On Autism 10/24/07.

Cherry Hill's Chokey!

We have an area in our home that my son calls his "safe zone." If he feels overwhelmed or stressed he goes there and sits to regain his composure. He initiates it and it is just a quiet area in our living room at the far end where the lighting is dimmer and the distractions are fewer. I call it a "reverse time out" because it eliminates the problem behaviors that would result in a time out for a typical child. It is a means of proactively addressing the triggers that would have resulted in rage type behavior.

I am highly sensitive to the subject of physical restraint and or physical seclusion. When my son was in Kindergarten he had been physically restrained quite often because of explosive behaviors. The end result was that his self confidence was reduced, he was embarrassed and humiliated in front of his classmates and began to have a negative attitude towards woman -- since it was always a female that restrained him. He became so frustrated by this that he often said that he wanted to die. He eventually began making suicidal threats. The physical restraint did nothing to prevent the explosive behaviors or teach him the skills necessary to regulate his behavior. After witnessing these behaviors first hand, our then Director of Special Education, Charlie Lang, ordered a new FBA and the Behavior Analyst carefully constructed a "positive" Behavioral Intervention Plan. The new plan is focused on teaching the skills for which he is deficient, rather than punishing the resulting behaviors.

My son's behavior plan is very consistent with the procedures outlined in the book "The Explosive Child" by Ross Green, PhD. Dr. Green, along with some other psychologists from Boston General and Harvard University put together a behavioral program called the Collaborative Problem Solving (CPS) approach. The CPS model is based on the belief that challenging behavior should be understood and handled in the same manner as other recognized learning disabilities. In other words, difficult children and adolescents lack important cognitive skills essential to handling frustration and mastering situations requiring flexibility and adaptability. The CPS model helps teachers (and parents) to teach these skills and it also helps children to realize the importance of problem solving and conflict resolution. We have seen tremendous results using this plan for my son.

There is information available online regarding the CPS approach. Here are a few links:
Center for Collaborative Problem Solving
The Explosive Child
Foundation for Children with Behavioral Challenges

Late last year, after a terrible experience in the mainstream setting, my son was placed back into a self-contained special needs classroom. They had an area in the classroom used for sensory breaks. The area is about the size of a double bed. The wall is recessed and makes up an area of about 6' wide by 4' deep. There was a duvet cover on the floor filled with chunky foam blocks. It provided cover for the floor and I guess some padding. I believe there was something over the concrete walls, too. It was a very dimly lit area that was obstructed by large storage cabinets. They were strategically placed to provide an opening to the area of about 2 to 3 feet wide. It was used when children needed a sensory break and was similar to our "safe zone" at home. I was aware that my son had been in this area several times. But again, this was used for children that requested a sensory break.

Last night I attended the Parents Forum held by the Cherry Hill Special Education PTA. At one point during the "parents only" portion of the meeting, someone mentioned a similar technique that was being used at Russell Knight School. Apparently they have a "closet" that has been padded with gym mats that they are calling a "Quiet Room." It turns out there is also one at Kilmer School. When the parents began talking about this I quickly realized that it was not being used as a "Safe Zone." It is being used to place children in when they have meltdowns or become non-compliant.

I asked the parent that mentioned this to clarify how this was used. I thought, I must be hearing this wrong! She said that it was a closet, with a door, no windows and padding on the walls! When a child became non-compliant one day, the child was placed in this closet. To make matters worse, the woman that spoke about this has a non-verbal child. Her child would have no way of telling her if placed in a closet.

I cannot even begin to describe the emotions in the room as parents listened to this Mom speak. Some looked horrified, others were holding back tears and there was anger and pain on the face of every parent in the room. My heart broke for this parent that became aware of this by accident. She had no way of knowing if it had been used on her child; and if so, had no opportunity to dispute the use of such aversives because no one had ever mentioned this type of procedure being used in Cherry Hill. I began to think about the tremendous psychological impact this must have had not only the child placed in the closet, but on the others that may have witnessed this.

During the question and answer session with Israela Franklin and Jim Gallagher they addressed this concern. They admitted that they had knowledge of a "Quiet Room" being used in at least two schools in our district -- Kilmer and Russell Knight. Jim Gallagher did his best to cast this in a positive light. He said that sometimes it is necessary to escort a child having a meltdown to the "quiet room." He did not mention the other uses, such as non-compliance, task avoidance, etc.

While all of this may sound perfectly acceptable to administration with their well chosen words of explanation -- the only words that ran through my mind were "why and how."

First, the "why" questions:
Why were these closets turned into "quiet rooms" without telling parents in advance?
Why was this procedure not explained to parents in an IEP meeting if there was even the slightest chance that it may be utilized?
Why would a child be allowed to reach such a high level of distress?
Why would a child prone to meltdowns not have a positive behavior plan in place?
Why would we not have trained staff to spot the child whose frustration is escalating and intervene before a crisis?

Perhaps it did not occur to anyone that the best way to handle a crisis is to prevent it from happening in the first place!

Now on to the "how" questions:
How do you justify the use of aversives when you did not make a plan to avoid this?
How is it that you go about "escorting" a child in a full blown rage out of a classroom? When they reach that level they are extremely combative. The mere act of trying to relocate them could bring injury to the child or even the staff attempting to physically move the child.
How is it that parents were not made aware of these questionable techniques prior to their use? How are these "quiet rooms" actually used? Are non-compliant children placed in these padded cells (for lack of a better phrase!) or is it just for full blown rages? There seems to be some indication that they are used for more than "meltdowns."
How is this explained to the other children in the room. Surely they are fearful and perseverating on the fact that it "could" be them next!

I am urging every parent that reads this blog to pass it along to other families. Mr. Gallagher indicated last night that some school principals are setting up these secluded areas in their schools. Please ask at your child's school if there is a "Quiet Room" or "Quiet Area" or any type of secluded setting, even if it is only used for a "sensory break." If there is, request to see that area so you know in advance what could happen. And please alert other parents to the existence of such an area.

I would also encourage parents to send a written letter indicating that you are against the use of physical restraint and the use of aversives such as these "quiet rooms" if you do not want this used for your child. Obviously, there may still be occasions when a child would react in such a manner that it would become necessary for their own safety for some type of preventative action by a staff member. But this needs to be clearly defined in a Crisis Intervention Plan and limited to true emergencies.

I think it is also important to recognize that in certain situations there may be children who have such severe sensory integrative dysfunction, that they may need an area for which to escape. In that situation however, it should NEVER be used as a punishment area. The child needs to be taught to go to that area independently and be permitted to leave that area willingly.

Any parent that is concerned with the possibility of disruptive behavior by their child, should have this addressed in a formal Behavioral Intervention Plan (BIP). I cannot stress enough the importance of the BIP! It tells the staff working with your child what is and isn't appropriate for your individual child. You most certainly do have a say in this! The behavior plan should be consistent with interventions used at home. Consistency is the key to effective behavior plans.

The Autism National Committee has had this to say on the use of such aversives as physical restraint and quiet rooms:
"[Physical restraint] should only occur when there is substantial threat of injury to self and others. Behavioral restraints are neither treatment nor education."

"The use of restraints should be considered a failure in treatment. We totally condemn the use of behavioral restraints. "

"The use of aversives is a human rights issue and a civil rights issue. When we allow punishments to be used on persons with disabilities which would be illegal if used on persons without disabilities, we are denying them equal protection under the law. Even our other devalued populations - people who are elderly, homeless, or in prison - cannot legally be "treated" with aversives, nor do we permit animals to be trained or treated by these means."

Additional Info is available on this subject at:
Autism National Committee
Asperger's Express
Kids in Confinement
Autismvox

A parent sent me this this morning: Remember the novel Matilda? The evil headmistress Agatha Trunchbull puts children in a horrific torture closet called The Chokey! Chokey is British slang for a prison. Trunchbull's treatment of her students is nothing short of child abuse and she seems to believe intimidation is the best method of teaching.

Is this really how we want to teach our children appropriate behaviors, social and communication skills?

This is an important issue that parents of both special needs children and typical children need to consider. If our school district is going to implement such aversives than every parent in the school district needs to know about this!

*Originally published in the Courier Post, Autism Blog, Kathi Magee: On Autism, 10/18/07.