Legislation and promising practices for reducing restraint seclusion use
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Legislation and Promising Practices for Reducing Restraint & Seclusion Use. Restraint and Seclusion in Foster Care Presented by Lloyd Bullard, M. Ed. LB International Consulting, LLC. Introduction. Legislation. Children’s Health Act of 2000 (H.R. 4365)

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Legislation and Promising Practices for Reducing Restraint & Seclusion Use

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Legislation and promising practices for reducing restraint seclusion use

Legislation and Promising Practices for Reducing Restraint & Seclusion Use

Restraint and Seclusion in Foster Care

Presented by Lloyd Bullard, M. Ed.

LB International Consulting, LLC.





  • Children’s Health Act of 2000 (H.R. 4365)

  • Signed into Law October of 2000 by President Clinton

  • The Act contains two significant section:

    • Part H and;

    • Part I.

Children s health act of 2000

Children’s Health Act of 2000

  • Part H - applies to public and private general hospitals, nursing facilities, intermediate care facilities, or other health care facilities

  • Part I – applies to public and private non-medical, community-based facilities for youth (as defined by the secretary)

Children s health act of 20001

Children’s Health Act of 2000

  • Part I – required physical restraints and seclusion to only be imposed in emergency circumstances and only to ensure the safe of the child, staff or others

  • Other less restrictive interventions would have been determined to be ineffective

Children s health act 2000

Children’s Health Act 2000

  • Restraints or seclusion are imposed only by an individual trained and certified by state recognized body (as defined by the secretary)

  • Interim Procedures – Supervisory or senior staff with training in restraint and seclusion who is competent to conduct a face-to-face assessment (as defined by the secertary)

  • Supervisor or senior staff continues to monitor the situation for the duration of the restraint or seclusion

  • Secretary 6 months to develop standards/States 1 year to develop standards once the Federal standards are implemented

Foster parents and restraint seclusion use

Foster Parents and Restraint & Seclusion Use

  • Cornell University’s Research – Numerous focus groups with children in foster carte and foster parents

  • Cornell has refused to train foster parents on restraint techniques.

  • Based on children perceiving that the foster parents were attempting to hurt them

  • Liability issues related to safety risks

Why so many restraints

Why So Many Restraints?

  • Caretakers say:

    • It’s the clients.

    • They have such severe problems

    • They often put themselves, other clients, and staff at risk.

    • It’s necessary to keep everyone safe.

But some studies suggest otherwise

But Some Studies Suggest Otherwise

  • Programs serving similar children have widely varying rates of restraint.

  • Some programs serving very difficult children have low restraint rates.

  • Many programs have significantly reduced restraint without changes in their populations.

What is it about us

What is it about us?

  • Our belief that the problem lies with the clients

  • Focus on management and control as opposed to support and teaching

  • Lack of staff skills in effective de-escalation

Bad news or good

Bad News or Good?

  • Being identified as the source of the problem may sound like bad news or an indictment of caretakers.

  • But it’s actually good news.

    • If it really were the clients, we’d be stuck doing thousands of restraints forever.

    • If it’s us, we can do something about it.

Successful strategies to reduce restraint and seclusion

Successful Strategies to Reduce Restraint and Seclusion

The issue brief neti 2003

The Issue Brief(NETI, 2003)

  • Reducing the Use of Restraint and Seclusion: Promising Practices and Successful Strategies

    • An issue brief that annotates policies and practices that successfully reduce the use of restraint and seclusion

      • Chapters

        • Leadership

        • Organizational Culture

        • Agencies’ Policies, Procedures and Practices

        • Staff Training and Professional Development

        • Treatment Milieu

        • Continuous Quality Improvement

The issue brief

The Issue Brief

  • Information pulled from a variety of sources as outcomes and data on children is scarce

    • Project’s own preliminary quantitative and qualitative findings

    • Subject matter experts

    • Focus groups findings (Federation of Families for Children’s Mental Health - FFCMH)

    • Published research findings

Leadership neti 2003

Leadership(NETi, 2003)

  • Supportive Executive Leadership

    • Identify Restraint and Seclusion as a Top Priority

      • Sustained commitment by the executive leadership team.

    • Set the Tone

      • Mission statement supports a violence- and coercion-free environment

      • Restraint and seclusion are crisis events, treatment failures, and high-risk interventions

      • Leaders must model the interest, time commitment, and “sell” the initiative to managers and direct care staff

Leadership neti 20031

Leadership(NETI, 2003)

  • Supportive Executive Leadership continued:

    • Provide Training and Resources

      • Emphasize training in alternatives to restraint and seclusion

      • Ensure integration of training into practice

    • Establish an Oversight Committee

      • Include executive leaders, managers, supervisors, direct care staff, family members, children, and advocates

      • Committee empowered to implement changes

Leadership neti 20032

Leadership(NETI, 2003)

  • Supportive Executive Leadership continued:

    • Take Responsibility

      • Administrators shoulder the burden of reducing restraint and seclusion

    • Maintain Accountability

      • Executive leader(s) on-call 24 hours a day to whom each incident is immediately reported

Leadership neti 20033

Leadership(NETI, 2003)

  • Supervisory and Managerial Involvement

    • Set the Tone

      • Send a clear message

      • Support coercion-free environment, partnerships, choice, and proactive communication

      • Elimination of the unnecessary use of restraints and seclusion is paramount

    • Model and Coach

      • Alternative approaches

      • High expectations, time commitment, training resources, 24 hour on-call support

Leadership neti 20034

Leadership(NETI, 2003)

  • Supervisory and Managerial Involvement continued

    • Lead Debriefing

      • Exercise for learning not punishment

      • Gather data

      • Discuss

      • Document timelines

Leadership neti 20035

Leadership(NETI, 2003)

  • Elimination by Mandate

    • Banning restraint use or types, eliminating of seclusion rooms, or use of prns

    • Constant vigilance and ongoing training in de-escalation

    • Requires emphasizing behavioral support instead of emergency intervention

Organizational culture neti 2003

Organizational Culture(NETI, 2003)

  • Relationship Building

    • Facilitates support of positive behavior

    • Helps de-escalate children in times of crisis

  • Healthy Relationships are developed over time

Organizational culture neti 20031

Organizational Culture(NETI, 2003)

  • Person-Centered Environment

    • Needs of the child are at the forefront of care

    • Use supportive language, and express an unwillingness to label children as “manipulative” or “needy”

    • Emphasize collaboration rather than compliance

    • Offer culturally and linguistically competent services

Organizational culture neti 20032

Organizational Culture(NETI, 2003)

  • Staff Empowerment

  • Youth Involvement

  • Family and Natural Support Involvement

    • Treatment Planning

    • Programming

    • Participation on Review Team

    • Advocacy

Agency policies procedures and practices neti 2003

Agency Policies, Procedures and Practices(NETI, 2003)

  • Comprehensive Assessment

    • History of aggression, and the physical, psychiatric, and emotional risks of restraint and seclusion

    • Inform the behavior support and treatment plans

  • Treatment Planning

    • Individualized and strengths-based

    • Developed in conjunction with child and family

  • Individualized Behavior Support Plan

    • Identify triggers, successful intervention strategies, and options for self-calming

    • Communicated to all relevant staff

    • Revisited regularly

Agency policies procedures and practices neti 20031

Agency Policies, Procedures and Practices(NETI, 2003)

  • Monitoring

    • Face-to-face, third party

    • Assess the physical and psychological well-being of child

    • Authority to stop intervention if signs of distress are evident

  • Debriefing

    • Occurs with the child, witnesses, staff, and family members

    • Express feelings about the incident and to make a plan to avoid for incidents

    • Debriefing does not assign blame

    • Should be carefully documented

  • Staff Designated to Implement Restraint and Seclusion

Staff training and professional development neti 2003

Staff Training and Professional Development(NETI, 2003)

  • Training on Trauma-Sensitive Care, Prevention, and De-escalation

    • AT LEAST 50% of all training should focus on these three core elements

  • Competency-Based Training

  • Culturally and Linguistically Competent Services

    • Tones, gestures, and postures that may be misinterpreted by youth

  • Frequent Refreshers to Minimize Training Drift

  • Regular Staff Supervision, Mentoring, and Coaching

Treatment milieu neti 2003

Treatment Milieu(NETI, 2003)

  • Treatment Philosophy

    • Coercion-free and non-punishment based

  • Trauma-Informed Care

    • Culture of empathy

    • Acknowledge that most children have experienced trauma

    • Restraint and seclusion is re-traumatizing

    • Staff should know signs of trauma

  • Positive, Structured Environment

    • Requires active programming

    • Well-maintained environment

  • Behavior Support

    • Give children anger and anxiety management skills.

    • Constant role playing.

Continuous quality improvement cqi neti 2003

Continuous Quality Improvement (CQI)(NETI, 2003)

  • Setting Organizational Goals

  • Collecting and Analyzing Data

  • Reporting Results

  • Corrective Feedback Mechanisms

  • Celebrating Successes

  • Program Evaluation

Cwla resources

CWLA Resources

Best practice guidelines for behavior management

Best Practice Guidelines For Behavior Management

  • Ethical & Legal Framework

  • Administration & Leadership

  • Continuum of Intervention

  • Medical Issues

  • Professional Development & Support for Caregivers.

Reducing the use of restraint seclusion promising practices successful strategies

Reducing the Use of Restraint & Seclusion: Promising Practices & Successful Strategies

  • Leadership

  • Organizational Culture

  • Polices, Procedures & Practices

  • Training & Professional Development

  • Treatment Milieu

  • Continuous Quality Improvement

Best practice guidelines for behavior support intervention training

Best Practice Guidelines for Behavior Support & Intervention Training

  • Organizational Leadership & Culture

  • Behavior Support & Intervention Training Programs

  • Risk Factors

  • Emergency Interventions

  • Training Process

Supervisors training curriculum

Supervisors Training Curriculum

  • Changing Organizational Culture

  • Behavior Support Plans

  • Program Factors

  • Family Involvement

  • Diversity Issues

  • Reward & Consequence Systems

  • Supervisory Role

  • No Blame Culture

  • De-Briefing

State regulations





Post Assessment


Family Notification




CQI Plans

Prohibited Practices

Data Collection

Reduction Plans

State Regulations



  • Restraint reduction is a 4-step process:

    • Admit it’s us who have to change

    • Look honestly at our contributions to this problem

    • Attack each of the six areas

    • Evaluate progress and don’t give up

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