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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

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.
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
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