Physical restraint procedures for managing challenging behaviours presented by mentally retarded adults and children

What are the most common restraint techniques taught by expert practitioners?

WHAT IS KNOWN ON THE SUBJECT?: Physical restraint is used across the NHS in Mental Health, Learning disability and other specialist settings. Physical restraint should be used as a last resort, with least amount of force for the minimum amount of time. There is no national set of skills from which trainers or practitioners choose what might be appropriate for them and the population they care for. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: A national online survey gathered insights from representatives of public and private training services in relation to 20 selected techniques and their perceived risks. The most frequently taught techniques are identified and evident trends were seen among respondents according to their perceived suitability for different population groups. The need to be able to compare and contrast techniques is discussed, and the utility of developing an evaluative framework is outlined. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: In England the restraint training is now being regulated. This survey reveals the variation in the techniques used across groups or settings. The ability to compare techniques and make informed decisions around which techniques to commission, specify or use, could support the aims of the RRN Training Standards (RRN, 2020a) and Towards Safer Services (RRN, 2020b) and in so doing support the goals of safer, less restrictive person-centred practice. Individuals are encouraged to reflect on their practice and think critically about what is a good restraint technique. ABSTRACT: Introduction Despite widespread use of restraint techniques, it is unclear what techniques are taught. Aim To identify the types of techniques commonly taught. Method A national online survey was developed through iteration and stakeholder involvement. Ethical approval was obtained and it was disseminated through the Positive and Safe network, and the Restraint Reduction Network Community of Practice where expert practitioners answered questions relating to 20 randomly selected used physical 'Holds'. Results One hundred seventy-two people completed the survey. The most commonly taught techniques were a Guiding Posture (71%), a Guiding Hold (44%), a Two-Handed Forearm Hold (36%), a Finger, Thumb & Wrist Hold (27%) and a Cupped/Capped Fist Hold (26%). The Guiding Posture (71%), and Guiding Hold were used most commonly across populations. Despite the potential to induce pain, the Finger, Thumb and Wrist Hold was deemed suitable for Adult populations, but not Older Adults, Young Persons and Children. Wrap-Type Holds were seen as unsuitable for all populations. Discussion There is currently high variation in which techniques are taught across different settings. An evaluation framework could be beneficial. IMPLICATIONS FOR PRACTICE: An evaluation framework could aid training commissioners, providers and practitioner reflect on what constitutes a good restraint technique.

Acknowledging caregivers' vulnerability in the managment of challenging behaviours to reduce control measures in psychiatry

BACKGROUND

The management of challenging behaviours in inpatient with intellectual disability and/or autism spectrum disorders can lead to an escalation of control measures. In these complex situations where patients have an intellectual disability/autism spectrum disorder accompanied by a psychiatric comorbidity, the experiences of caregivers related to the crisis management have rarely been studied.

PURPOSE

This study examined the moral experiences of caregivers related to challenging behaviours' management and alternatives to control measures.

RESEARCH DESIGN

Using Charles Taylor's hermeneutic framework, a 2-month focused ethnography with a participatory approach was used.

PARTICIPANTS AND RESEARCH CONTEXT

Sixteen caregivers were interviewed in a Canadian mental health setting for adults with intellectual disability/autism spectrum disorder and psychiatric comorbidity.

ETHICAL CONSIDERATIONS

The research was conducted in compliance with the Declaration of Helsinki and local Research Ethics Board approval. Written informed consent was collected systematically from participants.

FINDINGS

By accounting for caregivers' moral experiences, this study sheds light on a neglected dimension of the care relationship: the vulnerability of the caregiver. We highlight the main barriers and facilitators to alternatives to control measures. First, a caregiver's vulnerability was characterised by the overall impact of challenging behaviours and the moral distress associated with the use of control measures and exclusion mechanisms of intellectual disability/autism spectrum disorder patients. Second, a strong ambiguity between care and control measures and a lack of inclusive approaches were identified as the two main barriers to challenging behaviour management. Third, the involvement, both professional and personal, of caregivers was deemed necessary to implement alternatives to control measures.

DISCUSSION

A conflict of values opposes two conceptions of autonomy: a rational autonomy, which is counterproductive to the reduction of control measures, versus a relational autonomy based on shared vulnerability.

CONCLUSION

The recognition of caregiver's vulnerability is a benchmark to create alternative approaches, which defuse the logic of control and promote an ethics of care within which caregivers' self-concern can be understood as fostering mutual respect.

Restraint of adults with intellectual disabilities: A critical review of the prevalence and characteristics associated with its use

BACKGROUND

As part of their care, adults with intellectual disabilities are often subject to restrictive interventions including restraint.

METHOD

A review examining the prevalence of restraint use with people with intellectual disabilities and the characteristics associated with its use.

RESULTS

The seven papers identified used quantitative methodologies and had cross-sectional designs. Prevalence rates of restraint ranged from 11% to 78%, multiple forms of restraint were common. Most studies focused on characteristics within the person with an intellectual disability, three considered external factors. Challenging behaviour was the most consistent characteristic associated with the use of restraint, but how this was defined varied.

CONCLUSIONS

The review highlights a need for more consistent means of defining and measuring restraint and its associated characteristics. Future research into this area may also want to focus on the context of restraint such as whether it is the least restrictive option used.

Restraint interventions in people with moderate to profound intellectual disabilities: Perspectives of support staff and family members

BACKGROUND

Due to incompatibilities in communication, it is key that family members and support staff can take the perspective of people with moderate to profound intellectual disabilities (ID) whilst putting aside their own perspectives.

METHOD

Ten vignettes describing types of restraint interventions (RIs) were presented to 20 unique pairs of support staff and family members related to individuals with moderate to profound ID.

RESULTS

In taking their own perspective, more than half of the support staff and family members perceived all RIs as involuntary and severe. In contrast, when asked to put themselves in the position of the client/family member, only three RIs were considered involuntary by a majority of support staff and family members.

CONCLUSIONS

These results indicate that support staff and family members can take into account the perspective of people with moderate to profound ID in the evaluation and consideration of involuntary care.

Management of children with learning disabilities and behavioural disorders: ethics and law

A significant minority of children with learning disabilities present with severe behavioural disturbance that affects their integration in the community, and may seriously impair their physical and mental health, and cause distress to their carers. Useful interventions, which can reduce the frequency and severity of the behaviour, raise important ethical and legal issues when applied to these individuals. The paper presents a selective review of the literature addressing ethical arguments for and against the use of different interventions for a variety of behavioural disorders and the legal requirements that must be met. Although a balance must be struck between arguments for and against issues of best interest and the nature of the treatment, health professionals need to seek the views of all involved in the care of the child. It is recommended that attempts to obtain consent and the treatment decision-making process must be clearly recorded during routine clinical practice.

Clinical Peer Review

This article describes a comprehensive model of clinical peer review that was established at a large behavioral healthcare organization serving children, adolescents, and adults with developmental disabilities. The purpose of peer review is to provide routine evaluation of practice standards that will produce the highest quality of habilitative care. The major components of peer review address (a) clinical support and administration, (b) intervention policies and procedures, (c) case consultation, (d) utilization of extraordinary procedures, (e) performance improvement projects, and (f) communication at all levels of the organization. This article discusses implementation of the model, including examples and illustrations, and factors that contribute to positive outcome. This approach to peer review represents a systems methodology that can be adopted by behavioral healthcare and human service organizations to build an in-house program of clinical quality improvement. It is a necessary first step in the large-scale implementation of behavioral services.

The impact of restraint reduction meetings on the use of restrictive physical interventions in English residential services for children and young people

AIM

The aim was to examine the impact of post restraint reduction meetings upon the frequency and restrictiveness of restraint use in English children's residential services.

BACKGROUND

Attention has been drawn to the misuse, overuse and safety of some techniques used to physically restrain children in residential services. Successful interventions to reduce restraints have been reported, mostly from the USA.

RESULTS

Demonstrate a significant overall reduction in both, frequency and restrictiveness of restraints; the greatest percentage decrease in the most restrictive floor restraints. Whilst five services reduced both frequency and restrictiveness, five services showed some increases in frequency and/or restrictiveness of restraints employed.

CONCLUSIONS

Restraint reduction is most effectively reduced through employing multiple strategies and that post restraint reduction meetings maybe one useful component. Organisations seeking to promote restraint reduction meetings need to allocate sufficient priority and resources to support these.

The role of physiological arousal in the management of challenging behaviours in individuals with autistic spectrum disorders

Challenging behaviours restrict opportunities and choices for people with autistic spectrum disorders (ASD) and frequently lead to inappropriate and costly service interventions. Managing challenging behaviours of people with autism is an important area of research. This paper examines some of the evidence for the role of physiological arousal influencing these behaviours. Evidence from the emerging literature about sensory differences is examined. It is proposed that sensory reactivity is associated with hyperarousal; catatonic type behaviours are associated with low levels of reactivity (hypoarousal). A low arousal approach is proposed as a generalised strategy to managing challenging behaviours with ASD. The use of non-contingent reinforcement and antecedent control strategies are recommended for use with challenging behaviours which have a sensory component. Examples are provided to illustrate the approach. The implications of arousal and the use of physical interventions are discussed. It is proposed that arousal is a construct which has significant heuristic value for researchers and practitioners.

Effects of Fixed-Time Release Fading on Frequency and Duration of Aggression-Contingent Physical Restraint (Protective Holding) in a Child With Autism

We report the case of an 11-year-old boy with autism who displayed aggressive behavior and required aggression-contingent physical restraint (protective holding) to protect peers and teachers from injury. During a baseline phase, teachers implemented the boy’s behavior support plan and applied protective holding according to a behavior-contingent release (BCR) criterion in which they maintained physical contact with him until he was “calm” for a minimum of 30 consecutive seconds. In the intervention phase, baseline procedures remained in effect, but the teachers terminated protective holding with the boy according to a fixed-time release (FTR) criterion that was independent of his behavior during protective holding and faded (decreased) systematically over time. In contrast to BCR, FTR fading was associated with less exposure to and fewer applications of protective holding. Post-intervention and follow-up results revealed that protective holding was no longer required. We discuss the clinical implications of these findings.

Client factors as predictors of restraint and seclusion in people with intellectual disability

BACKGROUND

To gain more insight into the antecedent factors of restraint in institutionalised people with intellectual disability (ID), the role played by several demographic and psychological client variables was investigated.

METHODS

The data of 475 people (age range 12-95 years) who were residents in a Dutch institution for people with ID were collected. The severity of restraint was rated on an ordinal scale.

RESULTS

None of the demographic variables height, weight, age, or length of stay were related to the application of restraint. Significant predictors were the psychological variables: low adaptive functioning, the presence of challenging behaviours, and a relatively high intellectual level. Of the challenging behaviours, specifically behaviours other than actual aggressiveness proved to be predictors of restraint.

CONCLUSIONS

The fact that actual aggressiveness plays a minor role in predicting restraint is a new finding and should be further examined in future research.

Reduction of restraint of people with intellectual disabilities: an organizational behavior management (OBM) approach

We used an organizational behavior management (OBM) approach to increase behavior intervention plans and decrease the use of mechanical restraint. First, recipients were tracked as a member of the priority group if they engaged in frequent self-injurious behavior or physical aggression toward others and/or if they had been placed in mechanical restraint as a result of the problem behaviors. Second, a behavior data monitoring and feedback system was put in place. Third, organizational contingencies for the use of mechanical restraint or the occurrence of frequent self-injurious behavior or physical aggression toward others were initiated. Over the course of 17 months, behavior intervention plans were more than doubled to 124 and mechanical restraints decreased by almost 80%. This study represents the first to use an organizational behavior management (OBM) to reduce restraint with people who have intellectual disabilities.

Descriptive analysis of physical restraint (protective holding) among community living adults with intellectual disability

We analyzed incidence and implementation patterns of physical restraint (PR) among 448 adults with intellectual disability within community-based day habilitation programs and group homes. PR was implemented exclusively as a consequence for self-harming, aggressive, and environmentally disruptive behaviors. Less than 10% of adults received PR and more than 90% of documented restraints occurred as a planned intervention procedure. Several adults accounted for the majority of PR. The clinical implications of these findings are discussed.

Reducing and eliminating restraint of people with developmental disabilities and severe behavior disorders: an overview of recent research

This paper provides a brief overview of the most recent research (1999-2009) on restraint reduction and elimination efforts in the literature and also examines the characteristics of restraint along with the risks and benefits. Some earlier papers were included in this review because of their importance to the topic. The results of this literature review are discussed in terms of implications for practitioners and researchers.

Managing the risks of physical intervention: developing a more inclusive approach

Since psychiatry evolved as a professional discipline, mental healthcare professionals have had to, as a last resort, physically intervene to manage physically aggressive patients. In the United Kingdom, physical intervention techniques migrated from the prison service in the mid 1980s where there was extensive use of two particularly controversial practices; 'pain compliance' and the 'prone restraint position'. This paper examines how the classification of the 'prone restraint position' has led to a narrowed focus on one technique and a resultant misunderstanding around the wider risks associated with the applying force and managing restraints. The paper goes on to propose the 'transitional stabilizing position' (TSP) as an alternative concept and puts forward a dynamic risk assessment model. It explores how a shift in staff training away from developing pure competence in the performance of tightly specified techniques to managing the patient in TSPs could conceivably reduce the relatively low risk of death or serious injury associated with the application of restraint techniques to an even lower level.

Proposing a common sense approach to assessing the risks posed by physical intervention techniques

Irrespective of whether they are universally accepted or approved, physical intervention techniques are being applied, in a variety of health and care settings, on a daily basis. Every time a technique is applied there is a risk of injury. Therefore, there is an imperative to develop an effective way in which such techniques can be effectively risk assessed. The development of a process that is robust enough to evaluate all types of techniques, and is simple and concise enough to engender widespread and regular use could eliminate the use of unnecessary and inappropriate techniques. This paper discusses how the five-step model proposed in the UK by the Health & Safety Executive as well as a common sense approach to completing assessments could be used to simplify the process.

Physical intervention trainers: the case for greater accountability

Physical intervention training courses are commonplace events in psychiatric and mental healthcare settings across the UK. While there is still debate as to what techniques should be taught on such courses, there is good evidence as to the mechanisms whereby pain, injury and even death can be inflicted. There is also a wealth of literature identifying how organizational culture can influence the quality of service delivery and standards of client care. It is well documented that the dignity, well-being and physical integrity of service users can be compromised by staff acts and omissions stemming from corrupted cultures. What has not been explored in detail to date is the role of physical intervention trainer, specifically the values they model and how these may influence the readiness with which staff resort to physical restraint strategies. It is possible that even approved physical techniques can become compromised through poor training technique and expose end recipients to needless humiliation and potential harm. This paper discusses this area of practice, offers insight on how the learning process is compromised by trainers and suggests areas for future research.

A survey on mental health care for adults with intellectual disabilities in Asia

BACKGROUND

Mental Health Services for adults with Intellectual Disabilities (ID) in Asia is less described than those in the western world. With the improvements in the economy and medical care in Asia, there is an increase in awareness of mental health services for people with ID in this part of the world. A study was carried out to look into these aspects in Asian countries.

METHOD

A cross sectional survey using structured questionnaire was sent to 14 Asian countries/territories in 2005/2006 and returns were analysed in light of their demographics and health statistics.

RESULTS

The type and range of mental health services vary widely for people with ID in all the nine countries/territories that returned their questionnaires. Two of the respondent countries reported a lack of psychiatric services for their adult ID population.

CONCLUSIONS

In general, mental health services for people with ID in Asia do not keep pace with economic developments. More government commitment and international collaborations are necessary to improve the mental well-being of this population in Asia.

Behavioural and cognitive-behavioural interventions for outwardly-directed aggressive behaviour in people with learning disabilities

BACKGROUND

Outwardly directed aggressive behaviour is a significant part of problem behaviours presented by people with learning disabilities. Prevalence rates between 3.3% to 36% have been reported in the literature. Such behaviours often run a long term course and are a major cause of social exclusion.

OBJECTIVES

To determine the efficacy of behavioural and cognitive behavioural interventions for outwardly-directed aggressive behaviour for people with learning disabilities.

SEARCH STRATEGY

The Cochrane Library (CENTRAL) 2007 (Issue 1), MEDLINE 1966 to February 2007, EMBASE 1980 to February 2007, PsycINFO 1872 to February 2007 and Dissertation Abstracts late 1960s to February 2007 were searched. Where appropriate, research filters were used.

SELECTION CRITERIA

Studies were selected if more than four participants, children or adults, were allocated by random or quasi-random methods to either intervention or standard treatment/wait list.

DATA COLLECTION AND ANALYSIS

References identified by electronic searches, examinations of bibliography and personal contacts were screened against inclusion criteria by two independent reviewers. Two reviewers independently extracted and entered data into RevMan (Cochrane Collaboration software).

MAIN RESULTS

Four studies based on adult populations with learning disabilities were deemed to be suitable for inclusion in the current version of this review. Data were only available in a form suitable for meta-analysis in three studies, but due to heterogeneity of populations and interventions, meta-analysis was not performed. Direct interventions based on cognitive-behavioural methods (modified relaxation, assertiveness training with problem solving, and anger management) appear to have some impact on reduction of aggressive behaviour at the end of treatment and in some studies also at follow up (up to six months).

AUTHORS' CONCLUSIONS

The existing evidence on the efficacy of cognitive behavioural and behavioural interventions on outwardly directed aggression in children and adults with learning disabilities is scant. There is a paucity of methodologically sound clinical trials. Given the impact of such behaviours on the affected individual, his or her carers and on service providers, effective interventions are essential. It is also important to investigate cost efficacy of treatment models against existing treatments. We recommend that randomised controlled trials of sufficient power are carried out using primary outcomes of reduction in outward directed aggression, improvement in quality of life and cost efficacy as measured by standardised scales.

Restraint and self-injury in people with intellectual disabilities: a review

Most of the recent debate concerning the ethics of physical interventions has focused on the management of aggressive and destructive behaviours, neglecting the management of self-injurious behaviour. This is an important omission, given the extremely serious consequences that can arise from this form of challenging behaviour. The present article reviews types of restraint used to manage self-injury, prevalence of use, and main and side effects of restraint use. It describes some good practice standards and highlights the need for further research and debate in this complex area.

Correlates of restraint use in an institutional population: a replication

BACKGROUND

Reducing inappropriate restraint is an important mission of services for people with intellectual disabilities (IDs).

METHODS

In this study, 52 clients who had been restrained were compared with 52 other clients, individually matched on age, gender and level of IDs. Participants were mostly adults with severe and profound IDs in an institutional setting.

RESULTS

The two groups differed on six Diagnostic Assessment for the Severely Handicapped-II (DASH-II) and three Aberrant Behaviour Checklist (ABC) scales. However, discriminant functional analysis demonstrated that only DASH-II Impulse control disorder and ABC Irritability and Elimination disorder scores predicted group membership but only moderately.

CONCLUSIONS

Individual differences in maladaptive behaviours were only moderately predictive of restraint use.

Social validation data on three methods of physical restraint: views of consumers, staff and students

The use and evaluation of restraint methods with people with mental retardation is a continuing area of concern. Twenty-four undergraduate students, 21 residential care staff and 18 service-users from community settings rated videotapes of three physical restraint procedures. Two of the methods involved restraining an individual on the floor and a third method involved restraining an individual in a chair. Participants answered two open-ended questions to rate the methods of restraint and rated the methods on a 5-point scale of satisfaction [J. Ment. Defic. Res. 30 (1986) 369]. Participants also rated the three restraint methods by a forced-choice comparison. Restraint was rated negatively by all participants. However, both the satisfaction ratings and the forced-choice methods rated the chair method of restraint as most acceptable all three groups of participants. Consumers rated restraint more negatively than other groups. Restraint was evaluated negatively by all three groups, but the chair method was rated the least worst.

Antecedent analysis of therapeutic restraint in children and adolescents with acquired brain injury: a descriptive study of four cases

Therapeutic restraint is sometimes required as a component of clinical intervention for persons who have serious behaviour disorders. However, there are few studies that describe empirically the conditions under which restraint is utilized. This project was a retrospective analysis of incident reports on the application of therapeutic restraint with four students (ages 10-16 years) who had acquired brain injury and attended a community-based programme of education and neurorehabilitation. Specifically, situations and interactions were examined that were in effect immediately prior to the implementation of restraint. This antecedent analysis identified several common influences, as well as effects that were unique to individual students. The role of antecedent events as "precipitants" to restraint and respective treatment implications are discussed.

Practice parameter for the prevention and management of aggressive behavior in child and adolescent psychiatric institutions, with special reference to seclusion and restraint

This parameter reviews the current state of the prevention and management of child and adolescent aggressive behavior in psychiatric institutions, with particular reference to the indications and use of seclusion and restraint. It also presents guidelines that have been developed in response to professional, regulatory, and public concern about the use of restrictive interventions with aggressive patients with regard to personal safety and patient rights. The literature on the use of seclusion, physical restraint, mechanical restraint, and chemical restraint is reviewed, and procedures for carrying out each of these interventions are described. Clinical and regulatory agency perspectives on these interventions are presented. Effectiveness, indications, contraindications, complications, and adverse effects of seclusion and restraint procedures are addressed. Interventions are presented to provide more opportunities to promote patient independence and satisfaction with treatment while diminishing the necessity of using restrictive procedures.

The social validation of three physical restraint procedures: a comparison of young people and professional groups

The treatment acceptability of three forms of physical restraint was evaluated with three groups of raters. One restraint method involved personal restraint in a chair, two other methods involved personal restraint on the floor. The three groups of raters were special education staff, residential staff, and a group of young adults with no experience of residential services. Ratings, of videotaped role-play using the Treatment Evaluation Inventory (Kazdin, 1980) revealed that the chair method of restraint was rated as more acceptable than the other method to all three groups. The residential staff rated the chair method as more acceptable than the other methods. The results are discussed in terms of the importance of evaluating restrictive, emergency procedures, and future methodological refinements.

Changing care staff approaches to the prevention and management of aggressive behaviour in a residential treatment unit for persons with mental retardation and challenging behaviour

The impact of a new training procedure aimed at improving staff skills in the preventative and reactive management of severely challenging behaviours was investigated within a six-place residential treatment unit. The results showed that there was some evidence to support the notion that the training reduced the number of behavioural incidents for most residents. The rates of major reactive strategy use (restraint and emergency medication) also declined over time, as did rates of staff and resident injury. Although only a limited number of these changes showed statistically significant correlations with time, it is argued that they were clinically significant when viewed against the complexity of the client group under study.