Prone restraint is neither safe nor is it therapeutic

If we want to reduce and eliminate the use of restraint and seclusion we must stand up to misinformation. Recently an opinion letter was published in the Chicago Tribune related to legislative efforts to prohibit the use of prone restraint in schools in Illinois, a topic we have discussed in the past. The letter was written by Paula Bodzioch, the Director of Educational Services at the Marklund Day School in Geneva, Illinois.

Letters like this from “professionals” that include misinformation can be dangerous to children and families. Families expect professional educators in our schools to know what is best and to have our children’s best interest at heart. In her letter, Ms. Bodzioch asserts that prone restraint is a safe and therapeutic intervention necessary for some children however, this is simply not true.

What is Prone Restraint?

A prone, or facedown, restraints begin with a “takedown.” Staff then turn the student onto his front and secure his arms and legs. Staff is told to avoid putting pressure on the student’s back, which can inhibit breathing due to postural asphyxia, a form of asphyxia that occurs when one’s position prevents them from breathing adequately.

An effective therapeutic intervention?

In her letter, Ms. Bodzioch urges the Illinois General Assembly not to ban prone restraint in Illinois. She shares her belief that prone restraints are an effective therapeutic intervention that aids in de-escalation, in calming students who pose an imminent danger to themselves as well as staff and other students. We strongly disagree with her assertion that prone restraint is an effective therapeutic intervention.

We are not alone, a 2014 United States Senate report states:

“There is no evidence that physically restraining or putting children in unsupervised seclusion in the K-12 school system provides any educational or therapeutic benefit to a child. In fact, use of either seclusion or restraints in non-emergency situations poses a significant physical and psychological danger to students.”

Senator Tom Harkin

Suggesting that prone restraint aids in de-escalation is absurd. The use of any form of restraint is an indication that de-escalation has failed miserably and the situation has escalated to a crisis, that in the judgment of the staff, required the use of potentially deadly force.

Let’s dig a little deeper to discuss why the use of prone restraint is neither safe nor therapeutic. Let’s again consider that the majority of children who are restrained and secluded are disabled, black, brown, and very young students. In fact, according to recent data from the United States Department of Education’s Office of Civil Rights (OCR) 80% of restraints and 77% of seclusions are being done to disabled children in public schools across the nation. Children that are restrained and secluded are often children with a trauma history. Many disabled children have experienced trauma related to their disabilities.

Trauma is relevant for several reasons. Many children who are being restrained and/or secluded have a trauma history and the use of restraint and seclusion is itself traumatic. Trauma can change the brain. Brain areas implicated in the stress response include the amygdala, hippocampus, and prefrontal cortex. Traumatic stress can be associated with lasting changes in these brain areas. The amygdala detects threats in the environment and activates the “fight or flight” response. Children that have been traumatized may feel unsafe and may enter into a hyper-vigilant state. This can lead to distress related behaviors causing the child to become overwhelmed or triggered. When demands are placed on the child that they are unable to meet the situation may escalate. This may lead to fight, flight, or freeze behavior, which may lead to punishment, restraint, seclusion, and re-traumatization.

Restraint and seclusion perpetuate the classroom trauma cycle

While Ms. Bodzioch states that prone restraints are an effective therapeutic intervention, this is not the case and in fact, prone restraints can cause trauma. We are not alone in the belief that restraint and seclusion lead to trauma. In a 2016 Dear Colleague letter, the Office of Civil Rights discussed how the use of restraint and seclusion can lead to discrimination and a denial of a free and appropriate public education (FAPE).

“The use of restraint or seclusion may have a traumatic impact on that student, that even if she were never again restrained or secluded, she might nevertheless have new academic or behavioral difficulties that, if not addressed promptly, could constitute a denial of FAPE.”

2016 Dear Colleague Letter

Prone restraint is dangerous

Unfortunately, many individuals have died due to the use of prone restraint. In 2009 the Government Accountability Office (GAO) conducted research and found hundreds of cases of alleged abuse and death related to the use of restraint and seclusion.

“A 7-year-old girl died at a private day treatment center after being held for hours in a face-down, or prone, restraint on the floor by multiple staff members. The staff was allegedly unaware she had stopped breathing until they rolled her limp body over and discovered she had begun to turn blue.”

Report: Selected Cases of Death and Abuse at Public and Private Schools and Treatment Centers

In 2012 the United States Department of Education published the Restraint and Seclusion Resource Document, which stated:

“Prone (i.e., lying face down) restraints or other restraints that restrict breathing should never be used because they can cause serious injury or death.”

The dangers of prone restraint are well known. Research shows that many children have died over the past several decades due to the use of restraint in schools and residential facilities. On April 29th, 2020 Cornelius Frederick was restrained in a facedown position after he threw a sandwich in the cafeteria of the Lakeside Academy in Kalamazoo, Michigan. Two days later he died due to injuries caused by the restraint. His death was classified as a homicide. Law enforcement incidents have also shone a spotlight on the risks of restraint, particularly prone restraint. Police training started emphasizing the need to avoid the prone position about 20 years ago. On July 17, 2014, Eric Garner died in the New York City borough of Staten Island after Daniel Pantaleo, a New York City Police Department (NYPD) officer, put him in a prone restraint while arresting him. During the restraint, Mr. Garner said “I can’t breathe” at least 11 times before his death.

One of the reasons restraint is so dangerous is that humans have strong survival instincts when they are in danger. The “fight or flight” response is the body’s response to distress or threat. A part of the brain, the amygdala is our threat detection system. When we are threatened the amygdala sends a distress signal to the hypothalamus which in turn activates the sympathetic nervous system by sending signals through the autonomic nerves to the adrenal glands. These glands respond by pumping adrenaline into the bloodstream which brings about several physiological changes. When we are threatened our heart beats faster, pushing blood to the muscles, heart, and vital organs. Our pulse and blood pressure increase and we start to breathe more rapidly. This increase in oxygen being sent to the brain increases alertness. The result is our sight, hearing, and other senses become sharper. Adrenaline triggers the release of blood glucose and fats from temporary storage sites in the body which supplies energy to all parts of the body. Our body is ready to fight or flee, we no longer have the ability to access the frontal cortex that might help us to make logical and rational decisions, we are in survival mode. Why is this important? Because when you put hands on a child to restrain the child you will put them into a fight or flight mode. The person restraining the child will also likely enter into a fight or flight response mode. This is one of the reasons that the use of restraint is never without risks.

Many have come to realize the dangers of prone restraint. To date, over 30 states have banned the use of prone restraints in schools. There are far better ways to work with children, even children whose behavior may at times escalate.

Reactive approaches and low expectations

Ms. Bodzioch goes on to describe a typical Marklund student as “nonverbal and cognitively impaired, and has unique medical needs. Some students are unable to express themselves verbally; they often express their wants, needs, and emotions through behavior. At times, the intensity of the behavior increases and poses an imminent danger of serious physical harm to themselves, other students, and staff. The prone restraint is performed as a last resort by trained staff — not as punishment but rather a therapeutic technique to calm the student.” There are many issues here from low expectations to the assertion that prone restraint is therapeutic.

Expectations are important. At times providers express low expectations about the students they work with as a justification of the need to use restraint and seclusion. “You don’t understand the kids we serve” is something I have heard many times, but the truth is the greatest difference between two facilities is not the children but the adults and their approach and expectations. In facilities with low expectations, we see greater use of restraint and seclusion. The greatest necessary change to eliminate practices such as prone restraint is not a change needed from the children, but rather a change in the adults, the culture, and the practices. It is critical for educators and staff to change the lens through which they view children and behavior. It is critical that teachers and staff learn basic neuroscience to better support all children. When we understand that not all behavior is volitional and how trauma impacts the brain we can do better. In fact, research has shown that when we maintain higher expectations for disabled children they are likely to have better outcomes throughout their lives.

Despite the claim that prone restraint is therapeutic, the truth is that it is a reactive crisis management approach that most often signals that someone has failed to understand a child’s needs and has resorted to a “measure of last resort”. We agree that behavior is communication, and children may communicate through behavior, but what are children saying in situations that end in the use of restraint? They are likely communicating that they are afraid, they are frustrated, they are not being appropriately accommodated, and that they don’t feel safe, seen, and soothed.

The safety myth

Finally, Ms. Bodzioch goes on to say “When implemented under strict oversight and by trained staff, the prone procedure is safe for everyone involved — students and staff.” Let me say this clearly, restraint is NEVER without risks. This is not just a matter of opinion. Even the companies that provide training in the use of restraint acknowledge the risks involved.

Here is a short excerpt from documentation produced by the Crisis Prevention Institute (CPI):

“In circumstances where it has been identified that physical interventions are an appropriate response to manage a prevailing risk associated with an individual’s behavior, it is important that staff fully understand the adverse impact physical interventions may have.”

CPI lists potential restraint-related injuries or harm, may include:

  • Psychosocial Injury: Including post-traumatic stress disorder and damage to therapeutic relationships.
  • Soft-Tissue Injury: Including injury to skin, muscles, ligaments, and tendons.
  • Articular or Bony Injury: Including injury to joints and bones.
  • Respiratory Restriction: Including compromise to the airway, bellows mechanism, and gaseous exchange, which results in respiratory crisis or failure.
  • Cardiovascular Compromise: Including compromise to the heart and the peripheral vascular system.

The Crisis Prevention Institute provides training to school districts in the use of de-escalation techniques and hold (restraint) techniques. They clearly articulate the risks involved in using restraint, yet people trained in these practices sometimes begin to believe that training equates to safety. It is not uncommon for school staff and leadership to say things like “we are trained in safe restraint techniques”. Again I will say there is no such thing as safe restraint. Restraint is NEVER without risks, the greatest of which is death.

Beyond the fact that school staff often believe that restraint can be done safely, staff often think that they need restraint and seclusion as “tools” to keep themselves safe. This too is a myth, the data supports that the use of restraint and seclusion increases the chance of injury to teachers and staff. When you hear stories of staff being injured, it is most likely to occur while the staff is attempting to restrain a child.  Anytime we have children and staff in fight or flight mode we increase the likelihood of injuries to everyone. Long-term data from Grafton show that reducing restraint by 99% and eliminating seclusion led to decreased injuries to students and staff, cost savings, increased staff satisfaction, and decreased staff turnover.

It is simply not true that restraint can be done in a completely safe way – there are ALWAYS RISKS, nor is it true that staff need to use restraint to keep themselves safe – there are better ways.

There are better ways

There are far better ways to work with children and avoid the need for crisis management. Our schools should be moving towards neurodevelopmentally informed, trauma-sensitive, biologically respectful, relationship-based ways of understanding, and supporting students. 

So let’s talk about some specific things that schools like the Marklund Day School might consider to reduce and eliminate the use of prone restraint. I will mention that a number of these approaches are used in schools that work with children who are non-speaking, intellectual or developmental disabled, and have complex medical needs.

Collaborative and Proactive Solutions is one technique to reduce and eliminate restraint and seclusion

Ukeru

Ukeru is a trauma-informed crisis management alternative to restraint and seclusion. Developed by Grafton Integrated Health in Virginia. Ukeru centers on a philosophy of comfort vs. control:

  • Using a trauma-informed approach to create a supportive, caregiving environment sensitive to clients’ past experiences of violence and victimization.
  • Helping individuals thrive in the least restrictive environment consistent with achieving the best outcome.
  • Achieving the greatest impact with the least amount of disruption to an individual’s routine.

Collaborative and Proactive Solutions

Collaborative & Proactive Solutions (CPS) is the non-punitive, non-adversarial, trauma-informed model of care Dr. Greene originated and describes in his various books, including The Explosive Child, Lost at School, Lost & Found, and Raising Human Beings.

In the Collaborative & Proactive Solutions model we believe that children sometimes exhibit challenging behavior because they’re lacking the skills or have unsolved problems. If they had the skills, they wouldn’t be challenging. That’s because – and here is perhaps the key theme of the model — Kids do well if they can.

Low Arousal

The term ‘low arousal‘ was first used in 1994 (McDonnell, McEvoy & Dearden, 1994). McDonnell (2010) identified four key components considered central to low arousal approaches. These include both cognitive and behavioral elements:

  • Decreasing staff to client demands and requests to reduce potential points of conflict around that individual.
  • Avoidance of potentially arousing triggers (e.g. direct eye contact, touch, and removal of spectators to the incident).
  • Avoidance of staff’s non-verbal behaviors that may lead to conflict (e.g. aggressive postures and stances).
  • Challenging staff beliefs about the short-term management of challenging behaviors.

Restorative Practices

A growing body of research shows that schools and districts that have implemented restorative strategies report a range of impressive outcomes. 

These include reductions in student misbehavior and classroom disruptions and dramatic decreases in suspensions, improved academic outcomes, improved school climate indicators, and reduced absenteeism.

Trauma-informed Practices

As we’ve discussed, the majority of children and youth will be exposed to at least one potentially traumatic event before graduating from high school. Children with disabilities are perhaps more likely to have experienced adverse childhood experiences.

In a trauma-sensitive school, all staff shares a common understanding of trauma and its impact on students, families, and staff and a mission to create learning environments that acknowledge and address trauma’s impact on school success.

Children that have experienced trauma need to feel seen, safe, soothed, and secure.  Relationships are critical to helping children succeed.  

When you can do better, you should

We can make schools safer for students, teachers, and staff and reduce and eliminate the use of restraint and seclusion. We encourage schools like the Marklund Day School to consider options to make their classrooms safer for everyone. This might mean challenging current beliefs and investigating alternatives, but the investment could well save lives.

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