Reducing and Eliminating Restraint in Residential Settings

If you are anything like me, you may have wanted to work with children and youth for a long time. I grew up knowing I would be working with children and youth in some capacity. I always thought it would be teaching, but here I am, a case manager who wants to advocate for the youth in her care. As part of my job where I work now and at the residential facility I used to work at, I am required to have the ability to restrain youth. I have had many hours of training in what a crisis is, de-escalation, trauma, and how to do the restraints. Administrative staff, such as myself, review all restraints at my current place. We read the reports and watch the video (we have cameras everywhere but the bedrooms and bathrooms). We look for how de-escalation was attempted, the results, and whether the restraint was necessary. We look at whether the restraint was correctly done and what needs to change to prevent future use of restraint. We also review how to do proper restraints at least once a year. More importantly, we do training on de-escalation, the elements of crisis, and how to prevent restraint. As I write this on paper, it sounds easy and simple. It may even cause you to take a deep breath and relax about doing a restraint. It shouldn’t.

With no numbers to back this up, I can say that most restraints can be avoided.

Adults want compliance and order from dysregulated youth who are trying to calm themselves down. Adults often believe that yelling and crying is an act of non-compliance that is equal to violence and that dysregulated youth must be restrained to maintain the safety of others. In reality, the youth is often attempting to regulate their systems through yelling, crying, stomping, etc. However, adults often believe children should be able to regulate themselves in any situation after a certain age; this is called an expectation gap.

Often, our expectations for anyone under 20 are inappropriate.

As a child or youth yells, we as adults can become dysregulated because we are trying to retain what little order is left. We may begin yelling at the youth and even threatening to use restraint if the youth cannot calm down; this is an abusive attitude. This is when we as adults need to take a calming breath ourselves and help regulate alongside the youth. A youth in distress has already lost all use of their coping skills, and a dysregulated adult won’t help the situation.

So, it is good if you are trained in restraints but want to avoid using them. Restraints should always be the very last intervention you might use. You are the first intervention and should use your relationship with the youth to help. As you learn about the youth, you will learn what they like and dislike. You will learn about their background, and you learn about who they are as a person. This knowledge becomes helpful when you first notice the youth is escalating. Whether it’s withdrawing from the group or they start pacing. Your connection can help to stop things from escalating. When a child or youth escalates, you need to come alongside the child, follow the IEP/504 plan, offer sensory input, or ask the youth to help you with something.

Having that personal relationship with the youth makes it easier to enforce rules and set boundaries for your home, classroom, residential unit, or wherever the youth may be. You can also change the rules or reset expectations for dysregulated youth when you have a strong relationship. An example of this might be that you do not allow running in the hallway for safety, but when Felicity is becoming upset, more fidgety than usual, and cannot stay in her seat, she might benefit from running down the hallway. Things like this should never be a punishment. This example notices that Felicity is getting antsy, her work might be upsetting, and she needs a break. Allowing her to run down the hallway a couple of times provides valuable sensory input and releases pent-up energy. It could improve her mood by doing something fun. It also tells Felicity that you are an adult she can express emotions around. If running is not an option, you can ask Felicity what she needs. Does she need a hug (weighted blanket/ stuffed animal for a touch-avoidant youth)? Does she need some movement, does she need to go to a quiet area and lie down, or does she want to talk?

De-escalation interventions benefit everybody. When done correctly, it tells a youth that you are attuned to the fact that they need something even though they may not have the words to say so.

I was taught many ideas on how to de-escalate a situation, such as dropping expectations to prevent the power struggle from continuing, offering limited choices, or even something as simple as a distraction. Silence is a wonderful tool to use as well. I also allow youth to swear and yell at me about what is bothering them because it helps drain their emotions, and sometimes yelling that swear word is cathartic. When I am being targeted with yelling, I do not respond. I am silent because that child is not ready to speak to me. I will switch out with another staff member if I am the problem at that time (this might not be as easy in a school, but in my experience in a residential setting, it is pretty doable).

If the setting you work in uses restraints and isn’t talking about the dangers of restraints, then your program is dangerous.

Using restraint is inherently dangerous to the youth and those carrying out the restraint. You never need more than three people to do a restraint. I have been trained that three people are required for supine and two for prone, standing, and seated restraints. Additionally, I have never once had to apply any pressure on a youth once they are in a restraint. All restraints can affect the breathing and heart rate of a youth. Some youth have health conditions that make it more dangerous to do the restraint and significant trauma.

It has been four years since I have been involved in a restraint beyond being an observer. Not because I have great de-escalation skills or changed from direct care to administration. It is because of the simple fact that I do not see the value in restraining a child.

I also listen to what a child is saying. I also give them space because when adults are closing in on a child, it is scary for that child.

Children and youth have died in restraints. While those who are pro-restraint will argue that there were too many adults (as many as seven adults were restraining Cornelius Frederick, which led to his death), the restraint was poorly done, or going as far as victim blaming, none of it matters because the restraint still resulted in the death of a child. Pro-restraint people will argue that they have better-trained staff and nothing like that would ever happen at their facility, but that cannot be guaranteed. Pro-restraint people also say that restraints create safety for others and prevent injuries.

Anything that causes trauma does not create safety.

It’s traumatic to be in a restraint, it’s traumatic to see one, and it’s traumatic to the adults who have restrained a youth. My current place of employment showed the video of Cornelius Frederick’s restraint. We discussed what was wrong with the restraint to show the gravity of the situation. Restraints are a last-ditch intervention where I work, but I am researching, creating training, and finding ways to reduce and eliminate the restraints.

Restraints are rare at my facility. As an observer, I have been watching our youth care staff, listening to their interactions, and participating in some of their training to figure out why. The youth we serve can be highly aggressive and argumentative and often arrive with long behavior reports painting them to be volatile, disrespectful, and just downright horrible. Yet, while they are here, we have very few issues with most of them. I wondered why, so exploring how we manage such youth without restraints became a mission. We all go out of our way to build relationships with them that are built on respect. We have a schedule and stick to it, which helps with predictability for our youth. We also have fair consequences that never change and always match what they do. Our consequences never embarrass or mock the youth either. We create safety and provide three meals and two snacks a day. We also have outings and give the youth time to be kids. This is one of the most important things we do to help prevent restraints. We look at what we can do rather than what we cannot do.

Youth in residential care are often told what they cannot do. Their lives are so scheduled that they barely have time to decompress from one activity before going to the next. Some places are so regulated that youth are not allowed time by themselves for fear that they will harm themselves or do something that isn’t approved of by the facility. By stepping back, dropping certain expectations, and allowing youth and children to actively be youth, you allow children to create coping strategies and regulate their emotions in healthier ways than forcing them to take a deep breath when they are upset.

Initially, this was supposed to be an article full of sources, studies, and other scientific data, but sometimes, we must offer support without the jargon. Besides, I’m throwing all that into a project on why children and youth do not automatically owe you respect.

If you want to learn more about co-regulation and building healthy relationships, I cannot recommend the works of Lori Desautels Ph.D and Mona Delahooke Ph.D enough. They are both highly respected in the field of education and working with children. Additionally, Dr. Delahooke is a practicing psychologist who works with children and families, while Dr. Desautels is a professor of education at Butler University. Dr. Desautels is involved with multiple middle schools, teaching both students and teachers about neuroscience and trauma.

I encourage you to question the use of restraints at your school and facility.

Is there a review process? Is the IEP or 504 being followed? Are you creating a safe environment, or do you expect the rules to enforce safety? Places that are supposed to be safe for children and youth need to be just that. Safe. Building relationships means you are one step closer to preventing a future restraint.

Categories Advocacy, Residential, Restraint
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