Restraint & Seclusion
A Failing Grade
Protection & Advocacy, Inc.
Investigations Unit Staff:
Staff Acknowledgement for Editing and Production:
Protection & Advocacy, Inc. (PAI) encourages you to copy and distribute this report for training and educational purposes. You may do so as long as such publication is not done for profit, and, if the report is not published in its entirety, PAI is acknowledged as the source of the material.
Protection and Advocacy, Inc. (PAI) is an independent,
nonprofit agency responsible for ensuring the rights of people with
disabilities are protected and advanced.
Established in 1978, PAI is funded through a series of federal laws
enacted after horrific abuse and neglect was revealed at a state institution for individuals with
developmental disabilities in
For many years, PAI heard anecdotal reports of excessive
and inappropriate restraint and seclusion practices in schools but had not
received any specific complaints. In the
spring and summer of 2006, PAI received eight complaints of abusive restraint
and seclusion of elementary, middle and high school students in
PAI’s year-long investigations included extensive review of records, on-site inspections, victim and witness interviews, consultation with experts in education, and restraint and seclusion, meeting with key stakeholders, and thoughtful legal analysis. These investigations revealed the failure of school personnel to comply with existing regulations, as well as gaps in existing law designed to provide protections and safeguards for students subjected to restraint and seclusion. In recognition of the serious risks associated with the use of restraint and seclusion, state and federal authorities and others have imposed significant restrictions on its use and required extensive review and reporting requirements in most settings. Schools and education laws and regulations have not kept pace with these reform initiatives.
Restraint and seclusion are emergency interventions employed to protect an individual from imminent serious physical harm. Restraint is any manual method or mechanical device that restricts the individual’s freedom of movement or normal access to one’s body. Seclusion is the involuntary confinement or isolation of a person alone in a room or an area from which the person is physically prevented from leaving. Restraint and seclusion are dangerous and traumatic events that may cause serious physical and psychological harm – even death.
PAI issues this report to ensure that the same level of protections are provided to children in school settings who are subjected to behavioral restraint and seclusion as guaranteed in most other environments and that such incidents receive the same level of scrutiny and oversight by all responsible entities. This includes:
§ Defining restraint and seclusion consistent with state and federal law in other settings;
§ Prohibiting the use of seclusion, while permitting limited and planned use of supervised time-out;
§ Strictly limiting the use of behavioral restraint to the most dire circumstances, only for as long as absolutely necessary, and only if adequate safeguards can be instituted to minimize possible injury or trauma;
§ Ensuring that schools comply with current state laws and regulations limiting the use of emergency interventions, including restraint and seclusion, and promptly report its use to parents, school administrators and the California Department of Education;
§ Ensuring that school personnel proactively address serious student behavioral problems through timely and thorough individual functional analysis assessments and positive behavioral intervention planning;
§ Encouraging heightened scrutiny of emergency interventions by schools, Special Education Local Planning Areas, and the California Department of Education; and
§ Enhancing data collection regarding emergency interventions, including seclusion, restraint, unplanned time-out, and extended time-out.
Pseudonyms have been used throughout this report for all the names of individuals and school districts described in the cases.
In the past year, PAI has conducted in-depth investigations into allegations of abusive restraint and seclusion practices involving seven students in five public schools and one non-public school. These investigations revealed both the failure of school personnel to comply with existing regulations and the failure of current law to sufficiently regulate the use of these dangerous practices. School personnel applied restraint and seclusion techniques that are expressly prohibited and employed emergency interventions in situations that did not pose an imminent risk of harm.
Restraint and seclusion are dangerous and traumatic events. Manual and mechanical restraints, even when applied correctly, have been associated with grave physical conditions, including asphyxiation, broken bones, dehydration, oxygen deprivation to the brain and other vital organs, and death. Seclusion and restraint can cause lasting, severe psychological trauma from the experience of being seized violently and isolated. Studies show that children are subject to restraint and seclusion at higher rates than adults and are at higher risk of associated injuries and death.
In emergencies, school personnel are permitted to act to control a student’s behavior posing a clear and present danger of serious physical harm to the student or others, and which cannot be immediately prevented by a less restrictive response. Such interventions may include temporary physical restraint and/or unlocked seclusion. For students who regularly or predictably demonstrate serious behavioral problems in the classroom, schools may not default to these emergency interventions but must proactively evaluate the underlying cause of the student’s behavior and develop a plan to intervene positively to prevent it from occurring.
Examples of Prohibited Techniques: One 10 year old boy with significant physical and cognitive disabilities was bound to his wheelchair and left on the school van on two separate days, at least once without any adult supervision. One school built a locked seclusion room and routinely locked an eight year old boy with psychiatric and developmental disabilities in the room when he was non-compliant with staff instruction. Other children were dragged by their teachers into seclusion rooms or areas which were then barricaded to prevent their exit. Students at one middle school were secluded every day, at times for the entire school day, for not completing work assignments and disobeying adult instruction. Teachers and aides used unapproved and dangerous restraint techniques. Several of the students sustained physical injuries stemming from improper restraint techniques. Others were psychologically traumatized by incidents of seclusion.
Restraint and Seclusion Became Routine: Each of the students in the cases investigated had a history of serious behavior problems in school. Yet, school personnel implemented emergency interventions, including restraint and seclusion, in lieu of developing or modifying individualized positive behavior plans based upon a thorough assessment of the student. School personnel also did not evaluate the students’ problem behavior and failed to develop or revise individualized positive behavior plans. Instead, schools frequently used seclusion or physical restraint as the primary means of intervening with the children. As these events occurred repeatedly over time, restraint and seclusion became routine classroom events. None of the events were reported as required by law, including notifying the students’ parents or legal guardians.
Minimum Standards: PAI releases this report to reinforce compliance with current regulatory requirements and to challenge schools and the education system to bring standards regarding behavioral restraint and seclusion of students into line with current practices in all other settings. There are strict guidelines limiting the use of restraint and seclusion to extreme situations where there is an imminent risk of serious physical harm to an individual and only for the duration and to the extent necessary to protect the individual. Only staff who are currently and regularly trained in restraint techniques may apply them. Every restraint or seclusion event prompts rigorous scrutiny of events leading up to the incident, and details are collected, reported and reviewed in the aggregate to identify trends and opportunities to avoid its use. Schools must be held to these same standards.
Reducing Restraint and Seclusion as a Top Priority: In many health care and community settings, awareness about the risks of restraint and seclusion have prompted reform initiatives to eliminate their use. Given that these techniques are the same as those used in schools and given the enhanced risk of injury and death when used with children, the same restrictions and safeguards should apply. Schools must bring their standards regarding restraint and seclusion up to the minimum standards in other settings. Educators, parents, and others must ensure that the use of restraint and seclusion is scrutinized and limited to only the most imminently dangerous behaviors. Ultimately, schools and the California Department of Education must make reducing and, eventually, eliminating restraint and seclusion a top priority, consistent with initiatives in all other settings where used.
Exterior of locked seclusion room from inside classroom.
Interior of locked seclusion room.
The seclusion room (approximately eight by eight feet) was built in a corner of Aaron’s special day classroom. The walls to the room stopped several feet from the ceiling. There was no carpeting on the floor or padding on the walls. The door to the room had a window and could be locked from the outside. When locked, the door could not be opened from the inside. When PAI investigators inspected the room in May 2006, it contained several chairs, a small desk, and a thin mattress in the corner.
Aaron was repeatedly locked in the seclusion room alone. Although Aaron was known to be physically aggressive with staff, the evidence did not support that this behavior posed an imminent risk of serious physical harm. When he was placed in the room, Aaron would become upset and stand on the handle of the door and attempt to scale the walls. He would also throw himself against the walls. The dates and frequency of seclusion are not documented in Aaron’s school records but, according to a witness report, occurred approximately 15 times during the school year. A log from the school contained in the CDE investigation file documents Aaron being placed in the room 31 times.
Aaron’s parents were aware that the school built the
seclusion room, believing it would be used only when Aaron was a physical
danger to himself or staff. Because the
school was recommending this intervention, Aaron’s parents felt that such an
intervention was necessary and permissible.
Until another parent reported witnessing Aaron attempting to get out of
the locked room, his mother was unaware that the door was lockable or that
Aaron was ever locked alone inside.
Over the course of time, Aaron’s parents came to suspect he was being secluded for problem behaviors that did not pose a risk of physical harm. According to Aaron’s mother:
“….Over the course of several years or so, I just felt [that the use of the seclusion room] has been abused. I just feel that now he’s being put in there for anything. He’s put in there for throwing a pencil on the floor. He takes his shoes off, he gets put in the room. And I just feel it’s not what it was intended for. It specifically says in his IEP what it was intended for and now they’re using it [for] anything he does that is disruptive behavior and he gets put in the room.”
There were no behavioral emergency reports in his file documenting when Aaron was secluded, although school personnel do not dispute that locked seclusion was used. Despite repeated seclusion events, from November 2004 until PAI’s investigation in the spring of 2006, there is no record of the Individualized Education Program (IEP) team discussing whether Aaron’s behavior warranted an FAA or revising the BIP. Despite school and district personnel meeting regularly with Aaron’s parents regarding Aaron’s problem behavior, there is no notation in the record of the team discussing any restraint or seclusion incident.
In April 2006, a complaint was filed with the CDE, alleging that the BIP from November 2004 was not being followed by the school district and that instead, Aaron was being frequently placed in locked seclusion by untrained staff using physical restraints. This complaint was investigated by the CDE in conjunction with the following two cases. Despite the serious allegation of locked seclusion, the CDE did not visit the school until September 2006 and never interviewed Aaron. The CDE “deleted” the allegation addressing locked seclusion and excessive and inappropriate restraint, “because the issues… were addressed by PAI.” A second allegation was added by the CDE, focusing on the district’s failure to implement Aaron’s IEP. The district was found out of compliance and was required to take corrective action, namely reviewing and revising Aaron’s IEP to address the use of time-out and physical restraints, and providing staff training on the development and use of positive behavior support plans and time-outs. See page 14 for the further details regarding the outcome of PAI’s and the CDE’s investigations into this complaint.
During the 2005-2006 school year, Brian Richards was 10 years old and attending the same special day class as Aaron above. Since he was first enrolled in school, Brian was identified as having multiple disabilities. He is nonverbal, has moderate mental retardation, and uses a wheelchair for mobility. At times, Brian displays self-injurious behaviors, including slapping his face and hitting himself.
At two IEP team meetings held in September 2005, the school district agreed to provide Brian with van transportation to and from his home and reviewed “restraint options to use in the van.” Brian’s mother agreed to help get Brian on and off the van both at home and at school. In October 2005, the district behaviorist conducted an FAA of Brian and developed a “positive behavior support plan” to address Brian’s problem behaviors, namely noncompliance, tantrums, and physical aggression. The school’s behavioral consultant recommended strategies for intervention to avoid Brian’s problem behaviors, none of which involved the use of restraints.
Mid-day one cold, damp day in late March 2006, Brian’s
mother arrived at school and saw Brian seated in his wheelchair in the school
van in the parking lot. Brian’s wrists
were tied to the arms of his wheelchair with components removed from the safety
vest purchased for Brian to use during transport on the van. His legs were bound together at the ankles
with a nylon Velcro strap.
On another cold, damp day later that month, Brian’s mother again arrived at school close to and found Brian sitting alone in the van. Although Brian was not restrained to his wheelchair, the door to the van was locked and there were no school personnel within sight. Due to his disability, Brian was unable to leave the van without assistance.
On one occasion, Brian’s mother reported seeing Brian restrained to his wheelchair in the classroom. Although his hands were free, his legs were bound together with a Velcro strap. There were no provisions for the use of restraints with Brian, either as a transportation safety device or a postural support in the classroom, in his behavior plan. This is not a restraint technique approved for use by this school’s Special Education Local Planning Area (SELPA). None of the restraint incidents were reported as emergency interventions.
In late March 2006, an IEP meeting was held to address “parental consent to use mechanical restraint” on Brian to transport him to school. It was agreed that the only restraint to be used was for transportation to and from the school on the van. This was then added to Brian’s behavior plan. Later, the IEP team required Brian’s mother to restrain Brian physically when necessary to get him on and off the van. If she was unavailable, Brian could not attend school.
In April 2006, a complaint was filed with the
In September 2005, Eric Roe, a six-year-old boy, was enrolled in a regular kindergarten classroom at a different elementary school in the same school district. His teacher soon noticed that he was having academic and behavioral challenges. Eric was placed in a classroom for students with moderate to severe disabilities. In December, the IEP team requested an FAA; at that time, an interim BIP was implemented. In January 2006, a “positive behavior support plan” recommended the use of three-minute time-outs to address escalating disruptive behavior, with ignoring and physical cues (point to the tasks or places for him to go) for continued noncompliance. The team next met in early February to discuss the FAA, which identified “disruption and noncompliance” as Eric’s target behaviors. The team agreed to accept the behavior support plan.
In the spring of 2006, several school personnel saw Eric’s teacher physically restraining Eric numerous times outside the classroom in a basket hold. Eric told PAI investigators that his teacher restrained him when he did not listen to her. These restraint events lasted up to 20 minutes. One special education aide described the restraint she observed:
“[The teacher] would grab his arms and then cross them, and hold them like he was in a tight hug to himself, and she was holding onto his arms…. [L]ike in a straight jacket position.… And she’d be standing there holding him for however long it took for him to stop fighting. … He would be saying, ‘You’re hurting me, you’re hurting me. You’re hurting my wrists.’ And she’s like, ‘I’m not hurting you. You’re hurting yourself because you’re pulling. If you stop pulling, you’re not gonna get hurt.’ Other teachers would come out and look … he was making so much fuss that it would disrupt other classrooms down the hall.”
Other teachers and parents complained that Eric’s teacher was yelling at students and laying hands on their children in a variety of ways that were “inappropriate.” She was seen holding a first grade girl by the shoulders, “shaking her very viciously,” and yelling at her. In another incident, Eric’s teacher reportedly grabbed another boy by the arm and “started yelling … like a drill sergeant, ‘Why are you doing this?’… She just goes off like in another world. She goes into this rage and then…she stopped and backed off and said, ‘[I] hope I didn’t do anything wrong.’”
An instructional aide was also observed on several occasions “dragging” Eric by the wrists when he refused to walk down the hall and then dropped to the floor, “going limp.” This is not a restraint or escort technique approved for use by this school’s SELPA or consistent with the school’s restraint training program. PAI does not believe this aide had completed any restraint training.
Eric’s foster mother learned of the restraint events when Eric complained to her about them. Aside from one event, she was not informed by the school about Eric being restrained or requiring emergency behavioral interventions. According to Eric’s foster mother, when she asked the school about what happened on the one occasion when she was notified, “They dismissed everything. I was waiting for a write-up of some kind and I asked about it and they said it wasn’t necessary….” There were no behavioral emergency reports in Eric’s educational records. The school also failed to convene the IEP team following each incident of restraint, or to subsequently develop a BIP, or review or revised Eric’s behavioral support plan.
In April 2006, a complaint was filed with the
In the spring of 2006, Sean Thompson was an 11 year old in
the fifth grade at a third elementary school within the same school
district. Several years earlier, Sean
had been identified by the school district as having physical disabilities
necessitating accommodations, including placement in a resource classroom at
the school. In February 2004, after
finding that “behavioral and academic issues continue to place Sean at risk of
failure,” the IEP team referred him to a program specialist for a behavioral
evaluation. That referral was not
completed for nearly one year.
In late 2004 and early 2005, Sean was secluded on several occasions by his classroom teacher in a corridor between two classrooms.
Corridor between classrooms.
The corridor was approximately 10 to 12 feet long and about 4 to 5 feet wide with a door at either end into a classroom. There were doors off the corridor to two bathrooms and a utility closet. There was a window in the door from Sean’s classroom into the corridor, but it was entirely obstructed with paper. When secluded in the corridor, Sean could not see into the classroom and no adult could observe Sean in the corridor.
Although there was no lock on the door between the hallway and either classroom, Sean’s teacher would slide a classroom table in front of the door to barricade Sean’s exit. At times, a classroom aide would sit on the table to further secure the door closed.
Sean did not attempt to leave the hallway, believing that he had been locked or barricaded in. According to Sean, “They locked me in there” and “They put a table in front of it so I could not get out.” When asked if he ever attempted to leave through the door into the other classroom, Sean replied “No, ‘cause it was locked.” Sean was allowed to return to his classroom when he knocked on the door and told the teacher he had completed his work.
Sean said he did not recall exactly how many times he was secluded in the corridor, but said that he was put in there whenever he did not follow directions. Although there are no notations regarding the seclusion incidents, a witness verified that Sean was secluded for noncompliance with adult instruction. School records fail to document that Sean was ever violent or aggressive. There are no behavioral emergency reports in Sean’s educational records or other notations documenting Sean’s classroom behavior and his subsequent placement in the barricaded hallway.
Sean also described manual restraints being used in addition to seclusion. On one occasion, Sean recalled that his teacher, “picked me up by my arms and he threw me. [My teacher] picked me up in the air and threw me down” because Sean refused to talk on the telephone to his mother.
According to Sean’s mother, Mrs. Thompson, Sean would get angry when he was placed in the corridor. He would kick and throw his chair at the door. Mrs. Thompson complained to the principal about the seclusion incidents, but he reportedly did not intervene. Mrs. Thompson debated removing Sean and home schooling him.
Despite repeated seclusion incidents and the IEP team’s recommendation for a behavioral evaluation nearly one year earlier (in February 2004), no FAA or BIP was ever conducted. In mid-December, a behavioral consultant was retained to conduct a “full classroom analysis,” seemingly for the entire classroom. In late January 2005, a token system was implemented for all students. School records indicate that the generic token system was considered the “positive behavior support plan” for Sean, although it was not based on an FAA and lacked sufficient specificity to qualify as a BIP. Less than one month later, Sean was found not to have a qualifying disability and was returned to a general education classroom with support of the behaviorist.
In April 2006, a complaint was filed with the CDE, alleging that Sean had been physically restrained and placed in locked seclusion. It was also alleged that the school had conducted a classroom assessment instead of a FAA specific to Sean as required by the IEP team in December 2004. The CDE reported that they did not investigate Sean’s complaint because it had been withdrawn and Sean was no longer a special education student protected by the Hughes Bill.
Complaints were filed with the
In April 2006, PAI initiated its investigation into these allegations. PAI contacted the school district, alerting them to our concerns about excessive and illegal restraint and seclusion. In June 2006, PAI visited the schools, interviewed witnesses, and verified the students’ allegations of excessive and illegal restraint and seclusion. In August 2006, the school district met with PAI concerning all four students. At that meeting, the school district agreed to remove the door to the seclusion room and terminate the use of mechanical restraints on all students. They assured PAI that all students placed in time-out would be provided adequate adult supervision. The district reported retraining all relevant district special education staff in the SELPA approved emergency interventions and establishing a quality assurance system to track the use of behavioral emergency interventions in the district.
After the CDE concluded its investigations in late September and early October 2006, it found that the school district was not in compliance in two of the four cases, Eric and Aaron. In those cases, the CDE found that the schools had failed to implement students’ behavior plans as written and used time-out and physical restraints for behaviors not specified therein. In Brian’s case, the CDE found the school in compliance, in part relying upon an IEP drafted after the incidents occurred. The CDE reported that it did not investigate Sean’s complaint because the complaint had been withdrawn and Sean was no longer a special education student protected by the Hughes Bill.
In early 2006, PAI received information about excessive and inappropriate restraint and seclusion of students attending a special day class for emotionally disturbed children at the local middle school. The class had approximately eight students, one teacher, and two aides. The classroom was equipped with a seclusion room.
Exterior of seclusion room from inside classroom
Interior of seclusion room
Chair tethered to
The seclusion room was approximately 8 to 10 feet across with four carpeted walls reaching from floor to ceiling. At the time of PAI’s unannounced visit, the room was empty of furnishings. There was one small window in the back of the room facing an exterior classroom wall. The door of the seclusion room was solid, without a doorknob or lock, and swung open into the classroom.
To prevent students from leaving the seclusion room, at times, classroom personnel held the door closed. A handle on the exterior of the door was moved higher up the door to prevent staff from being hit by the handle as students attempted to kick the door open. According to school personnel, a classroom chair was also placed in front of the door to alert staff when the door was opened. One student reported that “the chair was jammed up against the door to keep the kids from getting out.” The chair was tethered to the door to prevent it from flying into the classroom when a student was able to force the door open.
School personnel acknowledged restraining students to control aggressive behavior, prevent property damage, or escort students into the seclusion room.
Only the classroom teacher had completed the SELPA approved restraint training program (Professional Assault Response Training 2000 or PART 2000) and his certification had expired. Neither classroom aide was trained in restraint techniques, although one participated in restraint events. PART 2000 does not teach or endorse single-person restraint techniques.
In February 2006, Jason Larsen was 12 years old and attending sixth grade at the middle school. Due to his history of behavioral problems in the classroom, Jason was placed in the special day class. At the time of PAI’s investigation, Jason was approximately 4’9” and weighed approximately 100 lbs. Jason had been diagnosed with ADHD and posttraumatic stress disorder. His school records show behavior problems beginning in second grade.
Since his enrollment in late August 2005, Jason was repeatedly manually restrained and forcibly secluded. Jason described his teacher holding his legs while one of the classroom aides grabbed him by the arms in a basket hold and then dragged or carried him to the seclusion room. On other occasions, Jason’s teacher used a prone containment (holding Jason face down on the floor, straddling Jason at his hips, and holding Jason’s hands behind his back) or wall containment (restraining Jason standing with his face pressed against the wall with an aide holding his legs). These techniques are inconsistent with PART 2000 training. Furthermore, the teacher’s PART training had expired; there were no records of the aide receiving any restraint training.
Beginning the first week of September 2005 until PAI’s involvement in early February 2006, Jason was ordered into the seclusion room nearly every day for approximately three hours at a time, although some seclusion events lasted the entire school day. Manual restraint likely preceded many of these events as Jason would not go into the seclusion room voluntarily. Classroom personnel held the door shut or placed a chair in front of the door to prevent Jason from leaving the room or kicking the door open. Notations by classroom personnel on Jason’s daily progress sheets confirm regular use of the “time-out” room, including incidents lasting the entire school day. For a period of time, the ceiling light in the seclusion room was burned out, leaving Jason secluded for hours in the dark. Jason said he did not tell his grandmother (i.e., his legal guardian) about the restraint and seclusion events because he trusted the teaching staff and believed that restraint and seclusion were just the way things were done at the school.
According to Jason and his grandmother, Jason was restrained or secluded for not following adult direction or instruction, inappropriate language, and not obeying classroom rules. Notations on classroom records confirm that Jason’s “time-out” followed incidents of inappropriate language, profanity, and refusal to complete work assignments. There is no evidence in the records that Jason’s behavior posed an imminent risk of serious physical harm.
According to Jason’s grandmother, she was not notified of many of the restraint or seclusion incidents, although she walked in on several, and she never received any behavioral emergency reports. Although the teacher acknowledged restraining Jason, none of these restraint events were recorded in Jason’s school file or in any manner by school personnel. School and district personnel met regularly with Jason’s grandmother about his problem behavior but, until PAI’s involvement, there was no notation in the record of the IEP team discussing any restraint or seclusion incident or whether Jason’s behavior warranted an FAA or BIP. With PAI’s assistance, Jason received an FAA in March 2006.
In February 2006, Jonathon White was 11 years old and attending sixth grade at the middle school. Jonathon had a long history of behavioral problems in the classroom, dating back to first grade. Jonathon was determined to be eligible for special education classes, with both emotional and learning disabilities. When Jonathon enrolled in August 2005, he was placed in the same special day class as Jason. Jonathon had been diagnosed with oppositional defiant disorder, rule-out ADHD, and dysthymia.
According to Jonathon, he was sent to the seclusion room involuntarily almost daily, often twice a day, and, at times, for almost the entire school day. The reasons for the seclusion primarily stemmed from Jonathon’s noncompliance with work assignments and disobedience with adult instruction.
In early October 2005, Jonathon’s arm was injured when his teacher dragged him to the seclusion room. Jonathon had been disobedient and refused to complete his assignment. His teacher instructed Jonathon to go to the seclusion room to complete his work. When Jonathon refused, the teacher grabbed Jonathon by the arm, twisted his arm up and between his shoulder blades, and forcefully led him into the seclusion room. This restraint technique is inconsistent with any approved PART 2000 technique. The seclusion room door was then closed. Jonathon’s arm immediately began hurting. Jonathon reported crying in pain, but no school personnel responded. When he was released from seclusion, Jonathon told his teacher that his arm hurt. According to Jonathon, his teacher responded, “Let’s just keep it between us.”
The following morning, Mr. White took Jonathon to the
health clinic to have his arm examined.
According to the medical records, Jonathon sustained a serious sprain
(“hyperpronation” of the left wrist with bruising and tenderness) consistent
with a twisting injury, not a sports injury.
After learning how the injury was sustained, health clinic personnel
reported the incident to Child Protective Services (
After the restraint incident, Mrs. White met with school personnel who suggested that Jonathon sustained the injury at football practice or another extracurricular activity, not from the restraint event. The teacher claimed that he had “gently led” Jonathon to the seclusion room. He denied dragging Jonathon by his arm.
Progress sheets completed by classroom personnel confirm that Jonathon was regularly sent to “time-out” for refusing to do sentences or schoolwork and being rude to or ignoring adults. Notations indicate the door was closed. One parent reported to Mrs. White seeing the door tied shut with a rope. Although the progress sheets do not generally indicate the duration of seclusion, on at least two occasions classroom personnel noted Jonathon remaining in “time-out” “all day” or “most of day.” Jonathon did not tell his mother of many of the seclusion and restraint incidents because, like Jason, he trusted the teaching staff and believed that restraint and seclusion were approved and sanctioned practices at the school.
At first, Mrs. White was not alarmed when she learned of the seclusion room. Jonathon’s previous school also had a time-out room where students went voluntarily to “chill out.” It was only later when she learned that the seclusion room was used punitively and that students were forcibly dragged into seclusion with the door held shut that she began to question its use. Mrs. White was not notified of many of the seclusion incidents involving Jonathon and never received any behavioral emergency reports.
Despite Jonathon’s long history of behavioral difficulties
and the repeated use of seclusion, there is no notation in the record of the
team discussing any restraint or seclusion event other than the incident on
Immediately following PAI’s visit, the school voluntarily removed the door to the seclusion room. PAI filed a complaint with the local Fire Marshal. After conducting an on-site inspection, the Fire Marshal ordered the school to either remove the carpeting covering the walls of the seclusion room or provide test results demonstrating that it met the necessary flame spread rating. The school elected to remove the seclusion room entirely.
School personnel admitted failing to report each behavioral emergency to parents and failing to complete behavioral emergency reports for any of the restraint and/or seclusion incidents occurring in the classroom, as is required by law. There are no behavioral emergency reports contained within the education records from the middle school for either of the students described above. In both cases, parents reported not being notified of restraint and seclusion incidents for months.
The following school year (2006-2007), the school district contracted with a non-public school to provide special education programming on the same site and in the same classroom. The non-public school service provider has a no-restraint policy.
Although recovered from their physical injuries, both boys and their legal guardians report lingering psychological trauma from repeated seclusion, particularly stemming from incidents when the room was without light. Jason told his grandmother that, even though the room is gone, he can still hear the crying of the children secluded there.
In April 2006, PAI was notified that a secondary non-public school operated by a non-profit agency was inappropriately restraining and secluding students. All of the students served by the school are “emotionally disturbed.” An informant advised PAI that one student was restrained and placed in a locked seclusion room on a number of occasions. At the time of the report, the student was no longer enrolled at the school.
Based upon this allegation, PAI visited the school and observed two seclusion rooms. The rooms were approximately 6 feet by 6 feet in diameter and had lockable doors with a small glass window at the top. Outside of each door was a red button. The school administrators explained that the door would lock when the button was depressed.
Original locked seclusion room
Unlocked seclusion room at new campus
The school reported installing the locking device after several students pushed their way out of the room.
PAI advised the school that the use of the locking device constituted locked seclusion and that locked seclusion was prohibited in school settings unless the school is otherwise licensed to use it. Although the school administrator believed that the locking mechanism and the manner in which it was used was appropriate under the law, they agreed not to install similar locking devices in the seclusion rooms at a new school site. During its visit to the new school site, PAI verified that the doors on the time-out rooms lack a locking mechanism and cannot be locked. Aside from removing the lock, the time-out rooms are essentially the same as those at the old school site.
In the spring of 2006, PAI was contacted by the mother of
a 6 year old boy regarding her son’s special day class at a public elementary
school in southern
According to the mother, the classroom teacher restrained
children by pulling their arms around the back of a chair and holding their
wrists together. This mother and other
parents witnessed the teacher restraining students in this manner on several
occasions. When the mother complained to
the teacher about this practice, he tried to bar her from entering the
classroom altogether. PAI advised the
mother to file a compliance complaint with the
The school admitted that the teacher had used restraints and that the teacher had not received any restraint training. Further, the school acknowledged not having BIPs for any of the students who were restrained.
LITERATURE REVIEW, THE LAW,
In the past 10 years, there has been increased recognition
of the grave risks and serious trauma associated with the use of behavioral
and seclusion to both
the individuals involved and personnel executing these interventions (Joint
Commission Resources [JCR], 2002; Joint Commission on Accreditation of
Healthcare Organizations [JC-
Manual and mechanical restraints, even when applied correctly, have been associated with the following grave physical conditions:
§ cerebral and cerebellar oxygen deprivation (hypoxia and anoxia),
§ broken bones,
§ injury to joints and muscles,
§ contusions or bruising,
§ overheating, dehydration, exhaustion,
§ blunt trauma to the head,
§ broken neck,
§ wrist and leg compression,
§ dislocation of shoulder and other joints,
§ hyperextension or hyperflexion of the arms,
§ exacerbation of existing respiratory problems,
§ decreased respiratory efficiency,
§ decrease in circulation to extremities,
§ deep vein thrombosis,
§ pulmonary embolism,
§ cardiac and/or respiratory arrest, and
(Child Welfare League of
These risks increase in individuals with preexisting medical or physical risk factors, such as obesity, respiratory and cardiac conditions, and prescribed and illegal drug or alcohol use (Stefan, 2002).
The risk of serious physical harm and death is verified in
the scant available public data regarding injuries and deaths occurring during
or resulting from restraint and seclusion.
Since August 1999, PAI has learned of 39 deaths in
Children are subject to restraint and seclusion at higher rates than adults and are at higher risk of injuries or death (United States General Accounting Office [GAO], 1999; Substance Abuse and Mental Health Services Administration [SAMHSA], 2002; Child Welfare League of America [CWLA], 2004a). In the landmark 1998 Hartford Courant articles exposing the risks of restraint and seclusion, a disproportionate number of young children died (more than 26%) (SAMHSA, 2002; CWLA, 2004a; Mohr, 2003). Children struggle against physical and mechanical restraints, particularly when the situation or method of restraint is extremely unpleasant or aversive (CWLA, 2004b). During the struggle, severe injuries and death can occur when adults physically overpower a child or when a child struggles well beyond the point of physical exhaustion (CWLA, 2004b; Mohr, 2003). In a crisis situation, cognitive or learning disabilities may impair a child’s ability to understand directions and are likely to compromise the child’s ability to comprehend staff instructions and communicate needs (CWLA, 2004b).
Beyond physical injuries or death, behavioral restraint and seclusion can also severely traumatize individuals and result in lasting adverse psychological effects (CWLA, 2004a). The risk of trauma is greater with individuals with a history of abuse (CWLA, 2002). Individuals who have been restrained and secluded describe these events as punitive and aversive, leaving lingering psychological scars (CWLA, 2004b). Children and adolescents restrained during a psychiatric hospitalization report recurrent nightmares, intrusive thoughts, avoidance behaviors, enhanced startle response, and mistrust of mental health professionals resulting from the incidents, even years after the event (Mohr, 2003).
Restraint and seclusion may evoke feelings of guilt, humiliation, embarrassment, hopelessness, powerlessness, fear, and panic (CWLA, 2004b; Huckshorn, 2006). Restraint and seclusion compromise an individual’s ability to trust and engage with others, and create a violent and coercive environment that undermines forming trusting relationships and, by extension to the education setting, learning (CWLA, 2004b).
B. Current Federal and State Laws and National Standards Governing Restraint and Seclusion Use in Health Care and Community Settings
Recognizing the serious risks associated with the use of behavioral restraint and seclusion, federal and state authorities and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) impose significant restrictions on its use in many settings and require specialized training of staff, rigorous event review, and detailed data reporting. Behavioral restraint and seclusion may only be used in emergency situations where there is an imminent risk of physical harm to the individual, staff, or others and less restrictive, nonphysical interventions have been determined ineffective. Individuals must be released from restraint or seclusion as soon as their behavior no longer poses an imminent risk of harm. Restraint and seclusion may not be used as a means of coercion, discipline, convenience, or retaliation by staff.
In many settings, there must be immediate oversight of the restraint or seclusion event by a physician or an otherwise specially trained clinician. In many facilities, the clinician must physically respond and evaluate the individual face to face within one hour after the initiation of behavioral restraint or seclusion.  JCAHO requires the training of non-physicians to include recognizing how age, developmental considerations, history of sexual or physical abuse, and other characteristics of the individual may affect the way the individual may react to restraint and physical contact.
Behavioral restraint or seclusion often requires a physician’s written order. In health care settings, these orders are time limited, based upon the age of the individual, generally to the following:
§ 4 hours for adults;
§ 2 hours for children and adolescents ages 9 to 17 years; and
§ 1 hour for children under the age of 9.
If the restraint or seclusion event exceeds these time limits, a new order must be obtained for continued use.
Orders for behavioral restraint and seclusion may not be written as a standing order or on an as-needed basis in anticipation of a potential event. Extended use of restraint or seclusion and repeated events within 12 hours trigger ever-increasing administrative and clinical oversight.
An individual in restraint or seclusion must be carefully monitored, including continuous in-person observation or simultaneous monitoring with video and audio equipment.
Only staff who receive training and demonstrate competence in the use of restraint and seclusion may participate in these interventions. The training must include: assessing an individual’s risk of restraint or seclusion; proper and safe seclusion and restraint application and techniques; strategies to avoid or minimize the use, including recognizing the underlying causes of threatening behavior; and alternative techniques staff may use to address threatening behavior, such as de-escalation, mediation, self-protection, and time-out.
The individual and all staff involved in a restraint or seclusion event often are required to participate in a debriefing of the incident as soon as possible (no longer than 24 hours) after the individual’s release. Debriefing includes discussion of what led up to the event, how it could have been handled differently, whether the individual’s physical well-being, psychological comfort and privacy were addressed, and whether the individual’s plan for care should be modified to prevent future occurrences.
Extensive documentation of each restraint or seclusion incident is required. Documentation minimally includes a description of the individual’s behavior and any alternative or other less restrictive interventions used before initiation of restraint or seclusion.
Facilities must collect and analyze restraint and seclusion data in the aggregate to monitor its use and ensure staff compliance with applicable requirements. Data elements minimally include the type of intervention (manual restraint, mechanical restraint, seclusion), duration of event, and any adverse outcome.
Hospitals maintaining JCAHO accreditation must develop and implement policies and procedures addressing prevention of restraint and seclusion and, when employed, guide their use, including: restrictions on their use; physician order, observation, and notification requirements; staff competence and training; nonphysical intervention techniques; criteria for release; post-restraint and seclusion practices (such as debriefing).
PAI attempted to assess current practices regarding
restraint, seclusion, and behavioral emergency interventions in
1. A list of schools within the SELPA that have time-out rooms, quiet rooms, or similar spaces used to separate students with disabilities during periods of crisis or behavioral difficulties;
2. The SELPA’s policies and procedures pertaining to the use of behavioral and emergency interventions, including the training of school personnel in the use of behavioral emergency interventions, including physical restraint and containment, and the types of interventions requiring such training; and
data of behavioral emergency reports collected by the SELPA and reported to the
PAI’s survey was limited to a paper audit based on a written request for information about restraint and seclusion practices. No on-site inspections or interviews with school or SELPA personnel were conducted except in the cases described earlier.
PAI received responses from 117 of the 122 SELPAs queried – a 96% return rate. The SELPAs were diligent about providing PAI with the information requested, and the materials provided were ample. Some of the information that PAI requested was not maintained as a record of the SELPA and, therefore, was not subject to disclosure pursuant to the Public Records Act. The SELPA Directors invited PAI to join two of their statewide meetings to explain and answer questions about the survey project and to discuss concerns identified in the cases summarized above.
It is difficult to draw conclusions from the information obtained except to say that SELPA policies regarding emergency interventions appear to vary considerably, and many offer limited clear guidance regarding their use. There was significant variation in the detail and content of the policies, with many SELPAs’ policies providing schools with little direction regarding approved emergency interventions and the special training required to use behavioral emergency interventions. Six SELPAs had no policies addressing the use of emergency interventions. Nearly 43% of responding SELPAs specifically listed approved intervention techniques and/or training programs. Another one-third had policies that provided insufficient detail or were so broad in their language as to not clearly indicate which restraint interventions or special training programs were approved by the SELPA. The last 17% failed to provide PAI with policies responsive to the request.
Approximately one-quarter of the SELPAs limited the use of emergency intervention techniques, including restraint, to staff who were currently trained in such interventions, suggesting that the majority of SELPAs permit staff to apply restraint techniques, regardless of training. Eighteen SELPAs approved the use of prone containment, a dangerous restraint technique known to cause positional asphyxiation in some cases. Only 14 SELPAs listed which staff were required to participate in training; eight specified the time frame for attending refresher training.
Most of the SELPAs do not maintain public information regarding the number of time-out rooms or similar spaces used to segregate students during periods of crisis or behavioral difficulties. Many queried school districts to gather this information and provided it to PAI. Approximately one-third reported not having time-out rooms. Another one-third reported having such areas but, because some SELPAs reported the number of schools with such spaces rather than the number of time-out rooms, PAI is unable to determine how many rooms or spaces exist, or to compare the number of time-out spaces by SELPA.
The data collection and reporting requirements are
rudimentary and insufficient to provide any meaningful oversight of restraint,
time-out, and seclusion practices in
In each of the cases
investigated, schools failed to comply with current
Emergency interventions, including restraint and seclusion, are only to be used to control unpredictable, spontaneous behavior that poses a clear and present danger of serious physical harm. They are never to be a planned intervention or a routine event to control a student’s behavior in lieu of a systematic behavior plan. Yet, in these cases, they became the regular method of intervening when these students refused to comply with teacher direction. There is no evidence in the records that any of the students in the cases investigated posed an imminent risk of harm at the time of restraint or seclusion. The primary problem behavior identified was noncompliance with adult direction in non-emergency situations.
Some of the restraint and seclusion events lasted for hours, even over several consecutive days. The evidence does not support that any of the children posed an imminent, on-going threat over such a prolonged period and it is challenging to imagine such a circumstance existing. It is likely that the seclusion or restraint had rather become something else – a punitive intervention or something improvised by school personnel challenged by the student’s problem behavior. Should a child’s behavior in school really necessitate restraint or seclusion for any extended period, immediate notifications must be made and additional resources devoted to determining and addressing the issues underlying the dangerous behavior.
Recommendation 1: Schools must comply with current state law that limits the use of emergency interventions to only those situations where a student’s unexpected behavior poses a clear and present danger of serious physical harm and all other less restrictive interventions are ineffective.
Current law requires that schools and school personnel limit emergency interventions to only those situations where a student unexpectedly displays behavior that poses a clear and present danger of serious physical harm and least restrictive means of intervention have failed. Verbal threats, profanity, non-compliance with a staff directive or school rule, disruption of school order, and property destruction alone do not constitute sufficient risk to necessitate emergency interventions.
Emergency interventions may be continued only for as long as necessary to protect the individual or others from an imminent risk of serious physical harm. As soon as that risk has passed, the emergency intervention must be terminated and less restrictive alternatives initiated. Emergency interventions must never be used as a substitute for behavioral intervention planning. Behavioral restraint and seclusion may cause serious injury or death, even when applied correctly. In light of this risk, schools must ensure that emergency interventions are reserved for only those situations where the student’s behavior poses a commensurate risk of harm and less dangerous interventions have failed.
In several of the cases that PAI investigated, school
personnel employed emergency interventions that are expressly prohibited. Aaron was repeatedly placed in locked
seclusion, as were students at the non-public school described above. On one occasion, all four of Brian’s limbs
were mechanically restrained. His arms
were tied to the wheelchair; his legs bound together with a Velcro strap. Eric, Jason, Jonathon, and students at the
School administrators and the
Parents in the cases above were not notified of restraint and seclusion events, and IEP teams failed to convene and address reportedly dangerous student behavior. None of the schools involved completed a behavioral emergency report, as required by law. Completion of the behavioral emergency report triggers the responsible school administrator to schedule an IEP team meeting. These reports set into motion an essential review process whereby the IEP team reviews the event and plans how best to address the student’s underlying behavior. Without the behavioral emergency report, this process seemingly fails to occur, as illustrated by the cases PAI investigated.
PAI’s SELPA monitoring verified that schools and SELPAs
have not been accumulating and reporting emergency interventions as
required. Until recently, the
Recommendation 3: Schools and SELPAs must comply with existing regulations regarding reporting the use of emergency interventions following every incident and annually to the Department of Education and Advisory Commission on Special Education. The Department of Education must ensure that data is collected, reported, and analyzed.
School personnel must notify parents (or the student’s legal guardian) as soon as possible following every incident of emergency intervention, including restraint and seclusion. These are critical events about which parents must be informed and immediately involved to prevent in the future. Parents should also receive a copy of the behavioral emergency report documenting the event. The report is not only an important communication tool but also triggers the IEP review process and ensures accurate data collection and reporting about the systemic use of emergency interventions.
Information about the use of emergency interventions should
be integrated into the
Finding 4: Schools failed to provide students, in the above cases, with timely functional analysis assessments or failed to develop or modify behavioral intervention plans, as required by state regulation.
In the cases that PAI investigated, each student had a history of serious behavioral difficulties. The behaviors that prompted the use of restraint or seclusion had been seen repeatedly at the school and in the classroom serving the student. Yet, schools failed to comply with regulations requiring evaluation the student’s serious behavior or development of a plan to proactively address it. The IEP teams failed to convene following each incident to review the circumstances prompting the emergency intervention and to discuss indications for conducting a FAA or developing or revising a BIP.
Some of the schools claimed a classroom program (e.g.,
token system) sufficed for the student’s BIP.
Such generic classroom programs fail to meet regulatory requirements for
BIPs which, as defined by regulation, require specific elements, individualized
to the particular student’s needs. The
Recommendation 4: Schools must comply with current state law and regulations that require assessing, developing and implementing positive behavior intervention plans for students with serious behavioral problems. The Department of Education must enforce compliance.
Education experts agree that most emergency interventions
can be prevented with individualized, targeted interventions, based on an
analysis of the student’s problem behavior.
Therefore, emergency interventions are only necessary when a student
unexpectedly demonstrates new and imminently dangerous behavior, so
unanticipated that the school has not had time to develop a plan to address
Schools must comply with existing state laws and regulations that require schools promptly to identify students with serious behavior problems that interfere with their learning and proactively develop a behavior plan based upon a thorough functional analysis of the student’s behavior. The behavior plan must be detailed in the student’s IEP and reviewed periodically and following every emergency intervention.
Pursuant to the Hughes Bill,
Currently, emergency interventions are not defined except by exclusion. Behavioral restraint and seclusion are implicitly referenced within some of the excluded practices, but are not otherwise defined. During the course of PAI’s investigations, it became clear that school personnel are not familiar with these terms or aware that the emergency interventions they had implemented in the cases described above would be considered restraint or seclusion in all other settings. In the past 10 years, there has been increased recognition of the grave risks and serious trauma associated with the use of behavioral restraint and seclusion. These terms have been consistently defined in most other settings where used and tightly regulated. Given that these are the same techniques used in schools, the same definitions and safeguards must apply.
§ Current Law Regarding Seclusion
Current regulations prohibit locked seclusion in schools. Yet, as the above cases establish, students are secluded in conditions replicating a locked door, but without violating the exact letter of the law. Students were isolated alone in rooms or corridors where they were physically prevented from leaving by staff holding the door or using furniture to barricade the door closed. The student may be unaware of an available exit and, therefore, may believe the room is locked. Both are the equivalent of locked seclusion and should be prohibited.
Seclusion must be distinguished from time-out. Time-out involves removing a student from sources of positive reinforcement as a consequence of a specified undesired behavior. The spectrum of time-out ranges from taking a time-out at one’s desk to removing the student to a separate area (exclusionary time-out). During time-out, a staff member should be continually present and immediately accessible to the student. Time-out must ensure continuous visual and auditory access by school personnel. In contrast, a student in seclusion is involuntarily sequestered from others, without access to school staff and where there is little or no view of the rest of the class.
§ Current Law Regarding Restraints
Current regulations do not provide adequate safeguards when applying behavioral restraint. All forms of mechanical and manual restraint are permitted with two exceptions. School personnel may not mechanically immobilize all four limbs simultaneously; tying down three or fewer limbs at one time, however, is permissible. School personnel are also prohibited from restraining a student face down (i.e., prone containment) unless they have been trained in this technique. Prone restraint is a dangerous restraint position, even when applied correctly by staff trained in such interventions. Neither of the prohibited restraint techniques adequately address or appreciably minimize the serious risks associated with many restraint positions and techniques
It is well known in the health care arena that seclusion and restraint are traumatic and dangerous events that can cause serious, lasting physical and psychological harm – even death. These risks are even greater with children. Physically restraining an individual can cause bruising, broken bones, muscles strains, and joint dislocation. Manual restraint techniques can severely limit an individual’s respiratory capacity, causing asphyxiation in extreme cases. The stress associated with an individual struggling against restraint can cause dehydration, exhaustion, and increased heart and respiratory rates, which can cause death in patients either with certain pre-existing conditions or in combination with medication. Mechanical restraint devices have caused strangulation, particularly when used with individuals with cognitive impairments who became entangled in an attempt to escape their confinement.
The Legislature and/or
Seclusion is a traumatic experience, especially for children. What little research exists shows that children experience immediate and lingering psychological harm from seclusion events. Furthermore, safety dictates that a child exhibiting dangerous or problem behaviors not be isolated, alone, without constant adult supervision.
So, while it may be necessary at times to remove a student
from a group area and provide him or her with a quieter space to complete a
task or regain focus and control (e.g., time-out), seclusion, as defined above,
must be prohibited in all schools, unless they are otherwise licensed to
perform seclusion. Time-out and positive
behavioral interventions should be implemented instead.
Behavioral restraint should be defined consistent with the definitions used in other settings. Restraint should be defined as any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the individual’s body that the individual cannot easily remove and that restricts freedom of movement or normal access to one’s body. This definition includes mechanical restraint with a device, manual or physical restraint, and use of medication to manage an individual’s behavior and that is not a standard treatment for the individual’s condition.
Recommendation 5 D: Temporary behavioral restraint should only be attempted when all other techniques are ineffective to prevent imminent serious physical harm and when there are sufficient safeguards to protect the individual.
As emphasized above, current law requires that temporary physical restraint should only be used when other techniques of intervention have been tried and have failed to prevent imminent serious harm. Everyone within the education system must ensure that the law is followed and that restraint is only used for such dire situations and not for mere noncompliance with adult instruction.
To minimize possible injury or death, all restraint techniques that impair the student’s breathing or respiratory capacity or obstruct the student’s airway should be prohibited, including techniques that place any pressure or weight on the student’s chest, back, lungs, diaphragm, or stomach. This restricts the student’s ability to breathe and further compromises respiratory and cardiac functioning. Whenever possible, an observer, not restraining the student, should monitor the student closely for signs of distress or respiratory compromise.
Restraint should be prohibited with an individual who has a known medical, physical, or psychological condition that could be exacerbated by restraint. Known risk factors include history of trauma or abuse, obesity, agitated or excited syndromes, preexisting heart disease, and respiratory conditions, including emphysema, bronchitis, or asthma.
PAI cautions schools about the significant risk of death
associated with certain physical restraint positions, in particular prone
containment and basket holds. Both
techniques may severely restrict the student’s respiratory capacity, thereby
reducing the supply of oxygen needed to meet the body’s increased demands. Neither Crisis Prevention Institution (CPI)
nor ProACT (two crisis intervention training programs used by many SELPAs) endorse
Aside from a reference to a training requirement for the application of prone containment, there is no requirement that staff executing emergency interventions be trained or that only staff who have completed training may apply emergency intervention techniques. This reference is contained within the prohibition regarding mechanical restraint of all four limbs. Prone containment is usually defined as a face down manual restraint; its inclusion in this prohibition addressing mechanical restraint is misleading, particularly without further definition. This reference fails to establish a training requirement for the application of other emergency interventions, including other restraint procedures.
PAI’s SELPA monitoring confirmed that many SELPAs’ policies do not limit the application of emergency interventions to staff who have completed training. The majority of SELPAs (74%) did not prohibit staff that lacked training from engaging in behavioral emergency techniques or, conversely, limit the use of these techniques to those staff that are currently trained. One SELPA’s list of approved emergency interventions requires training for prone containment but expressly permits “physical restraint by staff on hand” without a comparable training requirement.
Emergency interventions, including restraint and seclusion, can be traumatic to the student and may cause serious injury or death. Only staff currently trained and competent in seclusion, restraint and de-escalation techniques should perform emergency interventions. Staff must regularly complete refresher training. At a minimum, PAI recommends refresher training annually. Emergency intervention training programs should include (1) information regarding the physical and psychological risks associated with restraint and seclusion and (2) early intervention and de-escalation techniques to avoid their use.
Occasionally school personnel may need to apply a brief manual hold to stop a child from darting into traffic or from a self-injurious incident or to break-up a school yard brawl. These impulsive events are distinguished from serious behavioral problems that impede a student’s learning and for which emergency interventions, by trained staff, may be required.
Recommendation 6 B: School Administrators, Special Education and SELPA Directors, and the Department of Education must provide enhanced oversight of seclusion, restraint, time-out, and emergency intervention practices.
School administrators (i.e., the school principal or
designee) should be notified of every emergency intervention, including seclusion,
restraint, and unplanned time-out, and immediately contacted after any event
resulting in physical injury. School
administrators have the duty to ensure that the IEP team convenes, complies
with existing laws and regulations, and has the necessary resources to address
the underlying issues. The
Prolonged or recurring use of any emergency intervention or time-out should trigger ever-increasing administrative oversight and involvement (e.g., any emergency intervention lasting more than 15 minutes, two or more seclusion or restraint events in one week, time-out from normal school activities of more than three class periods a week, etc.). Extended seclusion, restraint, and time-out have not been found to be effective at reducing problem behavior, and they increase the risk of injury and trauma. Some experts recommend that time-out not exceed 15 minutes or one minute per year of age of the child (whichever is less). SELPA Directors and/or Directors of Special Education should be notified of repeated and prolonged use of seclusion, restraint and time-out. Experts in child trauma, and restraint and seclusion should be consulted for guidance regarding reasonable reporting parameters.
A debriefing of the incident should follow every restraint, seclusion, and unplanned time-out event to discuss how to avoid a similar situation in the future. Experts have found incident debriefing to be critical to successful restraint and seclusion reduction initiatives. Debriefing should occur as quickly as possible, no later than the following school day, and should include the staff involved in the event, the student and the student’s legal guardian, and, if reasonably available, school administrators. The debriefing should attempt to:
§ identify the precipitant of the incident and suggest methods of more safely and constructively responding;
§ assist school personnel to understand the precipitants and develop alternative methods of helping the child avoid or cope with those incidents;
§ help the IEP team evaluate the need for a FAA or develop/revise a BIP; and
§ assess whether the intervention was necessary and implemented in a manner consistent with staff training and school and SELPA policy.
A notation regarding the debriefing should be recorded in the student’s education file.
Using data in a non-punitive manner to elevate oversight of such practices, address trends, and identify successful alternative strategies is an essential component to reducing restraint and seclusion. PAI recommends enhanced data collection of every seclusion, restraint, and time-out incident. PAI includes recording information about time-out in this recommendation because overuse or extended time-out does not positively affect student behavior and may be abusive or traumatic.
Schools should minimally record:
§ Type of intervention (e.g., seclusion, method of restraint, planned or unplanned time-out, exclusionary time-out, etc.);
§ Duration of intervention;
§ Time of initiation and release;
§ Date and day of week;
§ Location of incident, including school and classroom/area where incident occurred;
§ Episode or events preceding incident, including whether harm was directed to self, peers, staff, or others;
§ Staff involved in restraint, seclusion, or time-out;
§ Resulting injuries, if any;
§ Age of student;
§ Type of disability of student, if any; and
§ Whether student has an FAA and/or BIP and date of most recent version.
Schools should maintain a copy of this information in the student’s education file for integration into the student’s FAA and/or BIP, and examination and review by the IEP team, the school’s Behavioral Intervention Case Manager, or behavioral consultant. For comparison of incidents across schools and districts, minimal demographic information regarding the school and district population should also be collected (student population, rural/urban, etc.).
Except for statistics about staff member involvement, aggregate data should be tallied quarterly, graphed, and posted publicly. School personnel should use this information to identify baseline use and set performance improvement goals. Subsequent data, monitored over time, can be used to identify and address trends and recognize successful programs so strategies can be shared. Schools with a proportionately higher incidence in one measure should compare their program and philosophy regarding positive behavioral support with other comparable schools. Information about staff members involved may be used by school and district administrators to identify training needs and individual coaching opportunities.
Educational leaders in schools, school districts, and SELPAs are encouraged to elicit input from individuals who have experienced restraint or seclusion, parents, and leading experts in the field to gain a better understanding of these practices, their significant risks, and ways to prevent and avoid their use. Many health care providers have found embedding consumers in roles within the facility critical to eliminating these practices. Such roles may include consumers sitting on key district or SELPA committees, assisting with satisfaction surveys, participating in debriefings, and working directly with staff regarding the trauma of restraint and seclusion.
1. A list of schools within the SELPA that have time-out rooms, quiet rooms, or similar spaces used to separate students with disabilities from others during periods of crisis or behavioral difficulties;
2. The SELPA’s policies and procedures pertaining to the use of behavioral and emergency interventions, including the special training of school personnel in the use of emergency interventions, including physical restraint and containment, and the types of interventions requiring such training; and
3. Annual data of behavioral emergency reports collected by the SELPA and reported to the CDE, from school year 2000 to 2006.
PAI requested the information pursuant to the Public Records Act. In many SELPAs, item numbers 1 and 3 above were not maintained as a public record and, therefore, were not subject to or available for disclosure. In response to item number 2, many SELPAs provided PAI with relevant portions of their local plan or policy manual.
PAI received responses from 117 of the 122 SELPAs queried (96% return rate). Due to limitations inherent in this survey process, it is imprudent to draw definitive conclusions about the information received. Rather, PAI presents this information as informative regarding general practice and possible gaps in the current oversight and regulation of emergency interventions, including seclusion and restraint.
Table 1 summarizes the responses received.
A. Time-out rooms, quiet rooms, or similar spaces used to separate students with disabilities from others during periods of crisis or behavioral difficulties.
SELPAs were roughly equally divided between those reporting to lack time-out rooms (30%), those having time-out rooms or spaces in some schools (33.3%) and those who do not maintain the data as a record (36%). Descriptions of these spaces varied from three-sided open cubicles where students are readily visible to small isolation rooms vacant of furnishings where students are segregated from all others behind a closed door. Because some SELPAs reported the number of schools with such spaces rather than the number of time-out rooms, PAI is unable to determine how many rooms or spaces exist or compare the number of time-out spaces by SELPA. The SELPA in Sean’s case, described above, did not report the corridor used to seclude Sean as a time-out room or space. Therefore, it is possible that students are being isolated or secluded by teachers in other areas not designated or recognized by schools or SELPAs as a time-out space.
Approximately half of responding SELPAs (51) specifically listed in their policy the behavioral emergency interventions that are approved for use, either by designating a crisis intervention training program or listing specific restraint and self-defense techniques. Approximately another one-third of the SELPA policies (40) were too broadly stated to readily identify which interventions were approved for use. Some policies essentially repeated verbatim that which is required by code or in regulation without further clarification or specification. For example, one policy states, “Only emergency interventions approved by the SELPA may be used,” without further information or detail. Other policies list specific crisis intervention training programs and “other professionally accepted programs.” Such policy statements lack sufficient specificity to meet regulatory requirements or to provide guidance to school personnel regarding which procedures have been approved for use. Six SELPAs reported having no policy addressing behavioral emergency procedures. Thirteen SELPAs provided policies regarding students with behavioral difficulties generally but which failed to address the use of behavioral emergency interventions specifically.
There appears to be considerable variation in the restraint practices and the requirements regarding staff training in behavioral emergency, de-escalation and restraint techniques. Few SELPAs (14) expressly listed which school personnel are required to participate in training. The majority of SELPAs (74%) did not prohibit staff that lacked training from engaging in behavioral emergency techniques, including restraint or, conversely, limit the use of these techniques to those staff that are currently trained. Some SELPAs (18) specifically endorsed prone (or facedown) physical restraint, a technique that places some individuals at risk for positional asphyxiation.
The majority of the SELPAs (65) acknowledged failing to
collect annual behavioral emergency report data or sending them to the
Of the SELPAs reporting the data, there was considerable variation in the number of behavioral emergency interventions. A few of the SELPAs provided a more detailed breakdown of the data. Emergency interventions were categorized as:
§ To stop assault/injury of another student;
§ To stop assault/injury of staff;
§ To protect the student from self-injury;
§ To prevent run-away;
§ To prevent throwing objects/missiles; and
§ To prevent property damage.
While this breakdown provides some useful information about the nature of the student’s behavior, it lacks sufficient detail for meaningful oversight and systemic reform.
Mary Margaret Kerr, Ed.D.
Mary Margaret Kerr received her Bachelor's and Master's
In 1989, Dr. Kerr joined the Pittsburgh City Schools as
Director of Pupil Services. In 1994, she
returned to her faculty position at the
Currently, Dr Kerr serves as Associate Professor of
Psychiatry and Psychology in Education where she directs a graduate training
program in school-based behavioral health and continues her work with the
Behavioral Intervention Plan (BIP) A written document, based upon a functional analysis assessment, which is developed when a student exhibits a serious behavior problem that significantly interferes with the implementation of the goals and objectives of the student’s IEP. The plan must include a summary of relevant information gathered from a functional analysis assessment, an objective and measurable description of the target behaviors, individual goals and objectives, and a detailed description of behavioral interventions, among other requirements.
Behavioral support plan A written document, supplementing the IEP; a proactive action plan to address behavior(s) impeding learning that include positive behavioral interventions, strategies, and supports.
CDE California Department of Education. See http://www.cde.ca.gov/
Functional analysis assessment (FAA) A detailed, individual assessment of the student to determine the function the behavior serves; the basis of a BIP.
Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) An independent nonprofit health care
accreditation organization. JCAHO’s
comprehensive accreditation process evaluates a health care organization’s
compliance with performance standards and other accreditation
requirements. JCAHO accreditation is
recognized nationwide as a symbol of quality that reflects an organization’s
commitment to meeting certain performance standards. JCAHO evaluates and accredits nearly 15,000
health care organizations and programs in the
Individualized education program (IEP) A written educational plan for the student with special needs, developed by a team, including the student if appropriate, the student’s parent or legal guardian, special education teacher, regular education teacher if appropriate, and district representative/school administrator, and others with knowledge or special expertise regarding the child (e.g., child’s therapist or school nurse).
PAI (Protection & Advocacy, Inc.) An independent, private, nonprofit agency authorized under state and federal law to protect and advocate for Californians with disabilities. 29 U.S.C. § 794e; 42 U.S.C. §§ 10801 and 15001 et seq.; Welf. & Inst. Code §§ 4900 et seq.; See www.pai-ca.org
Positive Environment, Network of Trainers (PENT) A CDE positive behavior training program for educators regarding the use of proactive positive strategies. See www.pent.ca.gov
Quality Assurance Process (QAP) CDE Special Education key performance measures. See http://www.cde.ca.gov/sp/se/qa/qap.asp
Restraint Any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the individual’s body that s/he cannot easily remove that restricts freedom of movement or normal access to one’s body.
Seclusion The involuntary confinement of a person alone in a room or an area from which the person is physically prevented from leaving.
SELPA = Special Education Local Planning Area.
California Department of Education (2006a). Mission & Vision, Roles &
Responsibilities. [Online] Retrieved:
California Department of Education (2006b). Quality Assurance Process (QAP). [Online]
Child Welfare League of
Child Welfare League of
Child Welfare League of
Commission On Mental Health (2003). Achieving the Promise: Transforming Mental Health Care in
Frueh, C., Knapp, R., Cusack, K., Grubaugh, A., Sauvageot, J., Cousins, V., et al. (2005). Patients’ Reports of Traumatic or Harmful Experiences Within the Psychiatric Setting. Psychiatric Services, Vol. 56, No. 9, pp. 1123-1133.
Huckshorn, Kevin A. (2006). Re-Designing State Mental Health Policy to Prevent the Use of Seclusion and Restraint. Administration and Policy in Mental Health and Mental Health Services Research, Vol. 33, No. 4, pp. 482.
The Alliance to Prevent Restraint, Aversive Interventions, and Seclusion (AP.R.A.I.S) (2005) In the Name of Treatment, A Parent’s Guide to Protecting Your Child From the Use of Restraint, Aversive Interventions, and Seclusion. [Online] Available: http://www.aprais.org.
Joint Commission on Accreditation of Healthcare
Organizations (2002). Restraint and
Seclusion –Complying with Joint
Commission Standards. Joint Commission Resources, Inc.,
Joint Commission on Accreditation of Healthcare
Organizations (2006-2007) Standards for
Behavioral Healthcare. Joint Commission Resources, Inc.,
Joint Commission on Accreditation of Healthcare
Organizations (2007). Hospital
Accreditation Standards. Joint Commission Resources, Inc.,
Kerr, Mary M., Nelson, Michael C. (2006). Strategies for Addressing Behavior Problems
in the Classroom, Fifth Edition.
Mohr, Wanda K. (2003). Adverse Effects Associated With Physical Restraint. Can J Psychiatry, Vol. 48, No. 5.
Nelson, Michael C. (1997). Effective Use of Time-Out. [Online] Available: http://www.state.ky.us/agencies/behave/homepage.html.
Restraint-Related Deaths in Health and Social Care in the
Stefan, Susan M., Phil M. (2002). Legal and Regulatory
Aspects of Seclusion and Restraint in Mental Health Settings.
Substance Abuse and Mental Health Services Administration (2005). Roadmap to Seclusion and Restraint Free Mental Health Services [Online] Available: http://www.samhsa.gov.
United States General Accounting Office (1999). Report to
Congressional Requesters. Mental Health – Improper Restraint or Seclusion Use
Places People at Risk.
Wright, D.B., Cafferata, G., et al. (2007 Training Manual). The BSP Desk Reference: A Teacher And Behavior Support Team’s Guide To Developing And Evaluating Behavior Support Plans for Behaviors that Interfere with the Learning of Student and/or Peers. [Online] Available: http://www.pent.ca.gov.
 A behavioral intervention plan (BIP) is a written
document that is developed when a student exhibits a serious behavior problem
that significantly interferes with the implementation of the goals and
objectives of the student’s Individualized Education Program (IEP).
 A functional analysis assessment (FAA) is a detailed,
individual assessment of the student to determine the function the behavior
 By regulation, a behavioral emergency report shall
immediately be completed and maintained in the student’s file.
 Anytime a behavioral emergency report is written
regarding a student who does not have a BIP, the school administrator shall,
within two (2) days, schedule an IEP team meeting to review the emergency
report, to determine the necessity for a FAA, and to determine the necessity
for an interim BIPs. The IEP team shall
document the reasons for not conducting an assessment and/or not developing an
 A basket hold restraint involves an adult holding the child from behind by the wrists with the child’s arms crossed in front of the child, often in a seated position. Basket hold restraints are not endorsed by the behavioral restraint training program used by the Special Education Local Planning Area (SELPA).
 Parents shall be notified within one school day
whenever an emergency intervention is used or serious property damage
 Educ. Code § 56344.
 For purposes of this report, behavioral restraint is defined as any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the individual’s body that the individual cannot easily remove that restricts freedom of movement or normal access to one’s body. Health & Safety Code § 1180.1(a), (c), and (d); 42 C.F.R. § 482.13(e)(1)(i)(A).
 For purposes of this report, seclusion is defined as the involuntary confinement of a person alone in a room or an area from which the person is physically prevented from leaving. Health & Safety Code § 1180.1(e); 42 C.F.R. § 482.13(e)(1)(ii).
 Serious injury is defined as any significant impairment of the physical condition as determined by qualified medical personnel, and includes, but is not limited to, burns, lacerations, bone fractures, substantial hematoma, or injuries to internal organs. Health & Safety Code § 1180.1(g).
 42 C.F.R. §§ 482.13(e)(2) and (3); 42 C.F.R. § 483.356(a)(3); Health & Safety Code § 1180.1(a); Joint Commission on Healthcare Accreditation Standards [JC-HAS], PC 12.10 and 12.60 (2007).
 42 C.F.R. § 482.13(e)(9); JC-
 42 C.F.R. §§ 482.13(e) and 483.356(a); Health
& Safety Code §1180.4(k); JC-
 42 C.F.R. §§ 482.13(e)(12) and 483.358(f); JC-HAS, PC 12.90.
 42 C.F.R. §§ 482.13(e)(5) and 483.358(a).
 42 C.F.R. § § 482.13(e)(8)(i) and 483.358(e)(2); JC-
 42 C.F.R. § § 482.13(e)(6) and 483.356(a)(2);
 42 C.F.R. §§ 482.13(e)(15) and 483.364(a); Health
& Safety Code §1180.4(i); JC-
 42 C.F.R. §§ 482.13(f)(1) and 483.376; JC-
 42 C.F.R. § 482.13(f)(2); Health & Safety
Code §§ 1180.2(c) and 1180.3(b)(2); JC-
 42 C.F.R. § 483.370; Health & Safety Code §1180.5(b);
 42 C.F.R. §§ 482.13(e)(16) and 483.358(h); JC-
 Health & Safety Code §§1180.2(d)(1) and 1180.3(c)(1);
 Health & Safety Code §§1180.2(d)(3) and 1180.3(c)(4);
 Stats.1990, c. 959 (A.B. 2586), codified in Educ. Code §§ 56520-56524.
 Aversive interventions are those that people choose not to encounter, including physical or sensory intervention(s) to modify the behavior that causes or reasonably may be expected to cause significant physical harm, serious, foreseeable long term psychological impairment, or obvious repulsion on the part of observers (Kerr, 2006; In the Name of Treatment, 2005).
 Educ. Code § 56523(a).
 Code Regs. tit. 5, §§ 3052 et seq. Serious behavior problems are behaviors which are
self-injurious, assaultive, or cause serious property damage and other severe
behavior problems that are pervasive and maladaptive for which
instructional/behavioral approaches specified in the student’s IEP are found to
 Diana Browning Wright & Harvey B. Gurman, Positive Interventions for Serious Behavior Problems: Best Practices in Implementing the Hughes Bill (A.B. 2586) and the Positive Behavioral Intervention Regulations, California Department of Education (2001).
 Diana Browning Wright & Gail Cafferata, The BSP Desk Reference: A Teacher And Behavior Support Team’s Guide to Developing and Evaluating Behavior Support Plans, California Department of Education (2007), available at http://www.pent.ca.gov/03Training/TrainingTOC/TOC_Forum07.htm.
 Non-public school system includes non-public schools and agencies, such as speech pathology, psychology, and occupational therapy. This is distinguished from private schools which are outside of CDE oversight.
 SELPAs are required to collect and report annually to
the California Department of Education and the Advisory Committee on Special
Education the number of behavioral emergency reports completed within their
 Gov’t Code §§ 6250-6270.
 Only Brian and Eric had FAAs. Aaron was the only student with a BIP. Brian and Eric had behavior support plans. None of the plans incorporated the use of exclusionary time-out, seclusion, or restraint as was routinely used with these children.
 Serious injury means any significant impairment of the
physical condition as determined by qualified medical personnel, and includes,
but is not limited to, burns, lacerations, bone fractures, substantial hematoma,
or injuries to internal organs.
 Planned time-out means use of time-out according to the student’s BIP.
 This information should be kept confidential and not part of the publicly posted data.
 Behavioral Intervention Case Manager is a designated certificated school/district/
or agency staff member(s) or other qualified personnel contracted by the school
district or county office or nonpublic school or agency who as been trained in
behavior analysis with an emphasis on positive behavioral intervention.