Behavior Intervention - Seclusion and Restraints

This paper provides an overview of the seclusion and restraint as well as alternative methods of controlling challenging behaviors. Children and adults with disabilities often possess challenging behaviors. Two methods, seclusion and restraint, have consistently been used over the years to control maladaptive behaviors. This paper should not be construed as advocating for any specific method. The methods provided are informational and allows the reader to decide which, if any, methods are appropriate based on individual needs and circumstances.

Keywords Applied Behavior Analysis; Behavior Intervention; Behavior Modification; Behaviorists; Challenging Behavior; Communication; Communication-Based Intervention; Functional Assessment; Punishment; Restraint; Seclusion; Time Out

Overview

Children with developmental disorders, cognitive deficits, autism, and mental retardation often demonstrate challenging behaviors in the school and community environment (Grey & McClean, 2007; Magee & Ellis, 2001; Mueller & Nkosi, 2007). The majority of professionals propose that challenging behaviors are the result of an individual's not being able to influence the actions of others (Weiss, 2005). In other words, many professionals propose that challenging behavior is a primitive form of communicating or influencing others. Thus, individuals with limited communication abilities have to be taught that verbal (speech) or nonverbal (signs) communication can influence others much more effectively. Once communication has been established, the challenging behavior can be replaced with a socially acceptable way of gaining attention, escaping or receiving desired items.

Grey & McClean (2007) state that challenging behaviors could be construed as a manifestation of an underlying psychiatric disorder. In these instances, the medical community often uses pharmacological intervention to manage challenging behaviors (Grey & McClean, 2007; Grey & Hastings 2005).

To eliminate or decrease inappropriate behaviors, one must understand why, when and under what circumstances the behavior occurs. Behaviorists report that with careful observation and data collection one can learn the triggers of inappropriate behaviors and seek interventions to assist in replacing inappropriate with appropriate behaviors (Mueller & Nkosi, 2007; Weiss, 2005).

Whatever the cause of a challenging behavior, a great debate surrounds how to deal with the challenging behavior. This paper will discuss current thoughts on the use of the behavior modification strategies known as restraint and seclusion. These two strategies are used in schools and residential facilities to eliminate challenging behaviors in individuals with disabilities. The use of restraints or seclusion may be necessary to keep the individual from harming him or her self or harming another individual.

Punishment & Problem Behaviors

Behaviorists use the term punishment to describe a method of controlling behavior and promoting learning. Punishment is defined as an aversive consequence immediately following a behavior that leads to a decrease in the behavior (Block, 2000). For example, someone is speeding on the freeway, stopped, and issued a ticket with a large fine; the person is likely to not exceed the speed limit.

If used appropriately, punishment as a form of behavior management can be effective. However, inappropriate use of punishment can lead to abuse and cause additional behavior problems (Block, 2000; Nelson, 1997; Weiss, 2005). When using punishment, one must keep in mind that the focus is not only on the behavior being modified but also on the behavior being learned to replace it. In other words, the individual must learn that actions result in consequences. Carr, et al. (1997) introduces four basic reactions a person can have to a problem behavior:

• Ignore The Problem

• Protect The Individual And Others From Harm

• Restrain The Individual During The Behavior

• Introduce Cues Or Distractions (Carr, Et Al., 1997)

Block (2000) proposed general guidelines to follow if punishment is to be used. The guidelines include:

• Establishing, Posting, And Reviewing Rules And Consequences Prior To Behavior Issues

• Consistently Model And Reinforce Acceptable Behavior

• Remain Calm And In Control Of Emotion

• Be Consistent With Punishment

• When Punishing, Identify The Behavior That Is Being Targeted

Problem behavior can be defined as aggressive acts such as kicking, hitting, or biting; self injurious behavior including hitting or biting oneself; destruction of property and tantrums with yelling, screaming and crying (Carr, et al.,1997; Mueller & Nkosi, 2007; Weiss, 2005). Problem behaviors are thought to be the result of developing adaptive behaviors to gain attention (i.e., banging head). For instance, an individual may learn that communicative attempts do not gain the attention of the caregiver. However, if the individual bangs his or her head against the floor, then the caregiver will immediately provide attention.

Those involved in behavior modification believe that to change the behavior one must identify the purpose of the behavior (Carr, et al., 1997; Mueller & Nkosi, 2007; Weiss, 2005). Once the purpose of the behavior is identified, intervention efforts must include replacing skills that are more appropriate in influencing people. The purpose of the head banging may be to request the presence of the caregiver. Thus, instead of the individual banging his or her head, the individual may be taught to activate a switch that will call the caregiver.

Typically, an adverse behavior does not consist of one inappropriate behavior. Thus, each behavior has to be viewed within the context of the behavior. For instance, controlling the behavior in one environment does not necessarily control it in another. When replacing a behavior, all stakeholders must have an interest and be consistent in altering the behavior. Thus, behavior intervention should change the quality of life for the individual. The goal of behavior modification is to allow the individual to become a part of society versus being secluded or isolated.

Restraint & Seclusion

Definition of Restraint & Seclusion

A restraint can be self-imposed by the individual (self-restraint), physical, or medical. Restraints are also used for safety purposes in cars or amusement park rides to provide safety for the individual. Self-restraint implies that the individual uses emotional control to manage verbal or physical behavior in emotional situations. Physical restraint is defined as controlling an individual by making them helpless or keeping them captive through the use of equipment or seclusion. Medical restraint, physically or pharmacologically, is used and prescribed by a physician to prevent an individual from harming themselves or others. Physical and medical equipment used as restraints consist of items such as straitjackets, wheel chair belts, and safety vests. Pharmacological restraint includes the use of medications to keep an individual sedated.

Any restraint can be dangerous if used improperly. Deaths and other injuries (i.e., broken bones) have been recorded due to the improper use of restraints in schools, hospitals, nursing homes, and private homes (Grey & Hastings, 2005; Protection & Advocacy, 2007; Weiss, 2005). Thus, due to the potential for abuse, restraints are regulated in many environments. Each state and local agency determines the specifics of restraint use. However, states often dictate that once a physician orders a medical restraint the order is only valid for twenty-four hours.

Seclusion can be defined as placing an individual alone in a room or keeping a person in an area in which they cannot leave (Nelson, 1997; Protection and Advocacy, 2007; TASH). As with restraint, seclusion or time-out can be dangerous or can increase inappropriate behavior of the individual. For instance, an individual who is repeatedly placed in isolation may develop additional psychological problems.

Restraints & Seclusion as Methods of Controlling Behavior

The use of restraint or seclusion should be used only in extreme circumstances, primarily when the individual needs protection from serious harm (Nelson, 1997; Protection & Advocacy, 2007; Weiss, 2005). Weiss (2005) has proposed that seclusion and restraint are considered to be aversive interventions. Weiss's viewpoint is that these types of procedures lead to traumatic injury and even death with no supporting research data on their usefulness. He proposes the use of positive behavior reinforcement as an alternative in controlling behavior.

TASH, an organization for individuals with disabilities, families, and advocates, developed a resolution for the use of aversive and restrictive behaviors (i.e., restraint or seclusion). The premise of the resolution is to advocate against the use of controlling behaviors through the use of restraints or seclusion. TASH does recognize the need for brief physical restraint for the purpose of protecting the individual. However, TASH is clear that restraint or seclusion in these circumstances is a safety measure not an intervention method.

The use of seclusion or restraint is considered a punishment for an aversive behavior. Chance (1998) stated that punishment could occur only if it is a consequence for a behavior that ultimately decreases the behavior. Proper use of punishment, regardless of method, should weaken the behavior and not the person. If punishment weakens the person then abuse occurs. Thus the use of seclusion or restraint should be used to decrease the frequency of the behavior not as a punishment for behavior.

For example, seclusion could also be known as time out. Time out involves removing the person from a situation in which the behavior occurs and placing the individual in an environment that provides limited reinforcement (Cook, Klein, Tessier & Daley, 2004; Kirk & Gallagher, 1986; Nelson, 1997). The amount of time in time out is unique to and depends on the child and behavior. For example, a small child might only need to be in time-out for one minute. However, a child with psychiatric problem or incarcerated youth may require longer or shortened periods of time.

Time out does not necessarily mean that the individual has to be placed into isolation or be secluded. Time out procedures can occur along a continuum of restriction. Time out could mean that a child is made to return to his or her desk for causing a disruption in the learning process for the learner or the classroom. In another instance the behavior may become disruptive to the point where the individual has to be placed in a separate environment. Time out is considered to be an aversive procedure in controlling a behavior (Nelson, 1997).

Restraints can be considered physical punishment. The purpose of physical punishment is to reduce the behavior by providing brief and noninjurious contact with the individual (for example, holding an individual's arms down during a tantrum to inhibit the individual from poking his or her eyes.) Restraint should not cause long-lasting discomfort or damage. Behaviorists view restraint as a form of punishment only after all others interventions have failed. Individuals who are self-injurious to the extent of causing severe bodily harm to self or others or to property are most often placed in restraints or seclusion.

Criticisms & Advantages of Restraints or Seclusion

The literature is extensive in discussing the criticisms of using restraints or seclusion across disability groups (Block, 2000; Nelson, 1997; Weiss, 2005). The most cited criticism is inappropriate use of the punishment. All stakeholders should remember that punishment is designed to reduce behaviors, not harm a person.

Another criticism is the ethical or moral concerns of using restraints or seclusion as a form of punishment. In general, society often frowns on the use of punishment with small children or with individuals with disabilities. However, many people find that punishment can be justified in order to protect the individual or others from harm. For instance, society would not tolerate allowing a child to poke his eyes out and blind himself. In this case, the use of physical restraint such as a securing the arms may be justified for the welfare of the individual. While objections are raised, most will agree that if all avenues have been exhausted and that the alternative is worse than the punishment the use of restraints or seclusion can be used.

Punishment can also evoke a flight or fight response. Punishment causes the emotional response to avoid the punishment or to fight the individual trying to provide the punishment. Many view this response as a basic human survival skill. In the use of restraints or seclusion, the punishment causes this basic emotional response to occur. When this emotional response occurs, the individual either attempts to flee the punishment or stand his or her ground and fight the punishment.

In some instances, the individual could actually interpret restraint as a positive versus negative reinforcement. In other words, the individual may demonstrate the challenging behavior in order to gain attention and cause interaction. Also, when being placed in restraint or seclusion the individual has escaped the task or situation by not responding to the "request" of the individual (Magee & Ellis, 2001).

The literature is limited in the advantages of the use of restraint or seclusion; the most cited advantage is to only to protect the individual from harm. Proponents of restraints or seclusion state that, used appropriately, either procedure may allow the individual the opportunity to learn control. However, this has not been substantiated in the research literature.

Non-Aversive Methods of Controlling Behaviors

Non-Aversive methods of controlling behaviors typically include some type of behavior modification program (Carr et al, 1997; Chance, 1998; Weiss, 2005). Two of the available methods for decreasing inappropriate behavior are discussed below. However, many additional intervention approaches are available.

The first method is applied behavior analysis (ABA) which is an evidence based approach to controlling challenging behaviors in individuals with a various disabilities. The second approach is centered on using a communication-based approach to control problem behavior and is also supported in the literature. While not intended to summarize all of the available literature, both approaches contain the basic fundamentals of the various approaches.

Applied Behavior Analysis (ABA)

The most widely used method in special education is applied behavior analysis (ABA) or behavior modification (Chance, 1998; Emerson, 2001; Grey & McClean, 2007; Grey & Hastings, 2005). ABA can be defined as arranging the environment to produce desired outcomes. This approach is considered to be efficacious and evidence based in the research literature and demonstrates how the environment affects learning (Chance, 1998; Emerson, 2001; Grey & McClean, 2007; Grey & Hastings, 2005). ABA has been used across disabilities (i.e., autism, mental retardation, etc.) to increase desirable behaviors while decreasing undesirable ones and teaching new behaviors.

A basic outline of the approach is to specify exactly what is to be learned by using task analysis. Task analysis requires large skills to be broken down into smaller sequenced steps. The skill is taught from easiest to hardest. For example, in learning to brush teeth, the following skills are involved:

• Pick Up The Toothbrush

• Wet The Toothbrush

• Take The Cap Off The Tube Of Toothpaste

• Put Toothpaste On The Toothbrush

• Brush The Top Teeth

• Brush The Lower Teeth

• Spit

• Rinse The Brush

• Fill A Cup With Water

• Rinse The Mouth

• Spit

• Wipe The Mouth

• Replace The Cap On The Tube Of Toothpaste

Obviously, each task could be broken down into smaller tasks. For example, to pick up the toothbrush one must know what a toothbrush is and where it is located. Task analysis is dependent on the individual's knowledgebase and the educator's ability to adapt the teaching of the task to the appropriate level of learning.

The second major component of ABA is to continuously and directly measure skills. This allows immediate adjustment in the daily teaching methods. Additionally, a well-designed behavior modification approach can be easily used by everyone, require repeated performance of target behavior, provide positive and immediate feedback though reinforcement, fade cues and prompts as the skill develops; and, develop methods to generalize the learned behavior to other environments.

A major concern with ABA is the number of specialists available to provide the intervention technique (Grey & McClean, 2007). Due to the lack of specialists, there are many individuals who use the strategies of ABA but who have not been appropriately trained. The lack of specific training leads to misuse and abuse and decreases the effectiveness of the method.

Communication Based Intervention

Communication is a human behavior that allows an individual to express thoughts, emotions and wants/needs. In communication based intervention programs, challenging behaviors are thought to be the result of an individual not being able to communicate wants, desires and/or needs. Thus, communication-based intervention can be defined as decreasing inappropriate behaviors by teaching an individual with challenging behaviors appropriate ways to express thoughts, emotions and want/needs (Carr, et al., 1997).

There have been many investigations into the link of an underdeveloped communication system and problem behaviors. In normal child development, many report that once an individual becomes a better communicator challenging behaviors decrease naturally (Aram, Ekelman, & Nation, 1984; Carr, et al., 1997; Emerson, 2001; Grey & Hastings, 2005). However, many children and adults with developmental disabilities do not become successful communicators. Communicative attempts that influence behavior can be to gain attention, escape from a task or situation, or attain an object such as food, toys, or activity (Carr, et al., 1997). When an individual is unable to verbally or nonverbally communicate choices or needs then challenging behavior often serves as a form of communication.

Communication-based approaches attempt to influence actions. In order to replace inappropriate actions with appropriate actions an assessment and intervention program must be completed. A functional assessment is conducted through interviews and observations of the individual to understand the communicative purpose of the challenging behavior. The functional assessment describes, categorizes, and verifies the purpose of the challenging behavior (Carr, et al., 1997).

The intervention phase of a communication based approach consists of building rapport through interactions with the individual. Carr and colleagues felt that this is an essential step in the intervention phase, as the speaker and listener must want to interact with each other. Once rapport has been established, the focus of intervention becomes finding a communication form and the appropriate context for communication. Gradually, one replaces the challenging behavior with acceptable communication in natural contexts. The last step in a communication-based approach is to generalize and maintain the behavior in all environments and contexts.

Viewpoints

Many discussions have been held about the most effective way to intervene with individuals who have challenging behaviors. This paper has discussed contemporary viewpoints on the use of the behavior modification strategies known as restraint and seclusion.

Society, professionals and non-professionals basically agree that circumstances do exist in which these two strategies may be employed. Specifically, there is agreement that the use of either procedure may be necessary in cases where the individual could cause harm to himself. For example, allowing an individual to chew his or her fingertips off would not be acceptable. Thus, for safety purposes the individual may need to be temporarily restrained or secluded.

The use of restraint and seclusion should not be used as a behavior modification technique but as a safety technique. Restraint and seclusion have here been defined in general terms, advantages and disadvantages have been offered, and alternative methods of influencing behavior have been proposed. Applied behavior analysis and communication-based intervention offer an alternative to managing challenging behavior.

Terms & Concepts

Applied Behavior Analysis (ABA): ABA is process of observing and modifying behavior by manipulating the environment.

Aversive Behaviors: Aversive behaviors are negative behaviors which cause a behavior change.

Behavior Modification: Behavior modification is a process of changing or extinguishing a behavior by using positive and negative reinforcement.

Challenging Behavior: Challenging behavior is a behavior that is socially or culturally unacceptable. Challenging behaviors can be harmful to the person or to other individuals.

Communication: Communication is a verbal or nonverbal way to exchange information or influence the actions of others.

Communication-Based Intervention: Communication-based intervention can be defined as decreasing inappropriate behaviors by teaching an individual with challenging behaviors appropriate ways to express thoughts, emotions, and want/needs (Carr, et al., 1997).

Fight or Flight Response: Fight or flight response is a theory that describes an emotional response to stress. Some think of it as being a primitive survival skill. It is also called the acute stress response.

Positive Reinforcement: Positive reinforcement is provided to increase a behavior by adding something tangible for the learner. For example, a child is learning to say the word "more" each time the child says more then he or she is provided with a piece of candy.

Punishment: Punishment is causing something unpleasant to happen to an individual in response to an inappropriate action.

Restraint: A restraint can be self-imposed by the individual (self-restraint), physical, or medical. The primary purpose is to inhibit the movement or action of an individual.

Seclusion: Seclusion means to place an individual alone in a room or keeping a person in an area in which they cannot leave. In some instances, this term can also be used synonymously with time-out.

Self-Injury: Self-injury is and injury that is intentionally caused by the individual upon his or her self.

Time Out: Time out is a procedure that is an alternative to physical punishment.

Bibliography

Arm, D., Ekelman, B. & Nation, J. (1984). Preschoolers with language disorders: 10 years later. Journal of Speech and Hearing Research, 27, 232-244.

Block, M. (2000). A teacher's guide to including students with disabilities in general physical education. (2nd ed.) Baltimore, MD: Paul Brookes Publishing.

Carr, L., Levin, L., McConnachie, G., Carlson, J., Kemp, D., & Smith, C. (1997). Communication based intervention for problem behavior: A user's guide for producing positive change. Baltimore: Paul Brookes Publishing.

Chance, P. (1998). First course in applied behavior analysis. CA: Brooks/Cole Publishing Company.

Cook, R. Klein, M., Tessier, A. & Daley, S. (2004). Adapting early childhood curricula for children in inclusive settings. New Jersey: Pearson Education, Inc.

Dix, P., & Bennett, T. (2013). Can schools justify the use of physical force?. Times Educational Supplement, (5060), 38-39. Retrieved December 15, 2013, from EBSCO Online Database Education Research Complete. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=90277980&site=ehost-live

Emerson, E. (2001). Challenging behavior: Analysis and intervention in people with severe intellectual disabilities. (2nd ed.). Cambridge: Cambridge University Press.

Freeman, J., & Sugai, G. (2013). Recent changes in state policies and legislation regarding restraint or seclusion. Exceptional Children, 79, 427-438. Retrieved December 15, 2013, from EBSCO Online Database Education Research Complete. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=88266506&site=ehost-live

Grey, I. & Hastings, R. (2005). Evidence based practice in the treatment of behavior disorders in intellectual disability. Current Opinion in Psychiatry, 18, 469-475.

Grey, I. & McClean, B. (2007). Service user outcomes of staff training in positive behavior support using person-focused training: A control group study. Journal of Applied Research in Intellectual Disabilities, 20, 6-15.

Kirk, S. & Gallagher, J. (1986). Educating exceptional children. Boston: Houghton Mifflin Company.

Magee, S. & Ellis, J. (2001). The detrimental effects of physical restraint as a consequence for inappropriate classroom behavior. Journal of Applied Behavior Analysis, 34, 501-504.

Mueller, M. & Nkosi, A. (2007). State of the science in the assessment and management of severe behavior problems in school settings: Behavior analytic consultation to schools. International Journal of Behavioral Consultation and Therapy, 3 , 176-202. Retrieved July 13, 2007, from Behavior Analyst Online http://www.ijbct.com/IJBCT-3-2.pdf

Nelson, M. (1997). Effective use of time-out. Retrieved July 10, 2007, from http://www.state.ky.us/agencies/behave/homepage.html

Protection and Advocacy, Inc. (2007). Restraint and seclusion in California schools: A failinggrade. Retrieved July 15, 2007, from http://209.85.165.104/search?q=cache:WTPuVT0BvMMJ:www.pai-ca.org/pubs/702301.pdf+seclusion+as+a+method+to+modify+behavior&hl=en&ct=clnk&cd=5&gl=us&client=netscape-pp

TASH (n.d.). TASH resolution opposing the use of aversive and restrictive procedures. Retrieved July 15, 2007, from http://www.tash.org/IRR/resolutions/res02aversive.htm

Vaillancourt, K., & Klotz, M. (2012). Seclusion and restraint: Federal updates and advocacy opportunities. Communique (0164775X), 41, 1-27. Retrieved December 15, 2013, from EBSCO Online Database Education Research Complete. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=83291111&site=ehost-live

Weiss, N. (2005). Eliminating the use of behavioral techniques that are cruel and dehumanizing. The Exceptional Parent, 35 , 42-43.

Suggested Reading

Arm, D., Ekelman, B. & Nation, J. (1984). Preschoolers with language disorders: 10 years later. Journal of Speech and Hearing Research, 27, 232-244.

Carr, L., Levin, L., McConnachie, G., Carlson, J., Kemp, D., & Smith, C. (1997). Communication based intervention for problem behavior: A user's guide for producing positive change. Baltimore: Paul Brookes Publishing.

Chance, P. (1998). First course in applied behavior analysis. CA: Brooks/Cole Publishing Company.

Magee, S. & Ellis, J. (2001). The detrimental effects of physical restraint as a consequence for inappropriate classroom behavior. Journal of Applied Behavior Analysis, 34, 501-504.

Mohr, Wanda K. (2003). Adverse effects associated with physical restraint. Canadian Journal of Psychiatry, 48 ,

Mueller, M. & Nkosi, A. (2007). State of the science in the assessment and management of severe behavior problems in school settings: Behavior analytic consultation to schools. International Journal of Behavioral Consultation and Therapy, 3 , 176-202. Retrieved July 13, 2007, from Behavior Analyst Online http://www.ijbct.com/IJBCT-3-2.pdf

Protection and Advocacy (2007). Restraint and seclusion in California schools: A failing grade. Retrieved July 15, 2007, from http://209.85.165.104/search?q=cache:WTPuVT0BvMMJ:www.pai-ca.org/pubs/702301.pdf+seclusion+as+a+method+to+modify+behavior&hl=en&ct=clnk&cd=5&gl=us&client=netscape-pp

Stefan, S. & Phil, M. (2002). Legal and Regulatory Aspects of Seclusion and Restraint in Mental Health Settings. National Technical Assistance Center for State Mental Health Planning.

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. Retrieved July 10, 2007, from: http://www.aprais.org