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Reece L. Peterson is in the Department of Special Education and Communication Disorders of the University of Nebraska-Lincoln, Lincoln, Nebraska. In this interview he responds to questions about the use of "restraint" and also provides some reference materials for those seeking further information or clarification.

1) First of all, let's be clear about terms---how do YOU define restraint and seclusion?

"Restraint" is defined as a method of restricting an individual's freedom of movement, physical activity or normal access to his or her body. The term is often used to address three different types of restraint strategies: using mechanical devices or objects to restraint a person's movement (handcuffs as one example), using chemicals which have the effect of restraining movement (for example psychotropic medications), or having one or more other person prevent movementby holding another (often called physical restraint).

All three types of restraint might occur in school settings.Mechanical devices have historically been used as assistive devices for children with disabilities. The use of these devices has become controversial when it has appeared that they may have been used to manage behavior rather than compensate for lack of orthopedic control. Although schools do not have a direct role in prescribing medications, they have been criticized for advocating to parents that they seek medication for their children as a tool for controlling their behavior. The use of medications prescribed for behavior problems such as Ritalin have become relatively widespread among school aged children. And finally, schools have also used physical or manual restraint procedures to hold down or restrain children who are out of control. Usually this entails one or more adults using their bodies to hold or control the body of a student, usually when the student has become agitated or "out of control".Most, but not all, of the discussion about restraint centers on the use of physical restraint by adults in the school environment using their bodies to restrain the bodies of students.

"Seclusion" occurs in schools when a student is sent from their normal educational setting to an environment where they are isolated from their peers, and prevented from seeing or hearing normal educational programming. Often this occurs in a small room or booth where the student is alone. The term seclusion is generally not applied to situations where students are sent to a hall, the school office, detention rooms or in-school suspension as these environments often do not prevent access to other people even though they may have some of the characteristics of seclusion such as lack of access to normal educational programming.

2) Is there any data as to how often they are used in the public schools?

Unfortunately, there is no scientifically sound data to know how often restraint or seclusion are used in public school settings. There is anecdotal evidence (newspaper reports, non-scientific survey data, individual teacher reports, etc.) however that both restraint and seclusion are quite widely used in public schools at the present time.

Both of these procedures have a long history of being discussed in professional literature related to the education of students with disabilities as well as in medicine and psychology. As students with more severe disabilities have been "included" in public schools within general education classrooms, it has been speculated that the use of seclusion and restraint has followed into these settings.It has also been speculated that fears about school violence, and school's efforts to take every possible action to reduce violence, or manage it when it does occur, have also fueled the use of these procedures in general public school settings for students who are, or who might become, violent or aggressive.

3) Should not all possible other interventions be tried before seclusions? I would think positive reinforcement, (both primary and secondary) and a token economy, and a myriad of other strategies should be implemented before schools resort to restraint and seclusion?

When asked, virtually all professionals agree that restraint should never be used except in "emergency situations" where there is threat of injury to the student restrained or to others in the environment. A very few guidelines have also included the threat of serious property damage as a justification for its use, but only in emergencies. Unfortunately, there are hints in anecdotal data we have that it is used when emergencies are not occurring, such as to address non compliance.

Seclusion has been viewed as a behavior reduction strategy which is used for more than emergency situations, but has always been regarded in the literature as a consequence which should only be used when other less drastic measure have been tried.

Generally, the professional community would view the use of both restraint and seclusion as a "last resort" when other interventions including those mentioned in the question have been tried and have not been successful. There are long standing and detailed guidelines for the use of each of these procedures which have detailed how they should be used "appropriately" in school settings. There are numerous anecdotal reports (such as newspaper reports of incidents at schools) which would seem to indicate that both restraint and seclusion are not always being used in accord with guidelines. Indications are that they are being used more frequently than might be required if guidelines were being followed.

4) In your mind, how does time out differ from seclusion?

Seclusion can be used as one way to removea student from their access to the reinforcing stimuli for an in appropriate behavior.Thus the phrase "time out from positive reinforcement". However, seclusion can also be used as an environment to "cool down"to think and reflect on behavior, do problem solving, etc., or simply as a punishment in itself. These other motivations for using seclusion have probably become far more widely used in schools than the more behaviorist use of "time out from positive reinforcement".

There are also forms of "time out from positive reinforcement" which can be used without seclusion. In these types of "time out" the student remains in the classroom environment such as a using a time out necklace or time out chair within the classroom environment.

Because of the original association, the term "time out" is often applied to the use of seclusion whether or not the seclusion is designed to address removal from positive reinforcement. It has become a generic term for seclusion in some places. However, a wide array of euphemisms or other terms are used for "seclusion" is various schools, with equally many explanations about why this strategy is being employed.

5) What legal challenges do schools face in trying to use physical restraint in the schools?

Numerous deaths and injuries have occurred when restraints have been used in schools and other types of treatment programs. Given this, schools may very likely have liability for the deaths or injuries that might occur, especially if they were not following appropriate procedures for their use.

Conversely schools that have custody of students in school and serve in loco parentis may also have liability if they do not restrain students who are violent or who might injure themselves or others.

I often refer to two newspaper articles which appeared not long ago in Iowa as an example of how schools can be liable if they do restrain and the student is injured (in this incident, the student died while being restrained), or if they do not restrain and the student is injured (in this incident the student who was not restrained fell in a river and drowned). My conclusion in the NY Times article was that they will be criticized and may have liability either way.

The use of seclusion entails somewhat different issues, there may be legal liability for the inappropriate use of this procedure or when students spend extended time periods in seclusion, thus preventing access to education.

6) I believe there is training for individuals who are dealing with violent, aggressive, assaultive children. Are you aware of these programs?

There are a wide variety of programs which provide training intended for human service professionals for dealing with aggressive or assaultive persons. These now focus primarily on conflict de-escalation but often include some training on physical restraint holds and procedures as well. Many schools obtain and use this training, but there is no requirement that they do so, nor data about the effect of this training on the use or non-use of restraints or seclusion. While I have provided a representative list of some examples of these training programs, no endorsement of these programs should be implied.

7) Can schools suggest parents take their child to a psychiatrist for medication rather than resorting to restraints and seclusion?

While schools can suggest that parents have their children medically evaluated as a part of a comprehensive assessment, and will provide behavioral data to physicians when requested by the parents, when using good professional practice schools should not advocate for parents to obtain medications. Federal and state regulation may also prescribe schools from advocating that parents seek medications for their children related to their behavior. These are viewed as medical decisions between family and physicians in which schools should not interfere.

8) Should not some type of FBA (Functional Behavior Assessment) be done before restraints and seclusion?

Appropriate professional practice would require that a Functional Behavioral Assessment be conducted as soon as there is potential for serious inappropriate behavior, particularly behavior which might be aggressive or violent. However, FBAs are only required by federal policy when a student with a disability has behavior which might violate the school's discipline policies. Most schools only do FBAs for students with disabilities, even though both seclusion and restraint might be used also with non-disabled students.

9) I understand that the NY Times and perhaps also the CEC site either misunderstood or misquoted you. Here it a chance to set the record straight. What did you say and how were you misquoted?

The New York Times article (July 15, 2008) did an adequate job of distilling information from an approximately two hour telephone interview and did not misquote me. The company which provides the CEC email news service which apparently was abstracting the New York Times article attributed statements to me which I did not make and which were not in the New York Times article. Although I have not seen it, I understand that at my request a retraction of that original CEC email announcement has been sent out to the CEC email news recipients.

10) Last tough question, but in my mind, if a school has to resort to physical restraint, should not the child perhaps be in a residential treatment facility or be receiving one to one graduated guidance or some other option?

Public schools have been asked to serve more and more students with serious behavioral disorders and mental health challenges. Many times as students have moved to or been identified in schools as having these challenges,the resources (smaller class sizes, specialized teachers, support staff, and counselors) have not been available to the extent required to be successful with them. For many of these students, we do not have effective treatment options, under the best of circumstances. Unfortunately, we are not under the best of circumstances in schools. There is a special education teacher shortage, and a lack of highly trained educators to work with these types of students which exacerbates the problem. Poorly trained and under resourced programs may be more likely to use restraint and seclusion as basic behavior management strategies rather than the way they are intended to be used.

It is certainly true that a student with a disability whose behavior cannot be managed in a particular setting effectively, and whose behavior might regularly require the use of seclusion or restraint, should be referred to a more restrictive setting (such as self contained classroom, day or residential treatment, or even hospitalization). At the same time parents and the principle of "least restrictive environment" expect that students should be given the chance to be educated in the most normal environment possible. The guidelines for predicting student behavior and making placement decisions are not clear-cut and whichever way schools go in making these decisions they may be criticized and "second guessed".

Very challenging behaviors by students, lack of resources and training, lack of effective treatment options all make this an increasingly difficult situation.

11) What question have I neglected to ask?

What are parent and advocacy positions on this topic?

Several parent advocacy and disability organizations have gone on record as opposing the use of restraint and seclusion, and have vowed to work for the total elimination of their use with children. (For example see the website of the APRAIS coalition at http://aprais.tash.org/ ) In addition, one federal governmental agency SAMHSA has taken a similar position (http://www.samhsa.gov/matrix2/seclusion_SAP.aspx). These organizations would argue that the risks associated with the use of these interventions do not merit their continued use, that these procedures do not have good evidence for their effectiveness, and that these procedures should be opposed because they attack basic human rights and dignity.

Does the federal government have any laws or guidelines which address the use of restraint or seclusion in school settings? What about individual states?

No, the federal government does not have any policy addressing the use of these procedures in schools or educational settings. The federal government does have a law requiring reporting of these procedures in certain hospital and residential treatment settings. States vary tremendously on this issue.Some have policies or regulations, andothers have guidelines or technical assistance documents on these topics for the school use of these procedures.. Several states are in the process of developing or modifying their policy on these topics in response to various incidents of abuse of these procedures or as a result of parent advocacy organizations requests. (I have contributed to two journal articles on this topic recently- see the attached reference list). Given the problems with the apparent over use and abuse of restraint and seclusion which have been emerging over the past few years in schools across the country, more strict and uniform policy requirements for schools on these topics may be needed. More data about and attention to how these procedures are used is certainly warranted.

Web Links Related to Restraint and Seclusion

Alliance for the Safe, Therapeutic & Appropriate Use of Residential Treatment http://cfs.fmhi.usf.edu/cfsnews/2005news/A_START.html,or http://astart.fmhi.usf.edu/AStartDocs/family.pdf

Alliance to Prevent Restraint, Aversive Interventions and Seclusion, www.aprais.org 

American Psychiatric Association.Behavioral Health Groups- Publish
"Learning From Each Other: Success Stories and Ideas for Reducing Restraint/Seclusion in Behavioral Health". This Resource Guide Provides Practical Help in Creating a Culture of Safety, Respect, and Dignity.
http://www.psych.org/Departments/QIPS/PatientSafety/SeclusionandRestraint.aspx

Child Welfare League of America. (2002). Advocacy: Seclusion and restraints: Fact sheet, http://www.cwla.org/advocacy/seclusionrestraints.htm

Coalition Against Institutional Child Abuse, www.caica.org 

Federation of Families for Children's Mental Health, www.ffcmh.org

National Association of Psychiatric Health Systems.Guiding Principles on Restraint and Seclusion for Behavioral Health Services, February 25, 1999.
http://www.naphs.org/News/guidingprinc.html

National Association of State Mental Health Program Directors.(2001). Position statement on seclusion and restraint [On-line]. Available:
http://www.nasmhpd.org/general_files/position_statement/S&R%20position%20statement.Forensic%20Div.%20prop.%20approved%20by%20NASMHPD.07.07.final.pdf.

Substance Abuse Mental Health Services Administration, www.samhsa.gov and specifically http://www.samhsa.gov/Matrix/SAP_seclusion.aspx

Representative Examples of Training Programs that include a component on Physical Restraint

Selected References Related to Restraint and Seclusion

American Academy of Child and Adolescent Psychiatry (2002). Practice parameter for the prevention and management of aggressive behavior in child and adolescent psychiatric institutions, with special reference to seclusion and restraint. Journal of the American Academy of Child and Adolescent Psychiatry, 41(2), 4S-25s.

Day (2002). Examining the Therapeutic Utility of Physical Restraint and Seclusions and Seclusion with Student and Youth: The role of theory and research in practice. American Journal of Orthopsychiatry, 72, 266-278.

Fogt, J.B., & Piripavel, C.M.D. (2002).Positive school-wide interventions for eliminating physical restraint and exclusion.Reclaiming Children and Youth: The Journal of Strength-Based Interventions, 10 (4), 227-232.

George, M.P. (2000) Establishing and promoting disciplinary practices at the building level that ensure safe, effective, and nurturing school environments. In L.M. Bullock & R.A. Gable (Eds.), Positive academic and behavioral supports:Creating safe, effective, and nurturing schools for all students.Reston, VA: Council for Exceptional Children, 11–15.

George, M.P., & George, N.L. (2000). A culture of hope: Fostering success in alternative day school settings. Reaching Today's Youth, 4, 23–27.

George, M.P., White, G.P., & Schlaffer, J.J. (2006). Implementing school-wide change: Lessons from the field.Psychology in the Schools, 44, 41-51.

Haimowitz, S., Urff, J. & Huckshorn, K.(2006) Restraint and Seclusion - A Risk Management Guide.Available: http://www.nasmhpd.org/general_files/publications/ntac_pubs/R-S%20RISK%20MGMT%2010-10-06.pdf

Nelson, C.M. & Rutherford, R. (1983).Timeout revisited: Guidelines for its use in special education. Exceptional Education Quarterly,3, 56-67.

Miller, D.N., George, M.P. & Julie B. Fogt, J. B. (2005).Establishing And Sustaining Research-Based Practices At Centennial School: A Descriptive Case Study Of Systemic Change. Psychology in the Schools, 42(5), 553-557.

Peterson, R.(2002).Physical restraint.Lincoln, NE: Safe and Responsive Schools Project, University of Nebraska-Lincoln.Available: http://www.unl.edu/srs/facts.html

Ryan, J.B., Sanders, S., Katsiyannis, A. & Yell, M.L. (2007). Using timeout effectively in the classroom. Teaching Exceptional Children, 39(4), 60-67

Ryan, J.B. & Peterson, R.L.(2004).Physical restraints in school.Behavioral Disorders, 29(2), 155-169

Ryan, J.B., Peterson, R. & Rozalski, M. (2007). State policies concerning the use of seclusion timeout in schools.Education and Treatment of Children, 30(3), 1-25

Ryan, J.B., Robbins, K., Peterson, R. & Rozalski, M.(2008).Review of State Policies concerning the use of restraint in schools.Manuscript in preparation.

Published September 2, 2008