A Closer Look: Seclusion and Restraint Practices in Children's Residential Facilities in Ohio

A Publication of the Ohio Legal Rights Service
April 2002

Table of Contents

• Letter from the Director
• Introduction
• Findings
• Follow-up
• Benchmarks
• Summary Statements
• Effects of Restraints on Children
• A Physician's Thoughts
• Recommendations
• About OLRS and Funding for This Publication

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Copyright © 2002 Ohio Legal Rights Service. All rights reserved.

Letter from the Director

Dear Colleagues:

Ohio Legal Rights Service (OLRS) is Ohio's federally mandated and state designated Protection and Advocacy system. With increasing accountability being imposed on every front by Congress, state legislators and policymakers, the use of data to support policy decisions in the human service arena has become critical. Since the mission of OLRS is to protect and advocate the human, civil, and legal rights of people with disabilities, Major Unusual Incident (MUI) reports seemed an excellent place to begin this data collection.

Within the past two years, OLRS has created a data collection system to monitor MUI reports submitted by Licensed Children's Residential Facilities to the Ohio Department of Mental Health. This data system has enabled OLRS to develop a rich data base that provides us the ability to track statewide trends and patterns and fulfill our obligation to monitor health and safety, remedy systemic problems, and provide assistance.

This document, "A Closer Look: Seclusion and Restraint Practices in Children's Residential Facilities in Ohio," is one of a series of publications based on the OLRS MUI data base. We are trying to portray an accurate and meaningful picture of activities and practices in facilities as reflected through an analysis of the MUI data. With our data base, OLRS is now able to recognize issues and concerns and validate those concerns with empirical data. We can also validate facility improvements and the best practices. Contrary to popular belief, OLRS recognizes how important it is to deliver positive information while we are documenting problems.

It is my hope that this document and the other "Closer Look" documents are helpful to you and the children in residential facilities.

Sincerely,

Carolyn S. Knight, Executive Director
Ohio Legal Rights Service

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Introduction

A review of the Ohio Legal Rights Service (OLRS) Major Unusual Incident (MUI) data base prompted OLRS to take a Closer Look at Seclusion and Restraint practices at Ohio's Mental Health Children's Residential Facilities.

In 2000, OLRS staff reviewed Seclusion and Restraint logs from four residential facilities. The four facilities housed a total of 226 children. The following seclusion and restraint information was recorded:

• Number of seclusion and restraint episodes in a one month time frame.
• Types of restraints used — physical, mechanical, chemical, or seclusion.
• Duration of each episode.

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Findings

OLRS surveyors found:

• All four facilities used physical restraint and seclusion.
• One facility used mechanical restraint or a combination of mechanical and chemical restraint.
• Of the 226 children in the four facilities at the time of the review, 41 per cent of them were restrained or secluded in the previous 30 days.
• The most one child was restrained during the one month time study was 30 times for a total of 626 minutes.
• Effective April 16, 2001, mechanical restraints are prohibited by the Ohio Department of Mental Health.
• Chemical Restraint is defined by the Ohio Department of Mental Health as "a drug or medication that is used as a restraint to control behavior or restrict the individual's freedom of movement that is not a standard treatment for the individual's medical or psychological condition." Ohio Administrative Code 5122-26-16(D)(2)(f).

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Follow-up

One year after OLRS' initial review of the four facilities, a follow-up survey was conducted to document the number of restraint episodes. It was found that there was a 52 per cent decrease in restraint use for these facilities. Table 2 shows these decreases.

This decrease could be attributed to:

• Increased attention by federal policymakers after reported deaths due to restraint.
• New Federal rules and Ohio Department of Mental Health rules regarding the use of seclusion and restraint.
• Improved training with an emphasis on de-escalation techniques.

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Benchmarks

In Ohio there are 18 Children's Residential Facilities that have 10 or more beds that are licensed by the Ohio Department of Mental Health. Staff at OLRS contacted these 18 facilities and requested that they forward seclusion and restraint logs for either the month of May or June of 2001. Table 3 outlines the findings from these 18 facilities.

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Summary Statements

• This informal survey found that children in Ohio's residential facilities are being secluded and restrained on a daily basis.
• Seventeen of the 18 facilities that have 10 or more beds seclude and restrain children.
• The average seclusion and restraint across all facilities lasted 12.3 minutes with a range of 5.2 minutes to 75.5 minutes.
• Assuming that the one month snapshot that OLRS took is a typical month, there will be over 9000 seclusion and restraint episodes in these 18 residential facilities over the course of a year.
• The average seclusion and restraint time in one facility for the month of May in 2001 was over 75 minutes.
• One facility with 12 beds had 172 seclusion and restraints in a one month time frame in 2001.
• There was a 52 per cent decrease in the use of seclusion and restraint over the past year in the four targeted facilities reviewed by OLRS in 2000 and 2001.
• Few facilities have a policy against the use of seclusion and restraint.
• Some facilities have written policies to reduce the use of seclusion and restraint.

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Effects of Restraints on Children

• Children are re-traumatized by the experience.
• Children die while in restraints.
• Children are injured—rug burns to broken bones.
• Children lose trust for staff and lose their sense of safety.
• Seclusion and Restraints scare children and make them more angry.
• It is embarrassing to be secluded and restrained.

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A Physician's Thoughts

These seclusion and restraint data were forwarded to Dr. Ellen L. Bassuk, MD of Boston, Massachusetts.
Dr. Bassuk is President of The Better Homes Foundation and is Associate Professor of Psychiatry, Harvard Medical School.

• "It is also important to acknowledge that at times children are out of control, but the providers must fully understand this response, its triggers etc. and determine ways to address this behavior that does not undermine a child's sense of safety."
• "Seclusion and restraint in a child with such a severe trauma history can only be severely retraumatizing and may have become one of the triggers for the persistence of the behaviors."
• "Stripping the patient, repeated mechanical and then physical restraints, and intramuscular medication indicate a unit that is not trauma sensitive."

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Recommendations

• Develop an institutional culture that views seclusion and restraint as a treatment failure.
• Develop policies for avoiding the use of seclusion and restraint.
• Provide on-going seclusion and restraint reduction training and include children as part of the training team to enhance staff's understanding of a child's perspective of seclusion and restraint.
• Develop alternatives to seclusion and restraint.
• Never restrain a child who is a victim of trauma. Research shows that 70 to 95 per cent of children in facilities have histories of violence in their lives.
• Develop quality control measures to develop a better understanding of when seclusion and restraint are used, by which staff, in what situations, length of restraint, and during which shifts.
• Each child should be assessed by a skilled trauma specialist so that trauma-specific programming can be developed.
• Ohio Department of Mental Health should enforce state regulations on the use of seclusion and restraint.

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About OLRS and Funding for This Publication

This publication was produced by the Ohio Legal Rights Service, 50 West Broad Street, Suite 1400, Columbus, Ohio 43215-5923. Telephone 614-466-7264/800-282-9181 TTY 614-728-2553/800-858-3542 Web site: http://olrs.ohio.gov

Ohio Legal Rights Service and this publication are funded in part by grants under the following federal laws:

• Developmental Disabilities Assistance (DD) Act, administered by the Administration for Children and Families;
• Protection and Advocacy for Mentally Ill Individuals Act (PAIMI), administered by the Center for Mental Health Services of the U.S. Department of Human Services; and the
• Rehabilitation Act of 1973 as amended, administered by the Office of Education Services and the Rehabilitation Services Administration of the U.S. Department of Education.

Ohio Legal Rights Service does not discriminate in provision of service or employment because of race, color, religion, sex, sexual orientation, national origin, military service, disability, or age.

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