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Face -down restraints

Hi Everyone:

The Alberta Association of Services to Children and Families has recently chosen to abolish the use of face down restraints, believing that they constitute a "behavior management practice that has been found to be dangerous and life threatening". I'm curious to know if other provinces/states/countries have implemented similar measures and, if so, how individual agencies have adjusted their practice, and their training, to accommodate this.

Thanks.
Gord Robinson,
Calgary
...


Replying to Gord Robinson's query of yesterday ...

In our agency we abolished them (face downs) and all staff retrained with one person and two person "side facing" restraints as an alternative option.

Neil
...

Hi

In Ontario, we have not had face down restraints in a while. PMAB, UMAB and the likes have developed face up restraints that I have heard are very safe and workable (I do not do restraints out of principle ... and have never needed to). They involve 2 staff and are a little more intimate than other restraints I have seen. It is hard to describe the technique in words but basically, the client's arms are bent up around the side of their head and entwined with the staffs arm to create a spit barrier/head hold, and the rest of the body is held in place with the staff's hips and legs on top of the clients ... like they are laying beside and partially on the youth.

See what I mean about hard to explain!

I would agree that the face down restraints are much easier to initiate than the face up, but due to the recent deaths of youth in the face down, this is the way it has to be I guess.

I have a great technique ... use words not hands. has worked for me for over 10 years!

Does that answer your question?
Laura
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Hi, Gord,

 I am from Alberta and I wholly embrace the idea of no restraints at all.

Joyce
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Mr. Robinson,

Please find the attached memo which outlines the Best Practices in Behavior Management project findings on the use of one-person restraints.

Lloyd Bullard
...

Hi Gord

I work in a residential care home in Edinburgh, Scotland. Edinburgh Council Social Work Department have decided to scrap Prone restraint ( face down ) for safety reasons for young people. I also believe that CALM ( Crisis & Aggression, Limitation Management) have put in place other safer techniques such as the two person figure four hold. This allows young people to keep their dignity as well as ensuring a safer restraint. This also allows staff to seat the young person down on to a sofa rather than face down on a floor.

Kind regards
Jane
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Hi Gord 
There have been a number of changes to legislation as it relates to the use of physical restraints within the province of Ontario, in part as a result of a number of deaths of children/ youth who died while in prone restraints. Following a number of reviews and inquests, the Ministry of Community, Family and Children's Services made these legislative changes. This includes all physical restraints must now be reported as serious occurrences if they take place in license residential setting. All direct care staff within residential settings must now be trained in a crisis management program that is approved by the Ministry. As well they must be
informed of the legislation, any changes or amendments , agency policies (within 30 of hire). There are crisis management programs included in the 6 approved by the Ministry that have prone restraints but the legislation now includes a statement that the child's condition must be continually monitored and assessed and when there is a risk that the physical restraint itself will endanger the health or safety of the resident it must be stopped.

I am an instructor in a crisis management program called PMAB, "The Prevention and Management of Aggressive Behaviour." Up until approximately 1 year ago this program included teaching participants how to implement a face down restraint. This technique has been removed due to risk such a position creates for many people. Prone positions can compromise a persons
ability to breathe and this can be further compromised if the person has any of the following medical conditions , respiratory or heart problems, obesity and several others. PMAB promotes that if a child ends up in a prone position, staff must quickly transition the child /youth to an up-right or face up position as quickly as possible due to these risks. I hope this is helpful.

Kim Stevens
Day Treatment ,
Intensive Services Supervisor
Vanier
...

I was interested to read the recent mailings with regard to many issues that are associated with the use, or not, of face down (prone) restraints. I am employed as a Professional Development Manager within a large Local Authority in the UK (Surrey). I am an instructor of the 'Positive Options' for the management of actual and potential aggression model of physical intervention, and am also responsible for co-ordination of county-wide training in this model, and involvement in policy and planning matters with
regard to the use of restrictive physical interventions with children & young people.

The risks associated with prone restraint are becoming increasingly documented and evident to us all, and last year the UK Government, through the Departments of Health and Education& Skills, issued joint guidance on the use of restrictive physical interventions. The elevated level of risk associated with floor restraints, and of using techniques which involve extending or flexing joints or putting pressure on the joints was emphasised.

I am particularly interested to pursue the thread emerging of organisations and authorities banning completely all prone restraints. How does one do this and yet still keep all concerned in a difficult or dangerous situation safe? Whilst I would agree entirely that it is a highly desirable outcome, I believe, based upon my own experience of twelve years as a practitioner working with children and young people who display difficult or aggressive behaviour in a variety of settings, that the subject of the intervention itself will on occasions take the restraint to the floor themselves, often in a very dynamic movement. This might be an attempt at self harm , or a determined attempt to evade the efforts of staff to manage their behaviour.

Is it not the case that in prohibiting staff from managing such an eventuality, rather than advising against its use if at all possible,
service users, staff and third parties might be put at risk or alternatively that service users could be given a tool (attempting to take the restraint to the floor) by which to force carers to disengage?

The 'Positive Options' model of physical intervention pays particular regard to the risks associated with floor restraints, and in particular that of positional asphyxia, and does not advocate the use of floor restraints but acknowledges that some situations will go to the floor, generally led by the client, and that these then should be controlled (the descent) and managed safely whilst at the safe time minimising the risk to staff and client alike.

I would welcome the thoughts of others on this matter.

Darryl Freeman
Professional Development Manager
Residential Care & Support Unit
Surrey Children's Service

If anyone is interested in knowing more about the Positive Options model, one of its originators, Chris Stirling, can be contacted
HERE. The joint guidance issued by the DoH/DfES can be found at http://www.dfes.gov.uk/sen/documents/PI_Guidance.pdf
...

As one of the CYC's that has been hit, kicked, hair pulled, and spit on, I truly have to wonder where the line gets drawn. I haven't been in the field for very long (2 years), but I have experienced a fairly wide variety of kids. The tough question about face down restraints is:

Even though it's against the rules (and I understand it is in many agencies), where is the line drawn to protect yourself as a person? And to what extent do I have to expect consequence? I would far rather talk a child/youth down, but sometimes that isn't
realistic ... at least when they are trying to hurt themselves and others (usually the worker). How do you provide quality care in environments where the youth are volatile and the worker has to be concerned about what method they use to keep that volatility under control — even when the rules in place may be to the detriment of at least one party involved. And what about those times (even though they really aren't supposed to happen) you are left alone? Here in Lethbridge there is a restraint system that is very common, BUT — all but a few need two people.

Just some things to think about.

Jami
Lethbridge, Alberta
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Sadly, it seems that some have become much more concerned with appearing 'politically correct' than appearing to have any semblance of common sense or real concern for clients. This 'issue' is a perfect example of that.

As one who has been teaching and performing manual restraints for over 20 years I can tell you that there is no increase in safety for a typical client when using a face up restraint. The only exception to that would be for pregnant females or clients with severe asthma. Also, many clients that I've talked with regarding the face up restraints have complained about feeling very vulnerable being hit or otherwise injured in the stomach region. Another complaint I've heard involved some panic reactions from
sexually abused clients who felt that the face up restraint was much like a replay of their abuse experiences.

Staff who use face up vs. face down restraints complain of being continually spat upon and bitten. Women staff members who do the face up restraints have had their breasts bitten very seriously.

There are two primary concerns with face down restraints:

* Any weight from staff members on the upper back/torso region of the client's body can compress the rib cage and make it difficult or impossible for the client to breath. It is completely unnecessary for weight to be used in this manner at all and, therefore, is a training issue and not a fault of prone techniques en mass. In addition, if weight is used on the client's chest area during a 'face up' restraint, the exact same problems
exist.

* If the staff members are not sure to place the client in a safe area for the restraint, the client could suffocate due to being restrained on overly soft surfaces like beds or pillows. Again, this is a training and quality of care issue for supervisors and administrators rather than an indictment of prone techniques.

I have either been involved in or supervised hundreds of prone restraints during my career. There is absolutely nothing inherently evil or dangerous about well thought out, safe, appropriately applied prone restraints. There is danger in any intervention, however, that is applied by careless or angry staff who are supervised by incompetent or uninvolved supervisors.

But, rather than deal with any real concerns as a field we will allow the bureaucrats to take over the issue yet again. Those who have no experience and will never have to deal with the consequences of their decisions will dictate to all of us how things must be done. Business as usual.

Jeff Glass
...

Recent threads: Touching. Hugging. Restraints, face-up or face-down, as discussed so perceptively and sensitively by Jeff Glass in his message yesterday. Note his final paragraph, quoted here: "But, rather than deal with any real concerns as a field we will allow the bureaucrats to take over the issue yet again. Those who have no experience and will never have to deal with the consequences of their decisions will dictate to all of us how things must be done. Business as usual."

My reaction: Is it time for us to think about putting touching and related issues--including the appropriate use of restraints--where we clearly have both experience and expertise (e.g., reread Jeff's carefully nuanced remarks) high on our social action/policy agenda for the field, perhaps with the guidance of understanding attorneys and in concert with like-minded educators and other mental health professionals? I think so!

Jerry Beker
...

Restraints. When the concept of face down, or up restraints are being addressed here I have not read if this is physical or mechanical in type. If mechanical are they hard or soft. If mechanical is it legs and hands, 5 point or what. I would say if you need to retrain get the mechanical devices on and then get off. Mechanical or soft Velcro restraints are much more safe than the brute force kinda thing. Also once the restraints are applied one can go about the working the youth through the process. I would refer you to some one like Steve Cable who knows much more about this than I. I would like to see the Policy and Procedures of the various agencies concerning restraints. I would venture to say that the face up restraint may come out of the hospital setting and the face down method from a more corrections environment. Hospital settings can use chemical/medication PRNs where most
corrections settings have very limited access to these forms of interventions. Again, I would value hearing from those who do the training in both settings.

I am the manager of a 20 bed proctor program so we are not able to utilize restraints, well almost never. Even so all foster parents and staff are trained in CPI and the Oregon Intervention models.

Larry
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