Saturday, January 1, 2011

When Restraint Should Be "Prescription Only"

Those of us who from time to time speak out against the use of inappropriate physical restraint of children can expect certain criticisms in response. We are told that we are na├»ve, inexperienced, professionally untrained, and that physical restraint is essential to protect adults from wild children, children from each other, and children from themselves. We even hear from a very small proportion of clinical psychologists and social workers that when children are upset and out of control, physical restraint has a beneficial therapeutic effect. Some therapists recommend to parents that they use “take-downs” and physical restraint in order to ensure the obedience of their children.

There is a tiny grain of truth in these criticisms. It is, of course, correct to say that there may be times with any child when physical restraint is the best and quickest way to prevent some sort of disaster, and no one has said otherwise. (The same is true for adults--- what if you see that your friend is about to walk into an unmarked glass door?) But the criticisms also contain many grains of falsehood, especially with respect to a speculated therapeutic effect of restraint, an outcome which is unsupported by any systematic evidence, in spite of the publication of several papers that make related claims.

So, why do people so easily accept the idea that physical restraint is a method of dealing with children that should be left unregulated? It’s possible that part of the thinking about this comes from the experiences most of us have had as parents or caregivers for infants and toddlers. Almost anyone who has cared for a toddler will have on one or more occasions picked up that resistant little person and carried her away for a diaper change (whoever said babies cry to have their diapers changed?!), a bath, a nap-- whatever needs to be done and is unwanted by little Ms. or Mr. Autonomy Stage. When we think about an older child who is resistant or aggressive, it’s easy for us to imagine the situation as parallel to what we’ve done ourselves, with physical restraint or coercion definitely being done for the child’s own good.

But, regrettably, this is often not the case. In too many situations, physical restraint left to the judgment of institutional caregivers results in tragedy. Although I am not given to sensational or “journalistic” language, I cannot find more descriptive words for some of these events than “torture” and “murder”.

I am going to describe a case of this kind, the death of Angellika Arndt in Wisconsin in 2006. Her death and its subsequent investigation have been described by Disability Rights Wisconsin at http://caica.org/Angie%20-%20Seclusion%20Paper.pdf. (Disability Rights Wisconsin has not copyrighted this paper and invites interested people to distribute parts or all of it.)

Angellika Arndt was 7 years old when she died following chest compression asphyxia at a facility of the Northwest Counseling and Guidance Clinic. She had been removed from the home of her biological parents at age 3 because of abuse and had been in foster care and later in the residential treatment center. She was diagnosed with a number of cognitive and emotional disabilities, including an attention deficit disorder and an oppositional disorder. It was reported that she could not remember the day of the week five minutes after it was told to her.

Angellika’s caregivers at the residential treatment center employed two notable approaches to her. The first was for the child to be placed in a “cool down” room where she was expected to sit straight in her chair with her feet on the floor and her hands in her lap for 15 minutes. Timing did not begin until she was in the required position, and if she fidgeted, the time started over. If she continued to fidget, she was placed in prone restraint for a period of time. According to the Disability Rights Wisconsin report, Angellika in the few weeks before her death spent 20 hours in “cool down” and 14 hours in prone restraint-- a face-down restraint on the floor that lasted as long as an hour and a half.

Here is a description of Angellika’s first day at the residential treatment center, from the DRWI report: “…less than two hours into the program, Angie was placed in the time-out room for hitting her own chin with her hand. No self-injury was noted in the record and she stopped this behavior within five minutes. When she continued to fidget in her chair she was threatened with a physical control hold if she didn’t stop. This was the standard admonition given by … staff in response to the occurrence of any behavior to be discouraged, along with the admonition ‘you know what the expectations are’. When Angie didn’t stop, eventually kicking off her right shoe, she was immediately placed in a prone restraint for 85 minutes. By the end of her first day…, Angie had spent 5 hours either isolated in time-out or being restrained, and less than 2 hours engaged in actual activities.” Over the next several weeks, she was to experience similar treatment for “disruptive” activities like having her hood on, talking baby talk, and gargling milk.

During some of her many prone restraints, Angellika vomited or appeared to fall asleep. On the final occasion, she was thought to have fallen asleep while restrained, but eventually a staff member noticed that her lips were blue and she was not breathing. She had died while pressed against the floor by several staff members, kept there despite her complaints of pain and nausea.

Deaths like Angellika’s are a rare but very possible result of the use of physical restraint by professional caregivers whose actions are poorly supervised and regulated, and whose training has been superficial. Given a powerful weapon to control children who are annoying them, they deploy it at once rather keeping it as a safety measure. Indeed, their constant resorting to restraint serves to exacerbate children’s mood problems, to increase resistance, and to limit the cognitive ability the child can bring to bear on a problem. Torturing the child by repeated threats and demands for impossible levels of compliance, they pave the way for a response that ends in death.

The people who killed Angellika Arndt were professionally trained caregivers, but still appear to have been incapable of making appropriate judgments about restraint of this child, whose attention deficits and emotional history made her less capable of compliance than many children. When medications have the potential for causing painful and tragic outcomes, they are legally available only on prescription. We need to awaken to the fact that serious physical harm can result from methods that adults are taught or advised to use, and that rather than letting caregivers decide how to use dangerous techniques, those techniques also need to be “prescribed” in schools or treatment centers as they are in hospital settings.

We need to give similar consideration to situations where parents are given brief training or reading material, and advised by certain therapists to use physical restraint in their daily interactions with their children. Those parents and their children are put in a potentially dangerous position and should question the advice they receive, as any resulting tragedy will harm the family and leave the advising therapist without legal responsibility. As for the therapists who give this kind of advice, I challenge them to show the public systematic evidence that these practices are effective and safe-- or to change their ways.

5 comments:

  1. I think your last sentence is especially important -- systematic evidence, collected and verified by independent investigators who have no vested interest in the outcome, is crucial.

    The prescription analogy is a good one. Just as no one would think of accepting a doctor's word that a prescribed drug that had not been tested in randomized clinical trials is safe -- based only on that doctor's assertions that no harm had been done in his or her experience, we should not accept anyone's word that a particular method of therapy is safe -- especially if it involves any type of physical intervention. The assertion that no harm has been done is not enough. How would one know? Only through an independently conducted investigation. It's a real tragedy that the people working at Angellica's day treatment center did not appear to understand this point and instead of continuing the evidence-supported interventions or at least the safe interventions such as play therapy that she appeared to be responding well to, they used this barbaric, harmful intervention.

    When it comes to what killed Angellica, however, asphyxiation from prone restraint, the evidence is quite conclusive that this is a procedure that has resulted in deaths (Angellica was one of many). This is why more and more states are are deciding to ban it altogether and those that do still allow it have stringent guidelines, such as no pillows under the head and no people straddling or on top of the torso.

    In Angellica's case one of the restrainers had placed his body over her torso, a practice even proponents of prone restraint do not recommend any longer. Even straddling is considered risky because people are only human and in an emotionally charged situation such as this, it is very difficult to make an accurate assessment of how much weight is too much. Especially after an extended period of time, the restrainers can become fatigued and it is just too risky to be in that position.

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  2. Your point about the independence of investigators is an important one. With all due respect for researchers who provide evidence to support their own techniques, we need to demand of behavioral approaches the same level of evidence we would require for medication, including supportive evidence assembled by investigators who have no personal or financial commitment to a treatment.

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  3. The saddest part is, her death was so unnecessary and I say this based on both research and clinical experience. During the years I worked for a neuropsychologist, I saw many children who had similar diagnoses to Angellica who had multiple diagnoses of ADHD, mood disorders such as bipolar and oppositional or conduct disorders and I can't remember anyone who worked in that office ever having to resort to prone restraint.

    There are so many other ways to deal with an oppositional child. More often than not, evidence-based positive behavioral supports that reinforce desirable behavior work and a little humor doesn't hurt either. The very worst thing one can do -- and I learned this very quickly -- with an oppositional child is to respond in an overly-harsh, disciplinary manner and get into some kind of power struggle to try to show the child who is boss. This can be a natural response in a new therapist to engage in that way, but any hint of that really sets off children with these types of problems, especially the ones who come from backgrounds of abuse and/or deprivation. It puts them right into a power struggle. Harsh, controlling behavior puts them right back into that mode which is why the therapies such as Parent Child Interaction Therapy, based on positive behavioral supports that are gentle and positively reinforcing rather than punitive, work.

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  4. A particular concern, in my opinion, is that the apparently harmless time-out technique was used to introduce demands the child was incapable of obeying, and thus served to exacerbate any problematic behavior and to provide a rationale for moving quickly to the control hold.

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  5. Jean I read this post on Jan 1, and have been trying to bring myself to comment on it ever since. That this is still happening is outrageous!

    Having a child with ADHD sit in a chair for an extended period of time, let alone with developmentally impossible expectations and restrictions – serves NO purpose therapeutic or other wise!

    Is a child’s unwavering compliance to any and all adult demands ever a responsible treatment goal? Is forceful external physical control ever going to teach self control? Reduce rage?

    As somebody who has survived these kinds of counter productive power struggles and “therapeutic restraint” I have to say the only thing it accomplishes is deepening the trauma already suffered and more rage.

    The act of coercion through physical force is assault, no matter who is involved.

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