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Face-down Restraints
JULY 2003

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
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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
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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 restrains 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
entwinded 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
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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
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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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Thom,

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 complain 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
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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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