Statement on Restraint and Seclusion1, 2010
The Association for Behavior Analysis International (ABAI) and its members strongly oppose the inappropriate and/or unnecessary use of seclusion, restraint, or other intrusive interventions. Although many persons with severe behavior problems can be effectively treated without the use of any restrictive interventions, restraint may be necessary on some rare occasions with meticulous clinical oversight and controls. In addition, a carefully planned and monitored use of timeout from reinforcement can be acceptable under restricted circumstances. Seclusion is sometimes necessary or needed, but behavior analysts would support only the most highly monitored and ethical practices associated with such use, to be detailed below.
This Position Statement on Restraint and Seclusion summarizes critical guiding principles. With a strong adherence to professional judgment and best practice, it also describes the conditions under which seclusion and restraint may be necessary and outlines proper strategy in order to implement these procedures appropriately and safely. This statement is consistent with ABAI's 1989 Position Statement on the Right to Effective Behavioral Treatment, which asserts numerous rights, including access to the most effective treatments available-while emphasizing extensive procedural safeguards.
I. Guiding Principles:
1. The Welfare of the Individual Served is the Highest Priority- Clinical decisions should be made based upon the professional judgment of a duly formed treatment team that demonstrates knowledge of the broad research base and best practice. Included in this process are the individuals being served and their legal guardians. The team should be informed by the research literature, and should determine that any procedure used is in that individual person's best interests. These interests must take precedence over the broader agendas of institutions or organizations that would prohibit certain procedures regardless of the individual's needs. A core value of ABAI with regard to behavioral treatment is that welfare of the individual being served is the absolute highest priority.
2. Individuals (and Parents/Guardians) Have a Right to Choose- ABAI supports the U.S. Supreme Court ruling that individuals have a right to treatment in certain contexts, and that many state and federal regulations and laws create such rights. Organizations and institutions should not limit the professional judgment or rights of those legally responsible for an individual to choose interventions that are necessary, safe, and effective. A regulation that prohibits treatment that includes the necessary use of restraint violates individuals' rights to effective treatment. The irresponsible use of certain procedures by unqualified or incompetent people should not result in policies that limit the rights of those duly qualified and responsible for an individual through the process of making informed choices.
3. The Principle of Least Restrictiveness - ABAI supports the position that treatment selection should be guided by the principle of the least restrictiveness. The least restrictive treatment is defined as that treatment that affords the most favorable risk to benefit ratio, with specific consideration of probability of treatment success, anticipated duration of treatment, distress caused by procedures, and distress caused by the behavior itself. One may conclude from this premise that a non-intrusive intervention that permits dangerous behavior to continue while limiting participation in learning activities and community life, or results in a more restrictive placement, may be considered more restrictive than a more intensive intervention that is effective and enhances quality of life.
1. General Definitions
i. Restraint involves physically holding or securing the individual, either: a) for a brief period of time to interrupt and intervene with severe problem behavior, or b) for an extended period of time using mechanical devices to prevent otherwise uncontrollable problem behavior (e.g., self-injurious behavior) that has the potential to produce serious injury. When used in the context of a behavior intervention plan, restraint in some cases serves both a protective and a therapeutic function. These procedures can reduce risks of injury and can facilitate learning opportunities that support appropriate behavior.
ii. Seclusion involves isolating an individual from others to interrupt and intervene with problem behavior that places the individual or others at risk of harm. When used in the context of a behavior intervention plan, seclusion in some cases serves both a protective and a therapeutic function. These procedures can reduce risks of injury and can facilitate learning opportunities that support appropriate behavior. ABAI is opposed to the use of seclusion when it is operationally defined as placing someone in a locked room, often combined with the use of mechanical restraint and/or sedation, and not part of a formal Behavior Intervention Plan to which the individual served and/or their Guardians have consented. We support the use of a planned time out treatment or safety intervention which conforms to evidence based research, is part of a comprehensive treatment or safety plan which meets the standards of informed consent by the individual served and/or legal guardian, and is evaluated on an ongoing basis via the use of contemporaneously collected objective data.
iii. Time-out from reinforcement is an evidence-based treatment intervention that involves reducing or limiting the amount of reinforcement that is available to an individual for a brief period of time. It can entail removing an individual from his or her environment, or it may entail changes to the existing environment itself. When time out involves removing an individual from the environment, it should only be used as part of an approved and planned Behavior Intervention Plan. Time out from reinforcement is not seclusion, but it may involve seclusion if it is not safe to have others in the room. In addition, some innocuous versions of timeout from reinforcement, such as having a child take a seat away from a play area, are not deemed to be intrusive. Such procedures are commonly used and are generally safe.
2. Use of Restraint as part of a Behavior Intervention Plan
i. The use of restraint in a planned Behavior Intervention Plan is done as part of an integrated effort to reduce the future probability of a specified target behavior and/or to reduce the episodic severity of that behavior. A Behavior Intervention Plan that incorporates contingent restraint must a) incorporate reinforcement based procedures, b) be based on a functional behavior assessment, c) be evaluated by objective outcome data, and d) be consistent with the scientific literature and current best practices.
ii. Procedures describing the use and monitoring of this type of procedure should be designed by a Board Certified Behavior Analyst, or a similarly trained and licensed professional who is trained and experienced in the treatment of challenging behavior.
3. Use of Timeout (or in rare cases, seclusion) as part of a Behavior Intervention Plan
i. Timeout may be used as part of an integrated Behavior Intervention Program designed to decrease the future probability of a pre-specified target behavior and/or to reduce the episodic severity of that behavior. The Behavior Intervention Plan that incorporates the use of time out must a) be derived from a behavioral assessment, b) incorporate reinforcement strategies for appropriate behavior, c) be of brief duration, d) be evaluated by objective outcome data, and e) be consistent with the scientific literature and current best practices.
4. The Necessity for Using Emergency Restraint and Seclusion
i. Emergency restraint involves physically holding or securing a person to protect that person or others from behavior that poses imminent risk of harm. These procedures should be considered only for dangerous or harmful behavior that occurs at unpredictable times that make the behavior not amenable to less restrictive behavioral treatment interventions and that place the individual and/or others at risk for injury, or that will result in significant loss of quality of life. The procedures should be considered only when less intrusive interventions have been attempted and failed or are otherwise determined to be insufficient given adequate empirical documentation to prove this point.
ii. When applied for crisis management, restraint or seclusion should be implemented according to well-defined, predetermined criteria; include the use of de-escalation techniques designed to reduce the target behavior without the need for physical intervention; be applied only at the minimum level of physical restrictiveness necessary to safely contain the crisis behavior and prevent injury; and be withdrawn according to precise and mandatory release criteria.
iii. Emergency restraint procedures should be limited to those included within a standardized program. Medical professionals should review restraint procedures to ensure their safety.
iv. Consideration of emergency restraint should involve weighing the relative benefits and limitations of using these procedures against the risks associated with not using them. Associated risks of failure to use appropriate restraint when necessary include increased risk for injury, excessive use of medication, expulsion from school, placement in more restrictive, less normalized settings, and increased involvement of law enforcement.
v. Crisis management procedures are not a replacement for behavioral treatment, and should not be used routinely in the absence of an individualized behavior intervention plan. The best way to eliminate restraint use is to eliminate behavior that invites restraint use via systematic behavioral treatment procedures. If crisis intervention procedures are used on a repeated basis, a formal written behavior plan should be developed, reviewed by both a Peer Review Committee and Human Rights Committee (when available), and consented to by the individuals served and their parents or legal guardians.
5. Informed Consent
i. As members of the treatment team, the individual and/or parents/guardians must be allowed the opportunity to participate in the development of any behavior plan.
ii. Interventions involving restraint or seclusion should only be used with full consent of those responsible for decision-making. Such consent should meet the standards of "Information," "Capacity," and "Voluntary." The individual and his or her guardian must be informed of the methods, risks, and effects of possible intervention procedures, which include the options to both use and not use restraint.
6. Oversights and Monitoring
i. Restraint or seclusion procedures (not including brief timeout procedures) for both treatment and emergency situations should be made available for professional review consistent with prevailing practices.
ii. The behavior analyst is responsible to ensure that any plan involving restraint or seclusion conforms to the highest standards of effective and humane treatment, and the behavior analyst is responsible for continued oversight and quality assurance.
iii. These procedures should be implemented only by staff who are fully trained in their use, regularly in-serviced, demonstrate competency using objective measures of performance, and are closely supervised by a Board Certified Behavior Analyst, or a similarly trained professional.
iv. The use of restraint or seclusion should be monitored on a continuous basis using reliable and valid data collection that permits objective evaluation of its effects.
v. Procedures involving restraint or seclusion should be continued only if they are demonstrated to be safe and effective; and their use should be reduced and eliminated when possible. Efficacy with respect to treatment programs refers to a reduction in the rate of the specified target behavior and/or reduction in the episodic severity of that behavior. With respect to emergency treatments, efficacy refers only to the time and risk associated with achieving calm.
Click here to view a reference list containing the body of literature that supports this statement.
A task force authorized by the Executive Council of the Association for Behavior Analysis International generated the above statement concerning the technique called Restraint and Seclusion. Members of the task force independently reviewed the scientific literature concerning Restraint and Seclusion and agreed unanimously to the content of the statement. The Executive Council has accepted the statement and it was subsequently approved by a two-thirds majority vote of the general membership. It now constitutes official ABAI policy.