The Therapy Beat


The Therapy Beat

Agitated Kids, Dangerous Punishment: Rethinking the Policy of Seclusion and Restraint

By Chris Lyford

March/April 2022


Guy Stephens isn’t a psychotherapist. He isn’t a neuroscientist. And he isn’t a politician, either. But the way he talks about trauma, the brain, and public policy, you wouldn’t know it. He knows about these things only because he has to know about them.

Stephens’s son, Cooper, is neurodivergent and suffers from anxiety. At school, he’s always needed extra care and support. But 10 years ago, when Cooper told teachers he didn’t want to come back to class after recess, he was forcibly returned to the building and locked in a classroom, alone, for the next hour. Distressed, he stripped off his clothes and began to wail. He was six years old.

Stephens was outraged. He moved Cooper to a different school placement, where the teachers better understood and met Cooper’s needs. But three years later, Cooper was again locked in a room alone, this time as punishment for hiding in the bathroom. In this instance after being locked in, Cooper tried climbing out an open window.

Stephens tried homeschooling Cooper for two years, but he missed his classmates too much, and Stephens felt he had no option but to return Cooper to school. But problems continued. Not long after returning, Cooper was again forcefully isolated for throwing a book. And again later, for splashing water.

Stephens suspects Cooper was subjected to isolation roughly eight times that year—and over half the time, he heard about it directly from Cooper, not from teachers or school administrators.

Fed up with the school’s handling of his son, Stephens pulled Cooper out and arranged through an independent program for a teacher, Steve, to visit him at home. Steve had been working with kids like Cooper for decades. Unlike previous teachers, Steve sat down with Cooper, asked him what he liked and didn’t like, and got to know him. And when Cooper became agitated, Steve didn’t put his hands on Cooper or isolate him. Instead, they walked around the block until Cooper calmed down. “They have a beautiful relationship,” Stephens says.

From there, he threw himself into learning as much as he could, about not only what his son had been going through internally when he’d been punished, but why teachers and school administrators had responded the way they had—and how they could’ve responded better. “I’ve always advocated for my son,” he says. “So I began doing research. I learned that when Cooper took off his clothes and tried to climb out the window, he was in a fight-or-flight state. Those were stress responses.”

Stephens delved into school policies for addressing what school administrators had deemed unruly behavior. “I began looking at data, scientific literature, news, regulations—anything I could find,” he says.

Then, he came across a term he’d never heard before: seclusion and restraint. Cooper’s teachers had never used that language to describe what they’d done. But as he continued researching, the term came up again and again.

“The more I dug,” he says, “the more I realized there’s a lot to be concerned about.”

Offenses without Consequences

Although it’s seldom discussed, the policy of seclusion and restraint is applied throughout the American education system. Across the country, school officials, should they deem it necessary for students’ safety or their own, are allowed to isolate—seclude—students alone in locked rooms or immobilize—restrain—them, using anything from their own bodies (for instance, by holding down a child’s arms) to devices like straps or chairs that prevent them from moving.

Critics point out myriad problems with seclusion and restraint. For one, the Department of Education (DOE), which establishes standards for seclusion and restraint in schools, broadly defines the two procedures, allowing for interventions that may be physically or psychologically harmful—sometimes even fatal. The last federal report on restraint-related abuse and deaths in schools, published in 2009 by the U.S. Government Accountability Office (GAO), lists “at least 20” fatalities occurring between 1990 and 2009. Case summaries are sparse, but nonetheless shocking:

Male, 14, diagnosed with post-traumatic stress: 230 lb. teacher placed 129 lb. child facedown on floor and lay on top of him because he did not stay seated in class, causing his death.

Female, 4, born with cerebral palsy and diagnosed as autistic: Child was “uncooperative,” so teachers restrained her in a chair with multiple leather straps that resembled a “miniature electric chair.”

Male, 9, diagnosed with a learning disability: Parents allowed school to use timeout room only as a “last resort,” but school put child in room repeatedly for hours at a time for offenses such as whistling, slouching, and hand waving.

A more recent study, published last August in Child & Youth Care Forum, reported that between 1993 and 2018, 79 restraint-related deaths had occurred in child welfare centers, correction facilities, and mental health and disability service centers. The leading causes were asphyxia and cardiac arrhythmia, the former suggesting a manual or mechanical restraint had prevented the child from breathing, and the latter indicating an extremely high stress response to the seclusion or restraint.

The cases cited by the GAO also point to accountability problems. DOE guidelines state that seclusion and restraint should only be used in instances where a student’s behavior poses “a threat of imminent danger of serious physical harm to the student or others.” But critics say seclusion and restraint is applied much more liberally, and often without consequences.

“As an adult, I’d want you to do whatever you needed to do to protect a child from a potentially deadly situation,” Stephens says. “Unfortunately, that’s not what happens in practice. Very often, kids are restrained and secluded for noncompliance, disrespect, minor behaviors, bad language, or property damage.”

Although the DOE’s Office for Civil Rights (OCR) requires that all incidents of seclusion and restraint be reported, enforcement is virtually nonexistent. A 2019 report from Education Week found that during the 2013–2014 school year, nearly 80 percent of districts—including all of New York City’s—reported zero incidents of seclusion or restraint.

There’s also little uniformity when it comes to seclusion and restraint procedures. In 2012, the DOE published a resource guide for educators, including a 15-point framework outlining how and when to use seclusion and restraint. Those points include recommendations that “every effort be made to prevent the use of seclusion and restraint” and that “the use of restraint or seclusion should address the underlying cause or purpose of the dangerous behavior.” But the points are just that—recommendations—and their execution is left up to state governments. Some only have guidelines in place for using seclusion and restraint with kids with disabilities; others have no reporting requirements.

Evidence also suggests seclusion and restraint is disproportionately used against children with disabilities and minority children. According to a 2018 report from the Civil Rights Data Collection, a biennial report required by the OCR, students with disabilities make up 71 percent of those restrained and 66 percent of those secluded, while African American students make up 27 percent of those restrained and 23 percent of those secluded, even though they make up only 12 and 15 percent of total enrollment, respectively.

In 2019, the GAO released findings from an investigation highlighting some of these shortcomings, reporting that “the use of restraint and seclusion is rare” but “students with disabilities and boys are disproportionately affected.” As a result, it announced a collaboration between the OCR and the DOE’s Office of Special Education and Rehabilitative Services to conduct compliance reviews focused on the inappropriate restraint and seclusion of students with disabilities.

“Guidelines are in place for a reason,” Jackie Nowicki, a director at the GAO, told National Public Radio in 2019. “When seclusion and restraint is inappropriately used, it can create some really dangerous situations, especially for some of our nation’s most vulnerable children.”

If the GAO’s heart was in reform, Guy Stephens wasn’t convinced.

Assembling Allies

Three years ago, on the heels of the GAO announcement, Stephens decided to take matters into his own hands. He founded the Alliance Against Seclusion and Restraint, an organization dedicated to raising awareness and effecting change around seclusion and restraint. Operating online, the Alliance’s website includes information about the use of seclusion and restraint, a data survey on its use (Stephens says the OCR and GAO’s sites “contain very little information”), alternative interventions, a toolkit for proposing new legislation, and a drop box for parents, educators, and advocates to share their stories.

“I wanted people to know they aren’t alone,” Stephens says of his decision to found the Alliance. “I wanted them to know that other people have been through this, and I wanted them to take action. We have an obligation to do better. Kids are being traumatized, seriously injured, and killed. This is a civil rights issue.”

To date, Stephens has assembled a team of nearly 20 volunteers who work with the Alliance part-time, including educators, medical professionals, adults who were secluded or restrained as children, and parents like himself.

Stephens has also found allies in the clinical community, like pediatric psychologist Mona Delahooke, who specializes in working with children with behavioral challenges and developmental differences. Having worked with children who were restrained and secluded, she says the approach isn’t only outdated, but it’s the worst possible response to an agitated child.

“We have to understand the difference between intentional misbehaviors and stress responses,” Delahooke explains. “If a child is out of control of their emotions or behaviors, it’s often because their nervous system is in fight or flight. In this moment, they need to know they’re not alone and that someone sees their distress. If you’ve resorted to seclusion or restraint, you’ve been missing their calls for help.”

In many cases, she says, seclusion and restraint actually increases agitated behavior. And most times, it leads to feelings of hopelessness or desperation. If it does appear to decrease agitation, Delahooke adds, “it’s because the child being secluded or restrained is giving up and losing hope in their fellow human.”

In fact, she explains, seclusion and restraint—and many other, more common disciplinary measures—are destined to fail because they focus on children’s behavior, rather than the source of that behavior. In other words, they target the symptom, not the cause.

“The prevailing approach in American education,” she says, “has been punishing inappropriate or noncompliant behavior and rewarding good behavior. Even if you’re just using sticker charts or timeout rooms, these are working with a child’s motivational system, talking to them in a cognitive, top-down fashion.”

But say you’re a teacher whose student has become agitated. What’s the best course of action? Delahooke offers a three-step process. First, you need to shift your thinking from this child is misbehaving to this child is in a stress response.

Second, check in with yourself. “Make sure you’re feeling grounded and calm enough to offer support,” Delahooke explains. “If you’re not, then take a few moments to gather yourself, because you, the adult, are the most important tool in the room.”

Third, customize your interactions to whatever will help the child’s nervous system calm down. To do this, Delahooke says to focus on what she calls the launching pad of all behavior: the body. Rely less on your words, she advises. Increase your emotional warmth, and try an activity that engages the student’s body, like rocking with the child, putting a gentle hand on their shoulder, or swaying together to calming music.

“This isn’t easy, and there isn’t a one-size-fits-all approach,” Delahooke clarifies. “After all, we’re talking about customizing two nervous systems, and every child is different. But if you experiment to see what helps their body calm down, eventually you’ll see those agitated behaviors melt away.”

Change on the Horizon?

Guy Stephens knows these types of interventions work. After all, he’s seen it in Steve’s gentle approach with Cooper. But convincing others that they work—and that seclusion and restraint is doing much more harm than good—is a slow and steady business.

Shortly after founding the Alliance Against Seclusion and Restraint in 2019, Stephens successfully lobbied his local board of education and superintendent to change the seclusion-and-restraint laws in Calvert County, Maryland, where he currently resides. That year, new trainings around seclusion and restraint were mandated for teachers and school staff overseeing the county’s 16,000 students. In 2018, before Stephens’ efforts, Calvert had the highest rate of seclusion and restraint in the state, with an average of 750 incidents per year. Last year, that number was seven.

Three years in, Stephens, with the assistance of his team and other advocates, has worked with senators to reform seclusion-and-restraint laws in Illinois, Maine, and other states, so as to restrict the use of facedown restraints, which can be particularly deadly.

Not all of Stephens’s lobbying efforts have resulted in changes, but as he likes to say, any progress is positive progress. People are starting to take notice. Last May, Congressional Democrats introduced the Keeping All Students Safe Act, which would prevent school personnel and campus police from using restraints that restrict breathing. It’s currently being reviewed by the Senate Committee on Health, Education, Labor and Pensions.

Stephens says it’s a step in the right direction, if a small one. Once the movement gains more steam, he says he’d like to see seclusion-and-restraint policies amended in other settings, such as inpatient mental health clinics and eldercare facilities, where problems persist.

Delahooke, too, knows the road to reform is long. She says punitive measures are woven into the fabric of our society, where people—including many prominent therapists who work with children—see a child’s agitation as a volitional, intentional act of misbehavior.

“Our culture believes that seclusion and restraint is a measure we need to keep people safe,” she says. “And I get it. Out-of-control kids are unpredictable, and that can be frightening for teachers working with them. But our interventions are missing the mark. All of us—especially therapists—need to speak up. What these kids need is someone to say, ‘I see you. I see you’re distressed. You’re not alone.’ We need less judgment, and more compassion.”

***

Chris Lyford is the Assistant Editor at Psychotherapy Networker.

Let us know what you think at letters@psychnetworker.org.

PHOTO © ISTOCK/LUMINOLA




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