THE REALITIES OF BANNING PRONE RESTRAINT

Based on comments submitted by Pennsylvania DPW facilities

 

Pennsylvania facilities can expect nearly a 40% increase in staffing budget to comply with proposed ban on prone restraint

Central Counties Youth Center submitted an impact statement relating to Pennsylvania-DPW proposed ban on prone restraint.  The Chief Administrator for the Center stated that by using any technique other than a prone restraint would require four (4) (rather than 3) staff to be present for the safety of the child and the safety of the staff.  Therefore, the Center would need to place additional staff on each shift for a total of 37% increase in staffing.  The Center also predicts higher turnover due to the fact that staff will no longer feel safe within the facility, as supine restraint is not as safe for the staff or child as prone restraint is, along with corresponding worker compensation and child injury claims and lawsuits.

Pennsylvania facilities project changing hiring strategies as a result of the proposed ban on prone restraint from hiring Youth Counselors who are able to communicate and interact with kids, to hiring staff with more "muscle" to comply with the proposed ban on prone restraint.

Central Counties Youth Center said that in order to keep its staff and children safe if they can no longer use prone restraint they will have to hire larger staff, as some of the smaller Youth Counselors will not be able to maintain their own muchless the children's safety.  So that the environment does not become one of fear where the children run the facility, these Youth Counselors will need to be moved to safer positions.  Hiring practices will have to change from hiring Youth Counselors who are able to communicate and interact with kids appropriately, to hiring staff that will be able to physically handle a restrictive procedure if prone restraint is no longer remains an option.

Pennsylvania facilities increase their use of psychotropic medications due to prohibitive regulations on the use of physical intervention and holds.

Scott Spreat, Vice President of Woods Services cautioned that Stephanie Stolz, former head of the National Institute of Mental Health warned that over regulation of the practice of behavior modification was not in the best interests of the child.  In Pennsylvania, which has placed high regulatory barriers restricting the use of applied behavior analytic strategies in our programs has resulted in reliance on psychotropic medications which has increased to almost double the national average among persons with intellectual disabilities.  DPW’s current approach is inconsistent with the prevailing trends in psychology. 

We believe (as does the Supreme Court, the Department of Health and Human Services, Pennsylvania Law, Pennsylvania Community Providers Association (PCPA) and DBH) it is the credentialed professionals and/or professional organizations, not DPW that should define what is best for the child.  Mr. Spreat further cautioned issuing a prediction of things to come, if administrators are to be scrutinized and questioned about every restraint use, individuals with significant behavior problems will be less likely to find placement in Pennsylvania programs.  Clearly this is not in the best interests of anyone.

Pennsylvania facilities project an increase of worker and child injuries as a result of the proposed ban on prone restraint.

Scott Martin, Commissioner of Lancaster County writes: DPW’s actions banning prone restraint will negatively impact all Pennsylvania residential treatment facilities.   

When a child engages in aggressive behavior, staff are trained to deflect punches and kicks and to get behind the child.  From this point, if the child is still fighting, staff are trained to assist the child to a seated position.  However, if this seated position cannot be maintained, there is a greater likelihood that this will transcend into a prone position.  First, a staff member is not going to fall backwards, second it is a natural reaction to go belly-down.  If the prone position is the natural progression of events in most restraint cases, why would we change that, forcing innocent individuals back into strike zones or causing injuries to the joints of the child [trying to turn her over or stand her up.]  When a child is in the prone position, they pull their arms in tight in most cases and resist them from being pulled out.  In order to get out of the prone position, and into a supine position, our staff would need to apply extreme torque on the child’s shoulder, wrist and elbow joints, just to get them onto their backs.

When a child is on their backs in the supine position during a restraint, you are affording them a position of power to inflict harm.  Being in the supine position enables them to be more successful in punching, scratching, eye-gouging, pulling hair, biting and spitting.  The most frightening tool they gain, is their ability to strike with their knees or legs.  Unlike the prone position, the supine gives full leg striking ability which has led to many serious injuries to staff members. 

By making these environments more dangerous, we will see more worker compensation claims because of staff injuries, and more lawsuits stemming from unnecessary injury caused to staff [as the state is creating a constitutionally dangerous condition] and child because [we could not maintain a safe environment] or by attempting to torque them into the supine position, out of the safer prone position.

If a resident strikes a staff member, bites, spits, hair pulls, knee kicks, they will be charged with aggravated assault.  When a child is placed in the prone position, they are limited in their ability to further assault. When you place them supine, you give them every opportunity to do so.  This increases the criminality of the child.

With regard to our female population, Many of these ladies have been raped or sexually abused prior to their involvement in the system.  To make it a policy that these females would have to be restrained on their backs with a staff member, many times male, on top of them will undoubtedly result in re-traumatization.

Prone restraints are safe if you transition youth to restrictive procedures that remove bodyweight off an assaultive child as soon as possible while continuing to monitor the physical and emotional well-being of the child.

Pennsylvania facilities project an increase in worker compensation and child injury claims as a result of the proposed ban on prone restraint.

James Jones, Administrator writes: The cost of workers compensation will increase due to more injuries to staff.  When a kid is in a prone position, his abilities to continue to struggle or assault staff in any way decreases.  In the supine or in a seated position, the possibilities of a kid continuing to act out are greater and so is the possibility of injuries.  In the supine or seated positions, kids can still kick, spit, bite or head butt staff easier than in a prone position resulting in injuries.  With the increase in the number of kids with life threatening diseases (HIV, Hepatitis, MRSA), more testing will need to be done with staff after a restraint.  I would expect an increase in my worker's compensation premium of at least 15%.  This does not include the coverage for shifts for a staff who may suffer an injury during a restraint procedure

Scott Martin, Commissioner of Lancaster County writes: When a child is on their backs in the supine position during a restraint, you are affording them a position of power to inflict harm.  Unlike the prone position, the supine gives full leg striking ability which has led to many serious injuries to staff members.  By making these environments more dangerous, we will see more worker compensation claims because of staff injuries, and more lawsuits stemming from unnecessary injury caused to staff and child because [we could not maintain a safe environment] or by attempting to torque them into the supine position, out of the safer prone position.

Pennsylvania Community Providers Association (PCPA). In some cases it is not in the best interests of the child to be placed face up.  Some children and adolescents, especially those who have experienced physical violence or sexual abuse, may feel much more vulnerable and “exposed” when restrained in a face up position.  This may actually contribute to a stronger and more dangerous reactive behavior from the child, an increase in the time it takes to deescalate the crisis, and a more significant impairment in the supportive and therapeutic relationship between the child and the staff.

Pennsylvania facilities project longer holding times and increased trauma to children who feel “exposed” when being held face up

Pennsylvania Community Providers Association (PCPA).  PCPA and its members have long supported efforts to improve practices related to behavioral crisis management.  In some cases it is not in the best interests of the child to be placed face up.  Some children and adolescents, especially those who have experienced physical violence or sexual abuse, may feel much more vulnerable and “exposed” when restrained in a face up position.  This may actually contribute to a stronger and more dangerous reactive behavior from the child, an increase in the time it takes to deescalate the crisis, and a more significant impairment in the supportive and therapeutic relationship between the child and the staff.

We believe (as does the Supreme Court, HHS, DBH, and Woods Services) that the crisis professionals interacting with the child on a day-to-day basis is the best person to devise a treatment and behavioral plan for the child [to find otherwise would violate the constitutional rights of the child].  In these circumstances the professional should be allowed to prescribe a safe and proven therapeutic face down approach that includes a technique and other elements of the plan that insure that the child is kept safe from pressure on the chest (back) or abdomen.

PCPA is concerned and disappointed that DPW has relied as the sole data on an advocacy based web site, rather than a more credible source like the Government Accounting Office Report from September 1999.  PCPA finds the reference to and use of information from this advocacy group, rather than a credible academic or governmental source to be highly questionable.  We strongly recommend that DPW finds a more credible source of data.

Central Counties Youth Center also believes that the use of the supine position is more traumatic on youth, especially kids who have had issues of sexual assaults in the past.  This position leaves kids feeling more exposed and gives them the feeling of being violated.  In addition, since the child is face up, it does not allow him to de-escalate due to being able to see and interact with what is happening around her.  The prone position allows the child the space to compose himself without losing his dignity and respect, and we have found that children have been able to compose themselves quicker when placed in a prone position.

Pennsylvania juvenile facilities project an increase in the use of handcuffs and shackles to comply with the ban on prone restraint.

 

County Commissioners Association of Pennsylvania.  As a result of the ban of prone restraint, facilities are reporting an increased use of mechanical restraints for the more violent youth.  They are experiencing staff hesitancy in confronting inappropriate behaviors as staff report fear of retaliation from licensing representatives should the confrontation result in aggressive behavior by the resident and a subsequent restraint should occur.  The biggest and most potentially dangerous adolescents are then likely to become bullies and use intimidation, believing that they will not be held accountable or they can easily claim they have been abused by staff when they themselves become physically aggressive.   This situation has resulted in resident youth willing to push limits further and thus increase the potential of harm to other residents and staff.

As a result of the lack of alternatives for the most physically challenging youth, we have begun to see a shift in employee response to include an increase in police reports, an increase in the use of mechanical restraints, and a decrease in staff willingness to work in detention facilities.  Bargaining unit representatives have encouraged staff to pursue criminal charges on youth who become assaultive.  Staff self-preservation and safety needs will take precedence over the juvenile's needs for treatment, supervision and rehabilitation based on staff's need to protect themselves.

Pennsylvania facilities foresee an increase of criminal charges filed against children.

James Jones, Administrator.  With the increase in possible injuries to staff, will come an increase in charges being filed against the kids which none of us want to see.  In the past, staff would accept some injuries as part of their position, but that has changed with the Department's interpretation of Child Abuse.  With the recent unsubstantiated charges being filed against staff that were ultimately dismissed, staff do not fee that they are secure and safe in their position and do not have the support of the Department.  Staff now expect Administration to call in Law Enforcement when they receive any injury during a restraint for the possibility of filing criminal charges against the child.  With a supine or seated restraint, more injuries are going to be incurred by staff [and child] which will result in more charges being filed against kids.  This will increase our length of stay due o the court process and it will make kids more difficult to place.

Juvenile Detention Centers Association of Pennsylvania.  As a result of the lack of alternatives for the most physically challenging youth, we have begun to see a shift in employee response to include an increase in police reports, an increase in the use of mechanical restraints, and a decrease in staff willingness to work in detention facilities.  Bargaining unit representatives have encouraged staff to pursue criminal charges on youth who become assaultive. 

Pennsylvania facilities challenge the assumption that prone restraint is dangerous - telling DPW - prove it.

Pennsylvania facilities got very upset with DPW's administration.  PA facilities asked DPW for some scientific, statistical or other evidenced or best-practices based foundation on the proposed ban on prone restraint.  DPW was unable to provide any substantiation for its proposed ban.  The best DPW could do was point to an advocacy web site.

The DPW facilities said -- the advocacy web site is not a sufficient enough foundation to jeopardize the lives and safety of the staff and youth in DPW's care. 

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info@thetruthaboutpronerestraint.com