a review of crisis intervention training programs for schools couvillon et al... · 2016-02-03 ·...

Recent advocacy organization reports,Congressional hearings, and proposedfederal legislation have called attentionto the abusive use of physical restraintprocedures in school settings. As aresult, administrators and school offi-cials wonder whether they should pur-chase “crisis intervention” training forstaff and faculty members from outsidevendors. Unfortunately, there is limitedinformation available regarding thecontent of these training programs, andthe vendors who provide this trainingview the subject matter as proprietaryand confidential. As a result, it can bedifficult for schools to obtain informa-tion that might help them make choicesabout the training they are purchasing.Comparing different programs’ empha-sis on certain topics, course content,duration, and type of instruction canassist administrators and educators inselecting a crisis intervention trainingprogram that is most appropriate fortheir school.

Educators, policy makers, and commu-nities recently have become focused onthe use of physical restraint proceduresin school settings. Physical restraint—sometimes referred to as ambulatoryrestraint—is “any physical method ofrestricting [an individual’s] freedom of

movement, physical activity, or normalaccess to his/her body” (InternationalSociety of Psychiatric and MentalHealth Nurses, 1999, ¶3). Althoughseveral commercial vendors offer train-ing programs intended to provideinformation and skills to deescalatecrisis situations and employ in a safeand effective manner, most educatorsknow little about their content or train-ing procedures. In this article, weexamine the content emphases of theseprograms and the differences in train-ing delivery methods. Issues relating toseclusion of students are beyond thescope of this study. In light of currentcontroversy and policy changes relatedto the implementation of restraint pro-cedures in schools, this informationshould be helpful to schools and pro-grams intending to purchase or renewcontracts for this kind of training.

Background

Over the last several years newspaperand television media have brought tothe attention of the community numer-ous instances of children being killedor injured as a result of being physical-ly restrained in schools. Among therisks associated with restraint includephysical injuries resulting from falls,punches, kicks, bites, or falling intofurniture. Students may also experiencepsychological trauma from being

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A Review of CrisisIntervention TrainingPrograms for Schools

Michael Couvillon !! Reece L. Peterson !! Joseph B. Ryan

Brenda Scheuermann !! Joanna Stegall

Physical Restraints

restrained, although the impact maynot be initially evident. Mohr, Petti, &Mohr (2003) cautioned that the use ofrestraint has resulted in fatalities fornumerous reasons, including asphyxia(e.g., suffocation), aspiration (e.g.,choking), and blunt trauma to thechest.

During this same timeframe nation-al protection and advocacy agenciesstrived to promote public awareness ofthis issue by releasing reports docu-menting abusive situations in whichrestraints were improperly used withchildren (Council of Parent Attor neysand Advocates, 2009; National Dis -ability Rights Network, 2009), as wellas supporting parent complaints andencouraging legal action on such cases.In spring 2009, a U.S. House of Repre -sentatives Congressional Com mittee on

Education and Labor held a hearing onthis topic, and the Govern mentAccountability Office (GAO) issued areport documenting many of theseabuses (2009). This was followedquickly by a White House briefing onthis topic and a letter from U.S. Secre -tary of Education Arne Duncan (2009)calling for all states and school districtsto examine their policies on the use ofrestraint and to ensure that appropriatepolicies and safeguards were in placeto protect children. In December 2009,federal legislation was introduced toregulate the use of these procedures inschools in order to prevent abusive sit-uations (H.R. 4247 and S. 2860, 2009),thereby emphasizing the need for pro-fessional training of staff members incrisis intervention.

Standards and Policies

Most medical, psychiatric, and lawenforcement agencies have licensingstandards that govern their use ofphysical restraint. The Children’sHealth Act of 2000 regulates the use ofrestraint in hospitals and treatmentcenters that receive federal funds.These requirements have resulted inwidespread training and certification ofstaff in medical and psychiatric pro-grams that employ physical restraints.Over the last 2 decades, many of thesetypes of programs have attempted todrastically reduce their use of restraint

procedures because of the number ofdeaths and injuries related to their use(Carter, Jones, & Stevens, 2008; Colton,2008).

Schools, however, are largely gov-erned by state education agencies.Unfortunately, there has been littleguidance on these topics from statedepartments of education; where poli-cies do exist, they vary greatly in con-tent and are often advisory in nature(GAO, 2009; Ryan, Robbins, Peterson,& Rozalski, 2009; U.S. Depart ment ofEducation, 2010). The lack of common-ly accepted written standards for the

use of physical restraint in school set-tings increases the potential for inap-propriate use of restraint due, in part,to inadequate training in the use ofthese procedures.

The Need for Behavior CrisisTraining in Schools

Challenging Student Behaviors

The number of students with seriousbehavior issues who are served in general school settings has increaseddramatically. This population includesstudents with emotional or behaviordisorders, autism spectrum disorders,traumatic brain injury, and otherhealth impairments (which mayinclude attention deficit disorders andother mental health diagnoses). Pro -blems may arise when students withbehavioral disabilities are integratedinto general education classroom set-tings in schools where staff lack theexpertise needed to effectively preventand manage student conflict and otherbehavior problems. Further, ineffectiveeducational programming (e.g., failureto provide appropriate curricular,instructional, and/or behavioral interventions) may exacerbate thebehavioral difficulties of some stu-dents, leading to a vicious cycle ofantecedents that set the stage for problem behavior (Long, 1996). Allthis, combined with personnel wholack training in effective responses for

preventing or managing behavioralescalation, may lead to seriously dis-ruptive or dangerous behavior that ismanaged by physically controlling thestudent through the use of restraint.

In addition, educators must copewith violent and disruptive behaviorcaused by other students, includingstudent gang members, students withdrug or alcohol problems, and studentswith undiagnosed or untreated mentalillness. Although infrequent, there havealso been widely publicized episodesof school violence and assault occur-ring in schools. Being able to manage

TEACHING EXCEPTIONAL CHILDREN ! MAY/JUNE 2010 7

Most medical, psychiatric, and law enforcement agencies have licensing standards that govern their use of physical restraint.

the aggressive behaviors commonlydisplayed by these students is nolonger the sole concern of only specialeducators who have historically servedstudents with the potential for behav-ioral crisis in segregated settings.Having the ability to safely manage abehavioral crisis has now become critically important for all staff mem-bers who work with these students,including general education teachers,paraprofessionals, counselors, andadministrators.

Prevention and Deescalation

Although physical restraint may beneeded in emergency situations inschools where student behavior maythreaten injury or death to that studentor others, these procedures are some-times being used in inappropriate cir-cumstances and without awareness ofthe dangers that their use creates.Being able to determine the need forphysical intervention and how to cor-rectly and appropriately use these pro-cedures in emergency situationsrequires staff training. Staff trainingstrategies for preventing behavior prob-lems and for conflict deescalation mayalso reduce the number of situationsthat might require using these proce-dures (Ryan, Peterson, Tetreault, & Vander Hagen, 2007).

There are several primary preven-tion strategies to prevent conflict andinappropriate behavior from initiallydeveloping. One widely used evidence-based preventive approach is positivebehavior interventions and supports(PBIS), which focuses on (a) teachingstudents how to behave appropriately,(b) increasing reinforcement for appro-priate student behavior, and (c) usingdata to design and monitor behavioralinterventions and supports. PBIS-basedinterventions have demonstrated effica-cy in increasing prosocial behavior andreducing challenging behavior when(a) applied universally throughout theschool or agency; (b) applied to partic-ular settings such as classrooms, play-grounds, or home settings; and (c)used with individual students (Sugai etal., 2005).

There is a variety of other preven-tive approaches, including curricula to

promote cooperation and reduce con-flict (e.g., Peaceable School Program,Bodine, Crawford, & Schrumpf, 1994;Creative Conflict Resolution, Kreidler,1984; Peace Patrol, Steele, 1994); medi-ation programs (e.g., CommunityBoard Program, 1990; Copeland, 1995;Kreidler, 1997); bullying preventingprograms (e.g., Bonds & Stoker, 2000;Espelage & Swearer, 2004; Garrity,Jens, Porter, Sager, & Short-Camilli,1994; Hoover & Oliver, 1996; Newman,Horne, & Bartolomucci, 2000; Olweus,2000); and schoolwide social skills orcharacter education programs (e.g.,Boyer, 1995; Likona, 1988; and organi-zations such as the Search Institute,Character Counts, and The CharacterEducation Partnership).

Research indicates that preventiveapproaches can indeed reduce chal-lenging behavior and thus reduce theneed for physical restraint to controldisruptive or dangerous behaviors(George, 2000; D. N. Miller, George, &Fogt, 2005; J. Miller, Hunt, & George,2006). There are also techniques fordeescalating individuals who areexhibiting out-of-control behavior, thatare essential for any school personnelworking with students who have thepotential for such behavior. Unfortun -ately, when staff are not properlytrained in effective crisis interventiontechniques and don’t know how toproperly respond to students as theyprogress through the various stages ofthe cycle of aggression (i.e., agitation,acceleration, peak, deescalation;Colvin, 2004), their actions, both ver-bal and physical, may inadvertentlyexacerbate the behavior.

Assessing Crisis InterventionTraining Programs

Although school-based programs mayoffer the potential for preventing orreducing the likelihood of crisis situa-tions occurring in school, specific train-ing is also needed regarding how tomanage crisis situations. Commercialcrisis intervention training programsare geared toward staff in a variety ofsettings where clients have the poten-tial for behavioral crises requiringintervention, such as psychiatric hospi-tals, correctional facilities, mental

health treatment programs, policeforces, and even schools. Althoughmany of these programs refer to “pre-vention” or “conflict deescalation”components, most people think of thistype of training as “restraint training.”

Selecting a program that providessufficient evidence-based informationabout the broad range of variables thatare important to prevention of behav-ioral crises (e.g., variables related tocurriculum, instruction, behavior man-agement, or verbal interactions) is animportant task for school and agencyadministrators. Unfortunately, it can behard to access the critical informationadministrators need to know prior toselecting an appropriate training pro-gram for their specific school, such ascourse content, emphases, length oftraining, and types of physical inter-ventions taught. How do these pro-grams differ regarding course content,duration, and training features?

Commercial Training Programs

We used a common Internet searchengine and nominations from profes-sional educators based on their experi-ence to identify 22 commercial pro-grams (for-profit and not-for-profit)that currently offer training in crisisdeescalation procedures for educators.We contacted either the company’sowner or a lead trainer directly andasked that they respond via interviewor in writing to a 38-item questionnaire(available from the first author uponrequest) addressing the followingareas: (a) purpose of program, (b) ter-minology, (c) components of trainingprogram, (d) time allotted for eachtraining component, (e) training andcertification/recertification require-ments, (f) types of programs offered,and (g) instructional strategies incorpo-rated within training. Potential respon-dents were able to review the question-naire in advance and were given theoption of responding via telephoneinterview or in writing. If we did notreceive a response within 1 monthafter initial contact we followed up.After we tabulated the informationfrom the completed questionnaires andcreated tables, we sent the results toeach respondent so that they could ver-


ify the accuracy of the information pro-vided in this article and correct anyinaccuracies.

Thirteen (60%) of the identified cri-sis intervention training programs vol-untarily responded to the electronicsurvey. Table 1 provides organization,program name, and contact informa-tion for each of these programs.Although each organization’s missionstatement varies, the primary focus ofall of the programs is to provide staffmembers who are working in hospital,school, residential facility, habilitationcenter, and community-based settingsprofessional training on how to proper-ly prevent and intervene in aggressivebehavior. Although all of these pro-grams focus on prevention of aggres-sive or out-of-control behavioralepisodes, all except one program (i.e.,Positive Behavior Facilitation) also offerinstruction on the use of physicalrestraint procedures as a part of thetraining.

Many of these programs offer sever-al levels of training courses, rangingfrom a basic practitioner level (thefocus of this article) to more advancedtrain-the-trainer programs which certifyparticipants to provide training to otherstaff members in their school or agencysites. Further information regardingother levels of training offered is avail-able from the vendors. It should benoted that all the information regardingthe content of training programs pre-sented in this review is proprietary orcopyrighted by the individual pro-grams. Further, most of these programsprovide training for a wide range ofclients, including hospitals, residentialtreatment facilities, and other facilities,not just schools. For purposes of thisreview, we use terminology reflectiveof schools (e.g., students rather thanclients or patients).

Training Program Components

To be able to distinguish how the vari-ous programs divided their emphases

in training, we asked vendors to pro-vide the total amount of training timein their basic or initial training pro-gram and how much of that timeaddressed each of six specific compo-nents: (a) general information and def-initions, (b) crisis antecedents anddeescalation, (c) restraint procedures,(d) restraint monitoring procedures,(e) debriefing and follow up, and (f)other additional training topics (seeTable 2). There was a wide range ofanswers among the 13 programs;“basic” training varied from 12 to 36hours. Most of the programs spend asubstantial amount of time on “crisisantecedents and verbal deescalation,”with all but one program (i.e., Safeand Positive Approaches at 17.5%)indicating between 25% and 50% oftime spent on this topic. In programsthat included training in physicalrestraint, 10% to 32% of the totaltraining time was devoted specificallyto training in various restraint proce-dures. Only one program (i.e., Safe &


Table 1. Crisis Intervention Training Programs

Note. The content of the programs reported in this article is copyrighted and may not be used or reproduced without permission fromthe individual programs. The names of most of these programs are trademarked and may not be used by others.

Organization Program NamePhone

Number Web Site

Crisis Prevention Institute (CPI),Inc.

Nonviolent Crisis Intervention (NCI) 800-558-8976 www.crisisprevention.com

David Mandt and Associates The Mandt System 800-810-0755 www.mandtsystem.com

Devereux National Safe & Positive Approaches 610-542-3107 www.devereux.org

JKM Training, Inc Safe Crisis Management 866-960-4SCM www.jkmtraining.com

NAPPI, International, Inc. BESST 800-358-6277 www.nappi-training.com

Pro-ACT, Inc. Professional Assault Crisis Training 949-489-5700 www.proacttraining.com

Quality Behavioral Solutions, Inc. Safety-Care 866-429-9211 www.qbscompanies.com

Residential Child Care Project,Cornell University

Therapeutic Crisis Intervention (TCI) 607-254-5210 www.rccp.cornell.edu/TCI

Rocket, Inc. Positive Behavior Facilitation (PBF) 301-980-2927 www.rocketinc.net

Satori Learning Designs, Inc.

Satori Alternatives to ManagingAggression

210-641-0955 www.satorilearning.com

Service Alternatives TrainingInstitute, A Division of ServiceAlternatives, Inc.

RIGHT RESPONSE 800-896-9234 www.rightresponse.org

Therapeutic Options, Inc. Therapeutic Options 302-753-7115 www.therops.com

University of Oklahoma NationalResource Center for YouthServices (OUNRCYS)

Managing Aggressive Behavior(MAB)

918-660-3700 www.nrcys.ou.edu/training.shtml

Positive Approaches) spent more timeon teaching restraint procedures thanon antecedents and deescalation; twoothers (Safety-Care and RIGHTRESPONSE) indicated nearly equaltime devoted to these topics.

For those programs that addressedrestraint, from 2.5% to 15% of avail-able time was devoted for each of thetopics of restraint monitoring proce-

dures and debriefing. Such procedurestypically include an evaluation of stu-dent and staff safety and breathingirregularities or other indicators of stu-dent safety and well-being during therestraint. All of the programs that teachphysical restraint procedures alsoinstruct participants how to monitorthe restraint procedures, although someof these amounts of time were minimal

(2.5% to 10% of training time). The

programs that teach restraint proce-

dures also spend a portion of their

training time (again, sometimes a

rather minimal 2.5% to 15% of train-

ing time) providing participants with

strategies for debriefing and following

up with students and/or staff after

administering a physical restraint.


Table 2. Crisis Intervention Training Components

Program

GeneralInformation/Definitions

CrisisAntecedents &Deescalation

RestraintProcedures

RestraintMonitoringProcedures

Debriefing &

Follow UpAdditionalTraining

Total Basic

Training

Nonviolent CrisisIntervention® (NCI)

4% (.5 hr) 48% (5.75 hr) 25% (3 hr) 8% (1 hr) 15% (1.75 hr) 0% 100% (12 hr)

The Mandt System 2.5% (.4 hr) 25% (4 hr) 15% (2.4 hr) 2.5% (.4 hr) 2.5% (.4 hr) 52.5% (8.4 hr) 100% (16–24 hr)a

Safe & PositiveApproaches

10% (2 hr) 17.5% (3.5 hr) 30% (6 hr) 2.5% (.5 hr) 2.5% (.5 hr) 37.5% (7.5 hr) 100% (20 hr)

Safe CrisisManagement

5% (.9 hr) 40% (7.2 hr) 25% (4.5 hr) 5% (.9 hr) 10% (1.8 hr) 15% (2.7 hr) 100% (18 hr)

BESST 5% (.8 hr) 30% (4.8 hr) 25% (4 hr) 5% (.8 hr) 5% (.8 hr) 30% (4.8 hr) 100% (16–20 hr)a

Professional AssaultCrisis Training (Pro-ACT)

10% (2 hr) 45% (9 hr) 10% (2 hr) 15% (3 hr) 15% (3 hr) 5% (1 hr) 100% (20 hr; 16hr basic course, 4 hr restraint cer-tification course)

Safety-Care 5% (.6 hr) 25% (3 hr) 25% (3 hr) 10% (1.2 hr) 10% (1.2 hr) 25% (3 hr) 100% (12 hr)b

Therapeutic CrisisIntervention (TCI)

5% (1.4 hr) 50% (14 hr) 30% (8.4 hr) 5% (1.4 hr) 10% (2.8 hr)Addnl 12-hrmodule avail-able)

0 100% (28 hr)

Positive BehaviorFacilitation (PBF)

50% (18 hr) 25% (9 hr) 0% (0 hr) 0% (0 hr) 0% (0 hr) 25% (9 hr) 100% (36 hr)

Satori Alternativesto ManagingAggression

10% (1.2 hr) 50% (6 hr) 15% (1.8 hr) 5% (.6 hr) 5% (.6 hr) 15% (1.8 hr) 100%c

RIGHT RESPONSEe 2% (.28 hr) 31% (4.34 hr) 32% (4.48hr)

5% (.7 hr) 5% (.7 hr) 25% (3.5 hr) 100%d

TherapeuticOptions

10% (1.4 hr) 35% (4.9 hr) 20% (2.8 hr) 2% (.28 hr) 5% (.7 hr) 30% (3.5 hr) 100% (14 hr)

ManagingAggressiveBehavior (MAB)

30% (3.9 hr) 25% (3.25 hr) 20% (2.6 hr) 5% (0.65) 15% (1.95 hr) 5% (.65 hr) 100% (13 hr)

Note. Many programs offer multiple levels of training. The percentages were provided by the programs. Hours were calculated on thelowest level training offered. aPercentage based on 16-hr training. bCore curriculum requires 12–16 hr. cPercentage based on 12-hr training. dPercentage based on 14-hr advanced certification program. eOffers 4 levels of training, ranging from 5–14 hr; each level adds additional layers of skills,depending upon the role and needs of the attendee.

Types of Restraint Interventions

The majority of crisis intervention programs provide training in one ormore of the following areas: (a) protec-tion and releases, (b) physical escorts,(c) standing restraints, (d) seatedrestraints, (e) prone floor restraints, (f)supine floor restraints, and (g) sidefloor restraints (see Table 3).

Protection and Releases. Releases areprotection techniques that a staff mem-

ber can use to avoid physical injuryfrom a physically aggressive student.Protection maneuvers allow staff mem-bers to avoid blows (e.g., punches orkicks) to the body; release maneuversteach staff members how to escapefrom a student’s grasp (e.g., studentgrabs staff member’s hair) with mini-mal injury if they are unsuccessful inavoiding an attack. Most of the pro-grams incorporate some training onprotection and release techniques,

although three programs did not speci-fy their content in this area (see Table3). This type of training can be benefi-cial to those dealing with physicallyaggressive students because it trainsstaff how to deal with physical aggres-sion in a manner that avoids injury toeither the student or the staff member.

Physical Escorts. Physical escorts areinterventions that staff members canutilize to transport a student from onesetting (e.g., classroom) to another for


Table 3. Releases, Escorts, and Restraint Procedure Components

Note. Number in parenthesis (e.g., 3) represents number of types of restraints taught for that category.aTaught only on request, where legal. bRequires advanced training to perform. cAdvanced training teaches transition from this to standing restraint.

ProgramProtection

and ReleasesPhysicalEscorts

Standing Restraint

Seated Restraint

Prone Floor

Restraint

Supine Floor

Restraint

Side Floor

Restraint

Nonviolent CrisisIntervention®(NCI)

Examples of prin -ciple based personal safety (7)

Yes (1) (4; includes trans-port position,counted in Escorts)

No Noc Noc No

The Mandt System Not specified Not specified Yes Not specified No No No


Yes (13) Yes (4) Yes (2) Yes (6) No Yes (4) No


Yes (2) Yes (3) Yes (8) Yes (4) Yes (3)a Yes (3)a Yes (1)

BESST Not specified Yes (2) Yes (3) Yes (2, for small bodies)

No No Yes (1)

ProfessionalAssault CrisisTraining (Pro-ACT)

Yes Yes Yes Yes Yes Yes Notspecified

Safety-Care Yes (7) Yes (2) Yes (2) Yes (2) Yesb Yesb No


Yes (10; protectiveinterventionsincluding releases)

Not specified Yes (1) Yes (2) Yes (1) Yes (1) No


No No No No No No No


Not specified Yes (1) Yes (2) No No No Yes (1)

RIGHT RESPONSE Yes (14) Yes (8) Yes (7) Yes (7) Yes (3)a No No

TherapeuticOptions

Yes Yes (3)a Yes (3) Yes (1)a No Yes (1)a No


Yes No Yes No No No No

purposes of safety. Escorts are typicallyconducted using either one or two staffmembers. Five (38%) of the programsprovide training on how to escort stu-dents (two programs did not providetraining on this topic, and two did notspecify their training here). It is impor-tant for staff to recognize that perform-ing a physical escort risks escalatingstudent aggression further given that itrequires a staff member (a) to force astudent to perform an action she or hedoes not desire, and (b) to physicallyplace hands on an agitated student.Both of these actions may result in anescalation of aggressive behavior.Escorts in a school setting are typicallyused to remove a student from a class-room or to move a student to a seclu-sion or time-out environment.

Standing Restraints. Standing physi-cal restraints typically entail one ormore staff members using their handsand bodies to immobilize a studentfrom the standing position. Most stand-ing restraint procedures attempt to con-trol the student’s arms while maintain-ing him in an unbalanced position toprevent him from being able to strike astaff member with his legs. All 12(100%) of the training programs thatteach restraints teach a standingrestraint hold. There are numerousvariations of standing restraint proce-dures and, as can be seen in Table 3,up to eight variations of standingrestraints may be taught. Selection of aspecific method is often determinedbased on the size of the student andnumber of staff available. Standingrestraints do pose a reduced risk ofdeath due to asphyxia because all par-ties are standing up, and with theexception of wall restraints, preventstaff from placing weight on the stu-dent’s back or chest.

Seated Restraints. Seated physicalrestraints are also discussed in most(8) of the training programs. The stu-dent is in a seated position, typicallywith arms interlocked to prevent hit-ting. Mechanical restraints are some-times used to secure students to theirown wheelchairs or other positioningequipment such as Rifton chairs.Because of the close proximity requiredfor seated restraints, staff members

may be at risk for head butts, punches,or kicks.

Prone or Supine Floor Restraints.Floor restraints including prone (facedown), supine (face up), and siderestraints can be very dangerous andhave resulted in death (National Dis -ability Rights Network, 2009). Injuriescan occur while trying to administerthese restraints (e.g., tackles, falls tothe ground) and also as a result ofexcessive pressures on the body (chest,lungs, sternum, diaphragm, back,neck, or throat) once the student isplaced in the restraint (Council forChildren With Behavioral Disorders,2009). This risk emphasizes the impor-tance of training programs teachingsome sort of restraint monitoring pro-cedure. Ongoing safety is a major con-cern with such restraints. The dangersassociated with this type of restraint(i.e., they have been associated withthe most injuries and deaths) may alsoexplain why 58% (7 of the 12 whichteach restraints) of the training pro-grams reviewed do not currently teachprone restraints. Approximately 50% (6of the 12 which teach restraints) donot teach supine restraints, probablybecause this position has much of thesame potential for injury or death.

Side Floor Restraints. Only three ofthe programs include training in sidefloor restraints, where the student isplaced on one side on the floor.Although intended to be less danger-ous than prone or supine restraints,these positions may still pose some ofthe same dangers as described forprone and supine restraints, and maybe hard to maintain without severalstaff members being involved.

Safety Procedures

Several types of safety procedures canbe considered in training programs thatemploy physical restraint including (a)having a time limit on the restraint, (b)having more than one person involvedin the restraint, (c) monitoring the stu-dent’s physical state for symptoms ofdistress, and (d) monitoring the stu-dent’s emotional state. These topics areaddressed for the responding programsin Table 4.

Time Limits. Physical restraint pro-cedures should only be utilized as longas necessary to prevent a student frominjuring themselves or others. Obvi -ously the time required to achieve thisgoal may vary based on both the cir-cumstances and individual beingrestrained. Nevertheless, maintaining arestraint after danger of injury haspassed could not only be viewed asunnecessary and therefore abusive, butmay also extend the potential forinjury. Currently, there do not appearto be any commonly agreed timeguidelines. Six of the programs did notset a time limit or even make a recom-mendation regarding length of time forcontinuing physical restraints. One pro-gram set a limit of 3 minutes, with 4programs making recommendationsthat restraints be conducted for 5 min-utes or less. One program (i.e., Thera -peutic Crisis Intervention) provided thelongest time limit recommendation (15minutes).

Requiring Involvement of MoreThan One Person. Another potentialsafety factor is a requirement thatmore than one staff member beinvolved in a restraint. This permitsadditional staff to manage therestraint, thus reducing the risk ofinjury by providing more control of thestudent’s body. In addition, it permitsmore than one person to monitor thestudent’s physical and emotional state.Three of the programs appeared torequire that more than one staff mem-ber be involved; four other programsrecommended more than one staffmember. All programs may recognizesituations where physical restraint maybe necessary, whether or not morethan one staff member is available.

Provisions for Monitoring PhysicalState and Symptoms of PhysicalDistress. Given the potential for injuriesand deaths due to restraint procedures,all 12 of the training programs indicat-ed that they train staff members tomonitor students for symptoms ofphysical distress. Although exactlywhat symptoms are monitored andhow training is accomplished varied;nevertheless, this appeared to be a uni-versal component across programs.



Table 4. Safety Procedures for Restraint Procedures

ProgramTime Limits

Requires More ThanOne Person

Provisions for Monitoring Physical State

Training Includes

Symptoms ofPhysical Distressa

Provisions for Monitoring Emotional State


No Yes Recommends team interven-tions; one team member notinvolved in restraint shouldmonitor student’s physicalstate.

Yes Staff members are taught tocontinually assess for signsof deescalation and oppor-tunities to use a lessrestrictive means of inter-vention; auxiliary teammembers monitor emotion-al and physical safety ofindividual.

The Mandt System 3 Minutes No Follows recommendations ofChild Welfare League ofAmerica

Yes Yes


Position ofstudent inrestraintshould bechanged inaccordancewith time-lines, (e.g., atleast every 5min).

Recommended Staff not involved in restraintshould observe and docu-ment student’s physical andemotional condition in accor-dance with established time-lines, (e.g., at least every 5min); recommend that allstaff members involved inrestraints be trained in firstaid and CPR.

Yes Yes; staff are taught specificobservational monitoringtechniques.


5 min forprone; 10 minfor all others

Recommended Utilizes assessment recom-mendations of Child WelfareLeague of America.Recommends an observer forall physical restraints.

Yes Yes

BESST No Yes Techniques designed withrespect to range of motion,avoidance of head and neckareas, maintain upright pos-ture; recommends CPR certi-fication for all direct-careemployees.

Yes: breathingmechanics andkinesiology

No, but staff are taughtthat restraints cause emo-tional distress and thereforeshould be ended as soon aspossible.


No Recommended Staff are taught physiologicalindicators of breathing andcirculation.

Yes Yes, staff are taught specificindicators of emotionaltrauma.

Safety-Care No Recommended Yes; recommends a licensedmedical professional monitoreach restraint.

Yes Yes; deescalation proce-dures continue duringrestraint.


No (decisionwhether tocontinueshould bemade by staffwithin 15min)

Yes Yes; recommends a healthcare professional be presentto monitor each restraint.

Yes Yes; staff are taught toassess level of agitationand listen to what studentis saying.


N/A N/A N/A N/A N/A

continues

Provisions for Monitoring EmotionalState. In addition to monitoring physi-cal state, the student’s emotional stateis potentially a strong indicator ofwhen physical restraint proceduresshould be discontinued. All except oneprogram suggested monitoring theemotional state, but all indicated thatconflict deescalation procedures shouldbe continued during the restraint andthat the restraint should be ended or aless restrictive intervention attemptedas soon as the student’s emotionalstate permitted. At least some of theprograms also provided training regard-ing the retraumatization of students,acknowledging that the use of restraintmay trigger in some clients emotionalresponses based on prior experienceswith physical or sexual abuse or othertrauma.

Documentation of Incidents

Seven of the training programs includ-ed procedures for documenting the useof restraint procedures (see Table 5).In most cases this included specificformats or templates for recording dataabout the incident. However, most ofthe programs did not include specificdocumentation of injuries occurring asa result of a restraint. At least a couple

of programs simply indicated thatinjuries be discussed as a part of thedebriefing procedure. One program(i.e., Mandt) indicated that injuries tostudents should be reported to localprotection and advocacy organizations.

Certification and Recertification of Trainees

All but one of the programs providesome form of time limited certificationfor completing basic training, but therequirements for recertification varied(see Table 5). Several had annual recer-tification, and a few biannual recertifi-cation. Others were not specific abouttheir recertification requirements. Itappeared that all of the programs hadrecurrent training and certificationrequirements for “trainers.”

Limitations

Of the original crisis training programswe identified, nine elected not to par-ticipate in the study and some did notrespond to our request. Some programsrequested that they have final approvalof any mention of their program in thisarticle prior to publication, which wedeclined, with the result that these pro-grams did not participate. There mayvery well be additional deescalation

training programs and other less formaltraining programs that local school sys-tems may have developed or adoptedfor their own training purposes, so ourfindings may not reflect all of the train-ing programs that might be available.

Even when training programs didrespond, our questionnaire may nothave permitted sufficient detail to adequately address program content orother details. This is particularly prob-lematic because most of these pro-grams are providing training that theyview as proprietary, and thus may notbe willing to share detailed contentinformation for fear that the contentmay be stolen by others. In addition,these programs compete with eachother and therefore do not want theirproprietary information being sharedeven inadvertently with their competi-tors.

Finally, although we believe that thedata for this article was accurate at thetime that it was gathered (summer andfall 2009), the curriculum and contentof these training programs may changeover time. This is particularly truegiven the media and public attentionon this topic, and given the deaths andinjuries caused by some restraint holdsor procedures.


Table 4. Continued

ProgramTime Limit

Requires More ThanOne Person

Provisions for Monitoring Physical State

Training Includes

Symptoms ofPhysical Distressa

Provisions for Monitoring Emotional State


No, but rec-ommend lessthan 5 min

Required forFloor Restraint

Yes Yes Yes, through the use of theAssisting Process.

RIGHT RESPONSE No No Yes, staff are taught safetyprotocols.

Yes Yes

TherapeuticOptions

Left up tolocal schoolpolicy andstate law

Yes, when pos-sible; supinehold requires 3people

Yes; nurses are summonedwhen available; nonmedicalstaff monitor in the absenceof medical staff.

Yes Yes; sensitivity to traumati-zation and retraumatizationis a focus; stresses theimportance of maintainingthe helping relationship.


Recommend 5min

No, but recom-mended

Yes; staff are taught to moni-tor student for risk factors ofrestraint and comfort.

Yes Yes, through check-ins andassurances.

aSymptoms that may be monitored include but are not limited to breathing, circulation, color of skin and nail beds, skin temperature,and bladder control.


Table 5. Documentation, Complaints, and Certification Information

aRequirements or recommendations for continued certification for staff and trainers.

ProgramType of

Documentation

Procedure for InvestigatingComplaints or Injuries

Related to Restraint

Certification/Recertification

of Traininga


Incident reports; data collectiontemplates provided.

Injuries and complaints should be documented and discussed duringdebriefing.

Basic training: Annual refreshertraining recommended.

Trainers: Annual recertification,testing every 2 years, renewalcourse every 4 years.

The Mandt System Training provided on documenta-tion requirements.

Recommend complaints or injuries bereported to state protection and advo-cacy organization.

Basic training: Annual certification.Trainers: Biannual certification.


Training provided on documenta-tion requirements. Documentationincludes antecedents, personnelinvolved, date and time, location,interventions, outcome, duration,injuries or damages, and eventsfollowing incident.

Yes, during postintervention assess-ment and debriefing.

Basic training: Annual certification.

Trainers: Annual certification.


Provides policy recommendationsfor recordkeeping, including modelforms.

Provides policy recommendations, butno specific procedures.

Trainers: Annual recertification.

BESST Provides recommendations forrecordkeeping.

No Basic training: Annual recertifica-tion.


Provides training on documenta-tion.

No Trainers: Annual training require-ments.

Safety-Care Provides training in documentationof all restraints and crisis incidents.

No Core curriculum: Annual certifica-tion.Trainers: Annual recertification.


Provides information that shouldbe included in documentationreports.

Yes; separate course for investigatingallegations of abuse and use of physi-cal restraint.

Basic training: Refresher courserequired every 6 months.


N/A N/A Trainers: Recertification every 3years.


No, but encourages agencies tomaintain data on use of restraints.

Recommends review of assistingprocess.

No recertification. Facilitators maylead “micro sessions” to keep skillsfresh.

RIGHT RESPONSE Recommends recordkeeping forpurpose of data analysis.

Recommends documentation throughincident reports.

Biannual recertification forElements, Elements+ Level; annu-al recertification for advanced level.

Trainers: Annual or biannual recertification.

TherapeuticOptions

No; left up to facility’s internalrequirements and those of the statesystem governing the program.

Not a formal part of the program, butmanual recommends formal investiga-tion of any incident involving injury.

Annual recertification for staff.


No No Basic training: Annual recertifica-tion.

Implications for Practice

The amount of time for basic trainingvaried considerably, although most ofthe training programs required about12 to 16 hours for basic training. Theredid not appear to be a consensusregarding the length of basic trainingneeded, although this may reflect vary-ing levels of detail provided by differ-ent training programs. This variationraises the question of how much train-ing should minimally be provided toeducators regarding these topics inorder to be effective. There is little

information or research to guide a deci-sion on this important issue.

Although some of the major topicsfor training are consistent across ven-dors providing this training, it is clearthat there are major variations in whatis emphasized. One of the most signifi-cant differences among the programshad to do with the relative emphasisplaced on restraints versus crisisantecedents and conflict deescalation.There may be a widespread need ineducational settings to provide trainingto all or certain staff members on conflict deescalation; the need for alleducators to be trained in physicalrestraint is much less clear. How ever, it can be argued that for the relativelyfew educators who need to be trainedin using restraint procedures, a morethorough training may be necessarythan can be accomplished in the rela-tively small amounts of time providedby some programs. This raises a ques-tion: Which type of training should be provided to whom? No guidelinesexist regarding the amount of timeneeded to provide proficiency on thesetopics.

Future research might examinewhether any vendors provide trainingthat is specifically designed for chil-dren, particularly young children.Techniques used on an adult may beinappropriate for a child, particularly asmall child.

Another growing concern is thatthese physical restraint techniquesmay retraumatize students alreadysensitive to touch due to previousphysical/sexual abuse or sensoryissues (e.g., autism). We did not deter-mine whether these programs providedany information to trainees regardingtrauma informed care or informationspecific to a disability or diagnosis.

Still another issue is whether train-ing should be differentiated for educa-tors versus care providers at psychiatrichospitals, detention facilities, correc-tional facilities, and so forth. Certainly,

such programs already exist. If schoolswere to rely more on preventive pro-grams, they may be less dependent onthe vendors described in this study fortraining on those topics.

It seems likely, however, that thevendors described in this report willstill be among the likely providers oftraining specifically addressing physicalrestraint for students in schools, asthese vendors have collectively thelargest set of experience and expertiserelated to this topic. They also havetrack records in providing this type oftraining. Although it is beyond thescope of our study to address stan-dards for content of crisis interventiontraining programs, either the federalgovernment or individual states maychoose to identify content standardsfor training on these topics. Creatingindependent standards would providean opportunity for further examinationof the content of training providedregardless of the source of the training.Further research should explore estab-lishing content standards and stan-dards for quantity as well as quality oftraining, and compare individual train-ing programs against these standards.

Final Thoughts

The use of restraint procedures in pub-lic schools will likely continue to be acontroversial issue for years to come,especially given the injuries, deaths,and litigation associated with its use.Training will continue to be a key pointof discussion related to this topic, andschool leaders will need additionalinformation about the content andcharacteristics of available training inorder to make decisions about trainingneeds. This preliminary examinationshould provide a springboard to moredetailed discussion of training needsrelated to physical restraint.

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Michael Couvillon (CEC IA Federation),Assistant Professor of Education, DrakeUniversity, Des Moines, Iowa. Reece L.Peterson (CEC NE Federation), Professor ofSpecial Education and CommunicationDisorders, University of Nebraska-Lincoln.Joseph B. Ryan (CEC SC Federation),Associate Professor of Special Education,Clemson University, South Carolina. BrendaScheuermann (CEC TX Federation), Profes -sor of Curriculum and Instruction, College ofEducation, Texas State University, San Mar -cos. Joanna Stegall (CEC SC Federa tion),Doctoral Student, Clemson University, SouthCarolina.

Address correspondence to Reece L. Peterson,202A Barkley Center, University of Nebraska-Lincoln, Lincoln, NE 68583 (e-mail: [email protected]).

Amy Hartmann, a special education teacherat Simon Middle School in Hays Consoli -dated I.S.D. in Texas, and Jenni Huber, apostdoctoral student at Arizona State Univer -sity, both made important contributions tothe development of this manuscript. Thesecontributions are gratefully acknowledged.

TEACHING Exceptional Children, Vol. 42,No. 5, pp. 6–17.

Copyright 2010 CEC.


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