Increasing efforts have been made in the field of special education to identify positive, evidence-based practices (EBPs) to meet the needs of students who engage in problem behavior, with a major goal being to eliminate or limit the use of reactive measures such as restraint and seclusion (Snell & Walker, 2014). Various stakeholders, including families and self-advocates, have voiced concerns about the dangers of restraint and seclusion and the lack of protection afforded to students who engage in severe problem behavior. In the previous article in this issue of Intellectual and Developmental Disabilities, Beaudoin and Moore (2018) echo these concerns in their account of a family's experience with restraint as told from the perspective of a father whose son was subjected to restraint, resulting in a number of adverse short- and long-term consequences that affected the entire family. In response to Beaudoin and Moore, we provide readers with a brief review of the current status of restraint and seclusion in school settings and evidence-based strategies that can be used to address severe problem behavior and reduce the need for restraint and seclusion. For readers interested in exploring restraint and seclusion in greater depth, we suggest recent work by Trader and colleagues (2017). We also have outlined guidelines for behavior support planning that should be considered by various stakeholders as educators work toward establishing safe and supportive school environments that address a wide range of student behavioral needs.
The exact prevalence of restraint and seclusion among children and adults with intellectual disability and related developmental disabilities (IDD) is unknown. However, recent reports from the Government Accountability Office (GAO; Kutz, 2009) provide insight into cases of restraint and seclusion resulting in physical and psychological harm and, in some instances, fatalities among students in school settings. Restraint and seclusion are considered emergency strategies only to be used in cases in which students or other individuals are in imminent danger (Simonsen, Sugai, Freeman, Kern, & Hampton, 2014). For all other instances of problem behavior, educators should implement the evidence-based strategies outlined in a student's behavior support plan (BSP). Unfortunately, seclusion and restraint are too often relied upon as acceptable ways to “manage” or “deal with” severe problem behavior, as was the case reported by Beaudoin and Moore in their article.
Even when schools have well-established systems of supports and interventions to address student problem behavior, it is reasonable to expect that some students may engage in dangerous, high priority problem behavior, thereby requiring the use of emergency strategies to maintain safety within the school. In such cases, school teams must be equipped with the knowledge and skills necessary to develop and implement crisis plans in the event that such measures are needed. Furthermore, teams will need to establish a plan that clearly outlines the specific conditions under which practices like restraint and seclusion can be used should behavior escalate to a dangerous level (for specific guidelines, see Simonsen et al., 2014). Establishing and following such a plan is particularly critical given that many states and school districts have little to no guidelines regulating the use of restraint and seclusion (Butler, 2017).
Implications of Seclusion and Restraint in Response to Problem Behavior
Using restraint and seclusion to address problem behavior can lead to serious consequences for both the students and school personnel. As documented by Beaudoin and Moore (2018), the use of these aversive, reactive behavior management techniques may result in trauma or further exacerbate existing mental health issues (Trader et al., 2017; Westling, Trader, Smith, & Marshall, 2010). Furthermore, and largely due to the reactive nature of restraint and seclusion, students will likely continue to engage in problem behavior, as restraint and seclusion procedures do not include strategies to teach the student prosocial alternative behaviors. It is also possible that students will develop new forms of problem behavior or existing problem behavior will increase in intensity as a side effect of restraint and seclusion. When punishment-based practices like these are used, the implementer and other conditions associated with implementation (e.g., the intervention setting) may become aversive to the student, potentially leading to problem behavior that results in escape or avoidance of the implementer or other aversive conditions. Finally, school personnel utilizing restraint and seclusion may inadvertently enter into a vicious cycle in which restraint and seclusion replaces implementation of interventions outlined in a student's BSP. Because restraint and seclusion often produce immediate effects (i.e., problem behavior decreases), the implementer is reinforced for utilizing the practice and is more likely to do so in the future instead of implementing BSP strategies that may produce less immediate effects.
There is limited evidence supporting the effectiveness of restraint and seclusion for addressing severe problem behavior (Simonsen et al., 2014; Trader et al., 2017). In order to promote a positive and safe school environment, evidence-based practices (EBPs) must be available for students who engage in severe problem behavior so that the use of restraint and seclusion becomes unnecessary or is significantly minimized. In fact, special education law emphasizes the importance of positive behavioral interventions and supports (PBIS) in developing function-based interventions for students with disabilities who engage in problem behavior (IDEA, 2004). A wealth of literature clearly shows the effectiveness of PBIS in not only reducing problem behavior, but also increasing prosocial behavior for students with disabilities (e.g., Goh & Bambara, 2012). In addition, decades of research have provided professionals with a strong evidence base supporting the effectiveness and social validity of function-based interventions to address severe problem behavior among individuals with IDD in a variety of school settings (Goh & Bambara, 2012; Walker, Chung, & Bonnet, 2017). In particular, and emphasized under a PBIS framework, function-based interventions comprised of multiple components are advantageous in that the BSP addresses ways in which the school team can prevent problem behavior, teach replacement behaviors, and respond to problem behavior. In contrast, restraint and seclusion are reactive practices that fail to provide students with supports that improve the educational environment and that teach prosocial behaviors or other critical skills (e.g., self-management, coping strategies) necessary to succeed in the school setting. As noted earlier, this can lead to reoccurrence or worsening of problem behavior. A multicomponent approach often involves input and collaboration among a range of school team members, including family members, and focuses on a student's quality of life (Carr et al., 2002). As such, the BSP development process reflects the types of person-centered planning activities that are recommended by Beaudoin and Moore (2018).
An in-depth description of the features and development of multicomponent function-based interventions is beyond the scope of this article. However, we provide readers with a brief description of the general assessment and intervention development processes to provide context for those guidelines outlined later in the article. Initially, the school team conducts a functional behavior assessment (FBA) to identify the function of the student's problem behavior. At minimum, this process involves the following activities: (a) reviewing student records; (b) interviewing individuals who are familiar with the student; (c) gathering information through questionnaires (e.g., Motivation Assessment Scale; Durand & Crimmins, 1992); and (d) observing the student and collecting direct observation data on problem behavior and environmental events that precede and follow problem behavior (O'Neill, Albin, Storey, Horner, & Sprague, 2015). If the team is unable to determine the function of problem behavior through this descriptive process, a functional analysis (FA) may be utilized as a means to gather information necessary to develop a BSP. This more complex assessment process involves systematically manipulating the environment to intentionally evoke problem behavior, thereby providing the assessor with information necessary to make judgements about the behavioral function (Iwata, Dorsey, Slifer, Bauman, & Richman, 1982). Teams new to FBA and FA should recruit assistance from behavior analysts or other school personnel who have expertise in these extensive assessment procedures, as the effectiveness of the BSP hinges on this assessment information. Regardless of the assessment method (FBA or FA), the school team will utilize the results of the assessment to inform the development of a BSP comprised of function-based interventions.
Function-based interventions included in the BSP are designed to address the identified function of problem behavior by preventing problem behavior, teaching alternative behaviors, and responding to problem behavior and targeted appropriate behaviors (Bambara & Kern, 2005; O'Neill et al., 2015). A key feature of BSPs developed under a PBIS framework involves identifying supports that prevent problem behavior by improving conditions under which problem behavior occurs (e.g., eliminating or modifying specific events that seem to trigger the behavior). These supports should be offered in conjunction with other elements of the BSP. As the BSP is developed and throughout its implementation, school teams should regularly assess whether the intervention strategies outlined in the plan have good contextual fit, meaning the extent to which they align with the values, needs, skills, and resources available in the setting (Albin, Lucyshun, Horner, & Flannery, 1996). Contextual fit is essential to the effective implementation of student BSPs. If a BSP includes strategies that are not valued and deemed important, or if the staff do not have the skills and resources to implement a BSP, effective implementation is unlikely (if not impossible).
Minimizing the use of restraint and seclusion in school settings serving students with IDD is an arduous task that will require systems-change efforts. Earlier in this paper, we discussed assessment processes (FBA and FA) and evidence-based interventions (function-based interventions to prevent problem behavior, teach replacement behaviors, and respond to occurrences of problem behavior) that are effective in assessing and treating severe problem behavior. The goal is that the student's team conducts a FBA/FA, develops a BSP that is technically adequate and contextually appropriate, and then implements the plan to improve student behavior and quality of life and decrease instances of seclusion and restraint. Each of these steps (assessment, plan development, and plan implementation) is essential. Often in applied settings there is greater attention to assessment and plan development and minimal (if any) attention to implementation (Pinkelman & Horner, 2017). The effective implementation of EBPs is a challenging and complex endeavor that requires attention to more than just the interventions themselves (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005). Teams must also consider a variety of relevant systems-level variables, particularly how staff will be trained and continually supported to implement the BSP and how data will be collected and reviewed to evaluate both implementation and student behavior (Pinkelman & Horner, 2017; Trader et al., 2017).
Staff Professional Development
Before staff can be expected to implement a student's BSP, they must be trained to do so. The goal is to train staff to implement interventions outlined in a student's BSP with high fidelity. Fidelity, also referred to as treatment integrity, refers to the extent to which interventions are implemented as planned (Gresham, Gansle, & Noell, 1993). Function-based interventions to address severe challenging behavior might look unlike other strategies staff are accustomed to implementing, and as such will require a good deal of training and coaching to implement with fidelity. Unfortunately, professional development provided to staff most often is characterized by didactic “one shot” workshops that are ineffective in training staff to successfully implement EBPs (Fixsen et al., 2005). Effective professional development requires that staff receive (a) information regarding the theory of the practice and rationale for use, (b) modeling of correct implementation, and (c) opportunities to practice implementation and receive feedback (Fixsen et al., 2005; Joyce & Showers, 2002; Parsons, Rollyson, & Reid, 2012). In addition, it is important that staff receive ongoing support in order to maintain high fidelity. Staff will certainly encounter unanticipated barriers that will impede their ability to effectively implement the strategies previously trained. It is crucial that systems are established to continually evaluate and support staff in implementation. Data on fidelity should be collected and reviewed regularly. When data demonstrate fidelity is low (more on this in the section below), teams must identify ways to better support staff in implementation. One potential way to support staff is through Implementation Planning (Sanetti, Collier-Meek, Long, Byron, & Kratochwill, 2015), which outlines an explicit process for adapting the intervention to the setting context, addressing logistical concerns, and identifying barriers to implementation and strategies to overcome those barriers. The Performance Diagnostic Checklist-Human Services (PDC-HS; Carr, Wilder, Majdalany, Mathisen, & Strain, 2013) is another tool that teams might find useful. Using the PDC-HS, teams can assess performance deficits and then plan for how they can provide support to improve fidelity of implementation. For more in-depth information on performance management, we refer readers to Daniels and Bailey (2014). This is an excellent text that describes how to effectively manage staff behavior in an easy-to-read format.
Monitoring Implementation and Student Behavior
Once the behavior support team develops a comprehensive BSP (i.e., one that is technically adequate and contextually appropriate) and staff members have been trained in implementation, the next step is to collect data. In addition to collecting data on occurrences of seclusion and restraint as recommended by Beaudoin and Moore (2018), it is essential that data be collected on the fidelity with which the BSP is implemented as well as student behavior. Data on fidelity allow the team to determine if the BSP is being implemented correctly, and data on student behavior allow the team to determine if the plan is effective (Detrich, 2014; Fixsen et al., 2005; Park & Pinkelman, 2017; Pinkelman & Horner, 2017). When behavior support teams review these two forms of data, there are four potential outcomes: (1) the BSP is not being implemented correctly and student behavior is not improving; (2) the BSP is not being implemented correctly and student behavior is improving; (3) the BSP is being implemented correctly and student behavior is not improving; or (4) the BSP is being implemented correctly and student behavior is improving (Detrich, 2014). Obviously, the fourth potential outcome is preferred, but it is not unusual for data to indicate otherwise. If the BSP is not being implemented as intended and student behavior is not improving, the team should work to improve the fidelity with which the plan is implemented using some of the tools outlined above, such as Implementation Planning (Sanetti et al., 2015), the PDC-HS (Carr et al., 2013), and other aspects of performance management (Daniels & Bailey, 2014). It is possible that, with improved fidelity, student behavior may also improve. If the BSP is not being implemented as intended and student behavior is improving, this should prompt the team to continue monitoring and closely examine the variables in the student's environment that may be producing the change in behavior. If data indicate the BSP is being implemented correctly and student behavior is not improving, the team should reconvene to revise the student's plan. Finally, if the BSP is being implemented with fidelity and student behavior is improving, the team should continue implementing and begin identifying a plan to fade supports (Detrich, 2014). It is more common that organizations collect data on student behavior, and collecting data on fidelity may seem like an extra and non-essential task. However, fidelity data are absolutely critical. If teams cannot ensure the BSP is implemented with fidelity, no judgments can be made as to whether the plan is improving student behavior.
In this article, we provide guidelines for addressing severe problem behavior that, if followed, could displace and eliminate restraint and exclusionary practices. To achieve this goal, we advocate that educational teams rely on EBPs. However, this is only possible if school personnel are equipped with the skills and resources necessary for implementing these complex interventions, in particular multi-component function-based interventions. Furthermore, it is essential that school personnel closely monitor both fidelity of implementation and student outcomes to ensure the efficacy of BSPs. Finally, all who are concerned with providing a free and appropriate public education to students with IDD must advocate for a continued and increased focus on establishing safe and positive school environments. To assure that supports are put in place that contribute to a better quality of life for students with IDD and challenging behaviors, the involvement of families in developing BSPs is vital. We believe that Mr. Beaudoin would have been able to tell a far different story about his son's and his family's experiences with educators and schools had evidence-based behavioral supports been introduced at an early age.