## Abstract

Restraint, restrictive interventions, and seclusion are hotly contested practices with inconclusive evidence of their effectiveness. Because the use of restraint and seclusion on people with intellectual and developmental disabilities (IDD) is controversial and its effectiveness doubtable, this study was conducted to explore if and how they were permitted in Medicaid HCBS 1915(c) waivers, the largest providers of long-term services and supports (LTSS) for people with IDD. To do so, 111 fiscal year 2015 IDD waivers from across the nation were examined to determine if and how states permitted restraint, restrictive interventions, and seclusion. Findings revealed an overwhelming majority of waivers permitted the use of restraint (78.4%) and restrictive interventions (75.7%). A smaller proportion (24.3%) allowed the use of seclusion.

Practices such as restraint, restrictive interventions, and seclusion have been traditionally applied to people with psychiatric disabilities and people with intellectual and developmental disabilities (IDD), particularly when they exhibit aggressive behavior. They are often used in institutions, schools, nursing homes, and hospitals (Ferleger, 2008). Yet these interventions prove to be controversial. The literature presents conflicting results about the safety of restraint and seclusion, and ethical concerns exist regarding their use, including concerns about the loss of personal freedom and rights (Scheirs, Blok, Tolhoek, Aouat, & Glimmerveen, 2012), not to mention evidence of physical and psychological harm. Staff may believe that restraint and seclusion are the safest and most effective ways to interact with an aggressive individual with disabilities despite evidence of negative outcomes of these interventions (e.g., death, injury, and/or emotional trauma; Knox & Holloman, 2012).

Table 1 describes the general definitions of restraint, restrictive interventions, and seclusion. There are three types of restraint that may be used for people displaying aggressive behavior: physical, mechanical, and chemical. Physical restraint is the application of force to address aggressive behavior; it is different from other types of physical contact that do not involve force and/or aggressive behavior (e.g., physically guiding an individual by holding their hand or physical contact to comfort an upset individual). Often, mechanical restraint is conceptualized as a type of physical restraint. However, mechanical restraint uses objects (e.g., straps) to restrain an individual while physical restraint uses bodily force to inhibit an individual. Chemical restraint introduces medications into the body in order to control or address aggressive behavior. Restraint may be planned or used in an emergency or crisis situation; emergency or crisis restraint is less safe than planned restraint (Williams, 2009). Factors such as organizational and governmental policies, staff training, and staff behavior affect the extent and application of restraint use (Ferleger, 2008).

Table 1

Literature Definitions of Restraint, Restrictive Interventions, and Seclusion

Restrictive interventions may be confused with physical restraints or even with seclusion. Generally, restrictive interventions impinge upon the rights of people who are exhibiting aggressive or problematic behavior. Examples of restrictive interventions include preventing a person from leaving their house or visiting a friend, loss of other privileges, loss of access to personal property (e.g., iPad or video game system), or increased supervision. Seclusion involves the separation of someone from others by placing them alone in a room that may be locked or unlocked, depending on policy.

### Controversies and Ethical Concerns

People with IDD may exhibit various types of aggressive behavior, such as damaging property, physical aggression, sexual aggression, verbal aggression, and self-oriented aggression (Crocker et al., 2006). Professionals generally agree that physical restraint should be applied only to address serious aggressive behavior (Luiselli, 2009). However, a Canadian study of people with IDD found that those who communicated using pictograms, took anxiolytics, exhibited severe aggressive behavior, and/or had a personal support worker with limited experience were more likely than their counterparts to encounter restrictive interventions (Merineau-Cote & Morin, 2013). Controversies and ethical concerns around using restraint, restrictive interventions, and seclusion coalesce around the physical health risks, psychological trauma, limitations of personal freedom, and humiliation that the procedures impose upon people exhibiting aggressive behavior.

Restraint poses the most serious physical health risks to people with disabilities. Despite the continued use of restraint, literature demonstrates that it poses serious threats to the health and safety of people with IDD and the person performing the restraint, especially when the restraint is not performed correctly (U.S. General Accounting Office, 1999). Restraint may result in death of the people being restrained but also physical and/or emotional harm to the person being restrained and/or the person restraining (Evans, Wood, & Lambert, 2003; Ferleger, 2008; Fisher, 1994; Mohr, Petti, & Moh, 2003; Rakhmatullina, Taub, & Jacob, 2013; U.S. General Accounting Office, 1999). A study of emergency restraints found that around one in three restraints resulted in injury, though most of the injuries were minor (Tilli & Spreat, 2009). Restraints that involve neck holds or that obstruct breathing (nose and mouth) have higher risks of fatality (Ferleger, 2008). A specific type of mechanical restraint called hobble tying is especially dangerous. Hobble tying occurs when a person is lying on their stomach (prone) and their wrists and ankles are tied together behind their backs; the tie acts as the mechanical restraint. A study of 214 excited delirium cases by Stratton, Rogers, and Brickett (2001) found that death occurred in 18 cases due to struggle or restraint using the hobble tying mechanical restraint.

These procedures can also cause psychological trauma. Physical restraint can elicit past memories of abuse for the person being restrained (Fish & Culshaw, 2005). Research has also found that staff implementing physical interventions found them to be upsetting and traumatic and consequently experienced feelings of guilt and self-condemnation when implementing these physical measures (Fish & Culshaw, 2005). Due to the emotional trauma associated with physical interventions, staff reported that these were a last resort—though people with disabilities did not necessarily agree with this statement (Fish & Culshaw, 2005).

In addition to physical and psychological risks, these techniques also limit freedom, dignity, and personal choice. One of the critiques of restraint is the humiliation of the person to whom the intervention is being applied (Ferleger, 2008). The very definition of restrictive interventions, for example, relies on the loss of personal freedom and rights.

In addition, the use of restraint, restrictive interventions, and seclusion may exacerbate problem behaviors, diminishing the effectiveness of the procedures (Luiselli, 2009). A literature review by Busch and Shore (2000) found a lack of evidence to support the benefits and risks of these procedures in addressing aggressive behavior in adults. Moreover, research also documents the low social acceptability of restraint use (Tilli & Spreat, 2009).

### Medicaid Home and Community-Based Services Waivers

Medicaid Home and Community-Based Services (HCBS) 1915(c) waivers were added to the Social Security Act in the 1980s during a time when people with disabilities received most of their services and supports in institutions. The purpose of the waiver program was to expand successful community living by providing community-based services. Prior to the creation of HCBS waivers, people with IDD who did not live with families had few options other than segregated institutional settings. However, the HCBS program allows service delivery in integrated community-based settings, including individual, family, and group homes.

Waivers allow states to waive key Social Security Act requirements including statewideness, comparability of services, and income and resource rules, which permits states to determine target groups, services furnished, participant direction, provider qualifications, health and welfare strategies, and cost-effective delivery (Disabled and Elderly Health Programs Group et al., 2015). As a result, states are able to target underserved populations of people with disabilities or chronic health conditions (e.g., HIV/AIDS, traumatic brain injury, older adults) and/or provide customized services to fit an elevated need for that population (Centers for Medicare and Medicaid Services, n.d.-b). For example, waivers may provide services such as personal assistance, day habilitation, or residential habilitation (Centers for Medicare and Medicaid Services, n.d.-b). The Centers for Medicare and Medicaid Services (CMS) requires waivers to describe CMS assurances and requirements; levels of care; waiver administration and operation; participant access and eligibility; participant services, including limitations and restrictions; service planning and delivery; participant direction of services; participant rights; participant safeguards; quality improvement strategies; financial accountability; and cost-neutrality demonstrations (Disabled and Elderly Health Programs Group et al., 2015). Although waivers are required to detail all of these parts, the flexibility granted to states by the waiver program has resulted in a wide variance across states in terms of service provision and waiver administration (Friedman, 2017).

## Discussion

Although restraint, restrictive interventions, and seclusion continue to be used on people with IDD, research has indicated that these techniques can pose a serious threat to the health and safety of people with IDD (U.S. General Accounting Office, 1999). Because of their prominence and the potential threat they impose, this study sought to determine the extent to which HCBS 1915(c) waivers, the largest provider of LTSS for people with IDD across the nation, permitted the use of restraint, restrictive interventions, and seclusion. Our study found that over 75% of HCBS waivers permitted restraint and restrictive interventions to be used on people with IDD in FY 2015, while a smaller proportion permitted the use of seclusion.

Of the waivers that permitted the use of restraint and restrictive measures, manual restraint was almost always permitted, and chemical and mechanical restraints were permitted nearly 70% of the time. Despite the widespread use of restraint and restrictive interventions, literature indicates that the use of these techniques may be harmful to both the person on which the intervention is applied and the person applying the intervention (Evans et al., 2003; Ferleger, 2008; Fisher, 1994; Mohr et al., 2003; Rakhmatullina et al., 2013; Tilli & Spreat, 2009; U.S. General Accounting Office, 1999).

Additionally, waivers that targeted adults only allowed restraints, restrictive interventions, and seclusion less often than waivers that targeted both children and adults or children only. More research is needed to determine why waivers for children with IDD, in particular, allowed restraints, restrictive interventions, and seclusion as much or more than waivers for adults or for both children and adults, as it seems counterintuitive given the harmfulness of these techniques. Perhaps these findings are related to the fact that there are a smaller number of waivers for children only (n = 27, 24.3%). Future research should explore states' reasons behind these decisions.

Waivers that targeted people with ASD allowed restraints and restrictive interventions less often compared to waivers that served the umbrella population of people with DD and ID- only waivers. Waivers that served the umbrella population of people with DD permitted seclusion more often than those that only served people with ID or ASD. Although the finding that waivers for people with ASD permit restraints and restrictive interventions less often is surprising given the history of aversive treatments for people with ASD (Lichstein & Schreibman, 1976), ASD waivers projected more spending on the average participant for behavioral health services (although not crisis services) than DD umbrella or ID-only waivers, suggesting that states are utilizing alternative treatment methods in lieu of these techniques.

While the majority of waivers permitted restraint, restrictive interventions, and seclusion, many particular practices were specifically prohibited, such as electric shock and other noxious stimuli, corporal punishment, and time-outs that included locking doors. These specific prohibitions convey an understanding of the ethical and physical implications of using particular types of restrictive interventions, arguably interventions that are the most frowned upon, especially with the United States' history of administering such treatments to individuals with psychiatric disabilities and/or IDD (Geller, 2006). Similarly, a small number of waivers required safeguards when implementing seclusion, such as not locking the door, sufficient air flow, and lighting.

Our findings also revealed relationships between provision of mental and behavioral health services, particularly behavioral therapy services and crisis services, and permittance of restraint, restrictive interventions, or seclusion. Waivers that permitted restraint, restrictive interventions, and/or seclusion all projected spending less per participant on behavioral health and crisis services than waivers that did not permit these techniques. More research is needed to determine the directionality of this relationship: Does states' provision of mental health services result in less need for interventions, or does a lack of interventions results in the need for more mental health services—or is the relationship bidirectional? In theory, as the claim is that these procedures address serious aggressive behavior (Luiselli, 2009), a better mental and behavioral health infrastructure should reduce the need for these aggressive and controversial techniques. Although determining whether the reduction in frequency of intervention techniques is due to a more successful mental and behavioral health infrastructure is outside the scope of this study, we believe it would be a fruitful avenue for future study. Given these techniques can produce negative outcomes, including serious harm, it is important that states take mental and behavioral health services into account when deciding if they shall permit or prohibit restraint, restrictive interventions, or seclusion.

This is especially pertinent as many professional organizations have denounced their use and in turn recommended alternative procedures for people with IDD displaying aggressive behavior. Two of the more prominent research and advocacy organizations on IDD—the American Association on Intellectual and Developmental Disabilities (AAIDD) and The Arc—produced a joint position statement denouncing the use of deprivation, physical restraint, and seclusion and noted that “these practices are dangerous, dehumanizing, result in a loss of dignity, and are unacceptable in a civilized society” (AAIDD, 2010). Instead, AAIDD and The Arc are proponents of the use of positive behavioral supports (AAIDD, 2010). Positive behavioral supports combine aspects of evidence-based practices such as applied behavior analysis (ABA) to address problematic behavior while working to increase independence, participation, and overall quality of life (Hieneman, 2015). For example, one study found organizational behavior management successfully reduced the use of mechanical restraints of people with IDD by 80% (Williams & Grossett, 2011). The American Psychiatric Nurses Association (2014) has also recommended that restraint and seclusion be used as a last resort for the minimum amount of time necessary and must never be used for staff convenience or to punish individuals for aggressive behavior. In addition, the United States Food and Drug Administration (FDA; 2016) has pushed for a ban on aversive restrictive intervention techniques because “they present an unreasonable and substantiated risk to public health.” In doing so, the FDA also proposes positive behavioral support as an alternative “for curbing self-injurious or aggressive behaviors” (U.S. Food and Drug Administration, 2016).

Future research and practice should work to identify other alternative methods that are safer, more effective, and less invasive on personal freedom than restraint, restrictive interventions, and seclusion. Because the majority of states permit the use of restraint and/or restrictive interventions in their HCBS waivers, it is important to have a plan in place to reduce and eventually eliminate their use quickly and safely. As identified by AAIDD and The Arc, positive behavioral supports are promising in addressing aggressive and problematic behavior. Professionals should work to eliminate the use of restraint, restrictive interventions, and seclusion.

### Limitations

When interpreting our findings, one limitation should be considered. Medicaid HCBS waivers are projections made to CMS rather than actual utilization data. Thus, our findings reveal where restraints, restrictive interventions, and seclusions are permitted rather than when they were actually utilized. However, waiver projections have been found to be a reasonably accurate proxy as they are based on previous years' utilization data (Rizzolo et al., 2013). Moreover, examination of FY 2010 HCBS waivers by Rizzolo et al. revealed findings similar to utilization analyses by Braddock et al. (2015). Future studies should examine how restraints, restrictive interventions, and seclusions are implemented in states that permit them in their HCBS waivers.

Another limitation of our qualitative findings is that our description of these themes only includes when states purposely noted these items; in these instances, it is not clear whether an absence of a description means states do not permit or prohibit the practices, or the state simply did not go into detail (Friedman & Rizzolo, 2016). Therefore, it is not necessarily clear if these techniques are always considered for emergency purposes only. Given these gaps, future studies should directly survey states to determine exclusion and inclusion criteria.

## Conclusion

A study by Lulinski-Norris (2014) found 91% of the people with IDD who returned to state institutions in Illinois did so because of behavioral issues. “This failure suggests an inadequate community capacity to provide necessary intervention for situations in which an individual is experiencing a behavioral crisis” (Friedman et al., 2015, p. 258). Many professionals believe the use of interventions such as restraint and seclusion are largely ineffective in treating behavioral issues in people with IDD (Antonacci, Manuel, & Davis, 2008), leading one to question: Why do so many HCBS waivers permit their usage?

As they can produce negative outcomes, as well as come with a serious risk of harm and injury, application of these restrictive techniques is intended as a last resort after other forms of intervention techniques have been applied; however, our study revealed restraint, restrictive interventions, and seclusion were permitted by an overwhelming majority of states. For this reason, our study also examined the relationship between these techniques and provision of behavioral therapy and crisis services to determine if states were considering these services as preventative or alternative methods to avoid use of restraint, restrictive interventions, and seclusion. Thus, we wanted to know if states that projected more funding for behavioral therapy and/or crisis services allowed the use of these techniques less often. Our findings suggest a relationship between a waiver's projected spending on behavioral therapy and/or crisis services and their permittance of restraint, restrictive interventions, or seclusion.

However, problematically, especially given these findings, there is a lack of prioritization of mental and behavioral health services for people with IDD among waivers in general. For example, in FY 2013, only 1.2% of HCBS waiver funding was projected for mental and behavioral health services for people with IDD, including crisis services (Friedman et al., 2015). Since these services are aimed at preventing the (re)institutionalization of people with IDD, we would suggest waivers allocate more funding toward behavioral health and crisis services. These services may be crucial to reduce the use of restraint, restrictive interventions, and seclusion, as well as promoting the community integration of people with IDD.

## References

References
American Association on Intellectual and Developmental Disabilities
. (
2010
).
Behavioral supports: Joint position statement of AAIDD and The Arc
.
American Psychiatric Nurses Association
. (
2014
).
APNA position statement on the use of seclusion and restraint
.
Antonacci,
D. J.,
Manuel,
C.,
&
Davis,
E.
(
2008
).
Diagnosis and treatment of aggression in individuals with developmental disabilities
.
Psychiatry Quarterly
,
79
(
3
),
225
247
. doi:
Bernard,
H. R.
(
1996
).
Qualitative data, quantitative analysis
.
Cultural Anthropology Methods Journal
,
8
(
1
),
9
11
.
D.,
Hemp,
R.,
Rizzolo,
M. C.,
Tanis,
E. S.,
Haffer,
L.,
&
Wu,
J.
(
2015
).
The state of the states in intellectual and developmental disabilities: Emerging from the great recession
.
Washington, DC
:
American Association on Intellectual and Developmental Disabilities
.
Busch,
A.,
&
Shore,
M.
(
2000
).
Seclusion and restraint: A review of recent literature
.
Harvard Review of Psychiatry
,
8
(
5
),
261
270
. doi:
Centers for Medicare and Medicaid Services. (n.d.-a). Application for a §
1915
(c) HCBS waiver: HCBS waiver application version 3.5
.
Centers for Medicare and Medicaid Services. (n.d.-b). Home & community-based services
1915
(
c
).
Chi,
M. T.
(
1997
).
Quantifying qualitative analyses of verbal data: A practical guide
.
The Journal of the Learning Sciences
,
6
(
3
),
271
315
.
Condition of Participation: Patient's Rights, 42 C.F.R. § 482.13
(
2006
).
Crocker,
A.,
Mercier,
C.,
Lachapelle,
Y.,
Brunet,
A.,
Morin,
D.,
&
Roy,
M. E.
(
2006
).
Prevalence and types of aggressive behaviour among adults with intellectual disabilities
.
Journal of Intellectual Disability Research
,
50
(
9
),
652
661
. doi:
Disabled and Elderly Health Programs Group, Center for Medicaid and State Operations, Centers for Medicare and Medicaid Services, & Department of Health and Human Services
. (
2015
).
Application for a §1915(c) Home and Community-Based Waiver [Version 3.5]: Instructions, technical guide, and review criteria
.
Evans,
D.,
Wood,
J.,
&
Lambert,
L.
(
2003
).
Patient injury and physical restraint devices: A systematic review
.
Journal of Advanced Nursing
,
41
(
3
),
274
282
. doi:
Ferleger,
D.
(
2008
).
Human services restraint: Its past and future
.
Intellectual and Developmental Disabilities
,
46
(
2
),
154
165
. doi:
Fielding,
N. G.
(
2012
).
Triangulation and mixed methods designs data integration with new research technologies
.
Journal of Mixed Methods Research
,
6
(
2
),
124
136
.
Fish,
R.,
&
Culshaw,
E.
(
2005
).
The last resort? Staff and client perspectives on physical intervention
.
Journal of Intellectual Disabilities
,
9
(
2
),
93
107
. doi:
Fisher,
W. A.
(
1994
).
Restraint and seclusion: A review of the literature
.
American Journal of Psychiatry
,
151
(
11
),
1584
1591
. doi:
Friedman,
C.
(
2017
).
A national analysis of Medicaid Home and Community Based Services waivers for people with intellectual and developmental disabilities: FY 2015
.
Intellectual and Developmental Disabilities
,
55
(
5
),
281
302
. doi:
Friedman,
C.,
Lulinski,
A.,
&
Rizzolo,
M. C.
(
2015
).
Mental/behavioral health services: Medicaid Home and Community-Based Services 1915(c) waiver allocation for people with intellectual and developmental disabilities
.
Intellectual and Developmental Disabilities
,
53
(
4
),
257
270
. doi:
Friedman,
C.,
&
Rizzolo,
M. C.
(
2016
).
Un/Paid labor: Medicaid Home and Community Based Services waivers that pay family as personal care providers
.
Intellectual and Developmental Disabilities
,
54
(
4
),
233
244
. doi:
Geller,
J. L.
(
2006
).
The evolution of outpatient commitment in the USA: From conundrum to quagmire
.
International Journal of Law and Psychiatry
,
29
(
3
),
234
248
.
Hieneman,
M.
(
2015
).
Positive behavior support for individuals with behavior challenges
.
Behavior Analysis in Practice
,
8
(
1
),
101
108
. doi:
Iwata,
B. A.
(
1987
).
Negative reinforcement in applied behavior analysis: An emerging technology
.
Journal of Applied Behavior Analysis
,
20
(
4
),
361
378
. doi:
Jick,
T. D.
(
1979
).
Mixing qualitative and quantitative methods: Triangulation in action
.
,
24
(
4
),
602
611
.
Knox,
D. K.,
&
Holloman,
G. H. J.
(
2012
).
Use and avoidance of seclusion and restraint: Consensus statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup
.
Western Journal of Emergency Medicine
,
13
(
1
),
35
40
. doi:
Lichstein,
K. L.,
&
Schreibman,
L.
(
1976
).
Employing electric shock with autistic children
.
Journal of Autism and Developmental Disorders
,
6
(
2
),
163
173
. doi:
Luiselli,
J. K.
(
2009
).
Physical restraint of people with intellectual disability: A review of implementation reduction and elimination procedures
.
Journal of Applied Research in Intellectual Disabilities
,
22
(
2
),
126
134
. doi:
Lulinski-Norris,
A.
(
2014
).
Community capacity to provide mental and behavioral health services to people with developmental disabilities
.
Paper presented at the Department of Disability and Human Development
,
University of Illinois at Chicago
.
Merineau-Cote,
J.,
&
Morin,
D.
(
2013
).
Correlates of restraint and seclusion for adults with intellectual disabilities in community services
.
Journal of Intellectual Disability Research
,
57
(
2
),
182
190
. doi:
Mohr,
W. K.,
Petti,
T. A.,
&
Moh,
B. D.
(
2003
).
Adverse effects associated with physical restraint
.
The Canadian Journal of Psychiatry
,
48
(
5
),
330
337
. doi:
Patton,
M. Q.
(
2002
).
Qualitative evaluation and research methods (3rd ed.)
.
Thousand Oaks, CA
:
Sage
.
Rakhmatullina,
M.,
Taub,
A.,
&
Jacob,
T.
(
2013
).
Morbidity and mortality associated with the utilization of restraints: A review of literature
.
Psychiatry Quarterly
,
84
(
4
),
499
512
. doi:
Restraints, 42 C.F.R. § 460.114
(
1999
).
Rizzolo,
M. C.,
Friedman,
C.,
Lulinski-Norris,
A.,
&
D.
(
2013
).
Home and Community Based Services (HCBS) Waivers: A nationwide study of the states
.
Intellectual and Developmental Disabilities
,
51
(
1
),
1
21
. doi:
Sandelowski,
M.,
Voils,
C. I.,
&
Knafl,
G.
(
2009
).
On quantitizing
.
Journal of Mixed Methods Research
,
3
(
3
),
208
222
.
Scheirs,
J. G.,
Blok,
J. B.,
Tolhoek,
M. A.,
Aouat,
F. E.,
&
Glimmerveen,
J. C.
(
2012
).
Client factors as predictors of restraint and seclusion in people with intellectual disability
.
Journal of Intellectual and Developmental Disability
,
37
(
2
),
112
120
. doi:
Stratton,
S. J.,
Rogers,
C.,
&
Brickett,
K.
(
2001
).
Factors associated with sudden death of individuals requiring restraint for excited delirium
.
American Journal of Emergency Medicine
,
19
(
3
),
187
191
. doi:
Tilli,
D. M.,
&
Spreat,
S.
(
2009
).
Restraint safety in a residential setting for persons with intellectual disabilities
.
Behavioral Interventions
,
24
(
2
),
127
136
. doi:
U.S. Food and Drug Administration
. (
2016
).
FDA proposes ban on electrical stimulation devices indtended to treat self-injurious or aggressive behavior [Press release]
.
U.S. General Accounting Office
. (
1999
).
Mental health: Improper restraint or seclusion use places people at risk
.
Ward,
T.
(
2007
).
Re-gendering data: Quantifying qualitative
.
Paper presented at the annual forum of the Association for Institutional Research
,
Atlanta, GA
.
Williams,
D. E.
(
2009
).
Restraint safety: An analysis of injuries related to restraint of people with intellectual disabilities
.
Journal of Applied Research in Intellectual Disabilities
,
22
(
2
),
135
139
. doi:
Williams,
D. E.,
&
Grossett,
D. L.
(
2011
).
Reduction of restraint of people with intellectual disabilities: An organizational behavior management (OBM) approach
.
Research in Developmental Disabilities
,
32
(
6
),
2336
2339
. doi:
Young,
F. W.
(
1981
).
Quantitative analysis of qualitative data
.
Psychometrika
,
46
(
4
),
357
388
.

Funds for this project were provided by a subcontract from the State of States in Developmental Disabilities project at the University of Colorado, School of Medicine. The State of States in Developmental Disabilities project is funded by the Administration on Developmental Disabilities in the U.S. Department of Health and Human Services (HHS). Research reported in this publication was also supported by the Council on Quality and Leadership (CQL). The content is solely the responsibility of the authors and does not necessarily represent the official views of the HHS or CQL and you should not assume endorsement.