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The use of physical interventions

David Allen, Associate Clinical Director, Special Projects Team, Abertawe Bro Morgannwg University Health Board & Professor in Clinical Psychology in Learning Disability, Welsh Centre for Learning Disabilities, Cardiff University.

Introduction

Challenging behaviours often endure over long periods of time. Getting effective support is often difficult, and even when really good support plans are in place, there may be times when challenging behaviours occur. At such times, carers will often need to intervene in order to prevent harm to the person concerned or to themselves. In the absence of well-thought out plans to manage out of control behaviours, the risks of injury for both parties are increased. As Horner and colleagues (1990) state ‘An effective technology for supporting people with severe challenging behaviours must provide families and staff with specific strategies for when these behaviours occur. It is not sufficient simply to recommend how to ignore or avoid undesirable behaviours’.

What are reactive strategies?

‘Reactive strategies’ is a widely used term to describe such interventions. As their name suggests, they are 'reactive' in the sense that they are brought into play once challenging behaviours occur and provide carers with clear plans for how to respond to them when they do. Their use will not result in any future change in the pattern of a person's behaviour; their goal is simply to help carers achieve rapid, safe, and effective control of risky behaviours.

Because of these limitations, reactive strategies must never be used on their own, but should instead be employed within the context of an overall Positive Behavioural Support plan, the focus of which is to try and prevent challenging behaviours occurring in the first instance. Such a plan must be built on a functional assessment of what drives the person’s challenging behaviour and is likely to include steps for reducing or avoiding known triggers for a person's behaviour and plans for teaching skills will enable them to get their needs met in a more constructive fashion.

The key to the effective use of reactive strategies is a detailed knowledge of the pattern of behaviour shown by a person. Despite the frequently held view that challenging behaviours occur 'out of the blue', most people show us signs that they are becoming agitated or distressed before they lose control. Learning to recognise these early signs is the basis for early intervention, and the earlier carers intervene, the more probable it is that serious behavioural outbursts can be avoided.

A good reactive plan should therefore follow a gradient approach, with the early signs of behavioural agitation being responded to with efforts to distract the person and defuse the situation; if this proves ineffective, the priority will change to thinking about the possible use of physical interventions to re-establish behavioural control.

Physical Interventions

The term 'physical interventions' refers to 'any method of responding to challenging behaviour which involves some degree of direct physical force to limit or restrict movement or mobility' (Harris et al, 2008). Three broad categories of physical intervention may be identified:

Direct physical contact between a carer and a person with challenging behaviour (e.g., self-protective 'breakaway' techniques for escaping from grabs and chokes or minimal restraint to briefly immobilise the person)
The use of barriers, such as locked doors, to limit freedom of movement
The use of materials or equipment to restrict or prevent movement (e.g., the use of arm splints to reduce self-injury)

Jones & Allen (2009) provide a review of the particular issues that govern the use of mechanical restraint.

Use of Physical Interventions

As can be imagined, this is an emotive topic which generates numerous ethical and practical concerns. Many care agencies shy away from considering this issue - despite that fact that physical interventions will almost certainly be being used on an informal basis within any service supporting children or adults with severely challenging behaviour. Evidence (Emerson, 2003) suggests that over 50% of people with intellectual disabilities and challenging behaviour are regularly exposed to restraint.

In 1996 (revised 2008), the British Institute for Learning Disabilities produced a set of policy guidelines designed to help services improve their practice in this area. Some key principles are that:

Restrictive physical interventions should only be used in the best interests of the person with learning disabilities
They should only be used in conjunction with other strategies to help people learn to behave in non-challenging ways
They should be individualised and subject to regular review
They should employ minimal force and not cause pain

The second of these points is particularly crucial because, as stated above, as physical interventions can only be ethically delivered within an overall context of an individualised Positive Behaviour Support package.

The policy guidelines were followed-up with a Code of Practice for Trainers (2001; revised 2006 & 2010) and an accreditation procedure for training organisations (2002). The Department of Health & the Department for Education & Skills issued their own guidance on restrictive physical interventions (DOH/DES, 2002). This guidance was prompted by a BBC documentary by Donal MacIntyre, which highlighted the inappropriate use of physical interventions in a residential care home. The document usefully draws attention to high- risk procedures, some of which have been associated with deaths of service users (Paterson et al., 2003). In response to these concerns, the Welsh Assembly Government (2005) has banned the use of prone (face down) restraint.

Legal Issues

The law surrounding the use of physical interventions is also extremely complex. Christina Lyon and Alexandra Pimor (2004) have produced a major review of UK legislation concerning the use of restraint with children, young people and adults with learning disabilities and severe challenging behaviour.

Physical Interventions in the Family Context

Joint research with the Challenging Behaviour Foundation (Allen, Hawkins & Cooper, 2006) found that:

87.5% of parent respondents to a postal survey had used physical interventions with their relative
20.8% did so frequently
Only 25% had received training
Most physical interventions were improvised therefore and often posed significant risks

Hawkins et al (2009) provide a comprehensive discussion of the barriers and issues involved in providing training in physical intervention to family members, and Hawkins et al (2011) report on the outcomes associated with providing such training and demonstrate that it can be an effective intervention.

Reducing the Use of Reactive Strategies

The use of reactive strategies should reduce over time with effective intervention. Unfortunately, in many services, their use appears to remain very frequent. We do actually know a tremendous amount about what to do in terms of reducing the use of restrictive practices at an organisational level. Essentially, we know that the use of restrictive practices can be significantly reduced in services that:

have leaders and managers that have reducing restrictive practices as a clear priority
use data to closely monitor how often they are used
use specific procedures such as proven risk assessment and management tools
involve service users in planning programmes to reduce restrictive practices
good debriefing procedures that ensure that lessons are learnt when things go wrong (and right!)
invest in developing appropriate skills (especially those to do with proactive, preventative approaches) in staff

Allen (2011) reviewed this research and outlined how the systemic implementation of Positive Behaviour Support could achieve reductions in the use of restraint, seclusion and as required medication; Allen et al (2011) provide some evidence that this can be achieved in practice.

Selected Further Reading

Reactive Strategies

Allen, D. (2003) (Ed.) Ethical approaches to physical intervention: Responding to Challenging Behaviour in Persons with Intellectual Disabilities. Kidderminster: British Institute of Learning Disabilities

Allen, D. (2009) (Ed) Ethical Approaches to Physical Intervention Volume II: Changing the Agenda. Kidderminster: British Institute of Learning Disabilities.

Allen, D. (2011) Reducing the use of restrictive practices with people who have intellectual disabilities. Kidderminster: British Institute of Learning Disabilities.

Positive Behavioural Support

Allen, D., James, W., Evans, J., Hawkins, S. & Jenkins, R. (2005) Positive Behavioural Support: Definition, Current Status and Future Directions. Tizard Learning Disability Review, 10, 2, 4-11.

References

Allen, D., Hawkins, S. & Cooper, V. (2006) Parents’ use of physical interventions in the management of their children’s challenging behaviour. Journal of Applied Research in Intellectual Disabilities, 19,4, 356-363.

Allen, D., James, W., Evans, J., Hawkins, S. & Jenkins, R. (2005) Positive Behavioural Support: Definition, Current Status and Future Directions. Tizard Learning Disability Review, 10, 2, 4-11.

Allen, D., Lowe, K., Baker, P. Dench, C., Hawkins, S., Jones, E. & James W. (2001) Assessing the effectiveness of positive behavioural support: The P-CPO Project. International Journal of Positive Behavioural Support 1,1, 14-23.

British Institute of Learning Disabilities (2010) BILD Code of Practice for Trainers in the Use of Physical Interventions. Third Edition. Kidderminster: BILD.

Department of Health & Department for Education & Skills (2002) Guidance for Restrictive Physical Interventions. How to provide safe services for people with Learning Disabilities and Autistic Spectrum Disorder. London: DOH.

Emerson. E. (2003) The prevalence of use of reactive management strategies in community-based services in the UK. In Allen, D. (Ed.) Ethical Approaches to Physical Interventions. Responding to Challenging Behaviour in People with Intellectual Disabilities. Kidderminster: BILD.

Harris et al (1996). Physical Interventions a Policy Framework. Kidderminster. BILD.

Harris, J. (1996) Physical restraint procedures for managing challenging behaviours presented by mentally retarded adults and children. Research in Developmental Disabilities, 17, 2, 99-134.

Harris, J., Cornick, M., Jefferson, A. & Mills, R. (2008) Physical Interventions. A Policy Framework. Revised Edition. Kidderminster: BILD/ NAS.

Hawkins, S., Allen, D. & Kaye, N. (2009) Physical intervention and family carers. Chapter 4 in Allen, D. (Ed) Ethical Approaches to Physical Intervention Volume II: Changing the Agenda. Kidderminster: Bild.

Hawkins, S., Kaye, N. & Allen, D. (2011) Training family carers in reactive strategies within a PBS framework. International Journal of Positive Behavioural Support 1,1, 32-44.

Horner, R.H., Dunlap, G., Koegel, R.L. et al (1990) Toward a Technology of ‘Nonaversive’ Behavioural Support. Journal of the Association for Persons with Severe Handicaps, 15,3,125-132.

Jones, E. & Allen, D. (2009) Mechanical restraint and self-injury in people with intellectual disabilities: an enduring cause for concern. Chapter 5 in Allen, D. (Ed) Ethical Approaches to Physical Intervention Volume II: Changing the Agenda. Kidderminster: Bild.

LaVigna, G.W., Willis, T.J., & Donnellan, A.M. (1989) The role of positive programming in behavioural treatment. In Cipani, E. (Ed) The Treatment of Severe Behaviour Disorders. Washington; AAMR.

Lyon, C.& Pimor, A. (2004) Physical Interventions and the Law. Legal issues arising from the use of physical interventions in supporting children, young people and adults with learning disabilities and severe challenging behaviour. BILD.

Paterson, B. et al (2003) Deaths associated with restraint use in health and social care in the UK. The results of a preliminary survey. Journal of Psychiatric and Mental Health Nursing, 10, 3-15.

Welsh Assembly Government (2005) Framework for Restrictive Physical Intervention Policy and Practice. Cardiff: WAG.

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