The Medical Use Of Restraints In Children

What are restraints?

Restraints are methods used to limit or restrict the movement of your child. They are used to protect the health and safety of your child, other patients, and caregivers.

What are the types of restraints?

• Physical and mechanical restraint: One or more caregivers may handle or hold your child to limit movement. Caregivers may also apply a mechanical restraint. Types of mechanical restraints include cloth or leather arm ties and hand mitts.
  
  
• Chemical restraint: This is the use of medicines to calm your child, limit his movement, or both. The medicine used is not part of your child's regular treatment. Chemical restraint may also be called rapid tranquilization. It may allow your child to talk with caregivers, be examined, and receive treatment without harming himself or others. Chemical restraint may be used alone. It may also be used along with other types of restraint. Medicines used for chemical restraint include sedatives and anti-anxiety medicines.
  
  
• Environmental restraint: This means putting your child into a limited area, such as a locked room, for a period of time. Environmental restraint is also called seclusion. It may be used to remove your child from a stressful situation and give him a chance to calm down.

When may restraints be needed?

• When behavior is violent or self-destructive: Restraint is used because your child may be dangerous to himself or others. Restraints may help control harmful behavior caused by problems, such as head injury, mental illness, or drug abuse.
  
  
• When behavior is non-violent or non-self-destructive: Restraint is used to allow caregivers to give your child medical treatment. For instance, restraints may help keep your child from removing a feeding tube or a tube that helps him breathe.

Are there guidelines for the medical use of restraints?

Yes. The Joint Commission is one of many medical organizations that provide guidelines for the medical use of restraints. General guidelines for the use of medical restraints include:

• Restraints are used only when other methods to control behavior have not worked. Restraints are used only when there is a risk of your child harming himself or others.
  
  
• Restraints are not used for punishment or to make your child easier to care for. They are not used to make your child do something. They are also not used because of your child's past restraint use, or your child's past behavior.

What must caregivers do before medical restraints are used?

Caregivers may ask about your child's health history and do a physical exam. Caregivers will try to learn the cause of your child's behavior to help avoid the use of restraints. Caregivers will also explain the rules about restraint use to your child. They will help him change his behavior to avoid restraint use. Caregivers also may try any of the following:

• Violent or self-destructive behavior management: De-escalation is when caregivers use methods to help calm your child and help your child control his behavior. Caregivers will work with your child to learn what may cause him to become upset and possibly violent. De-escalation can begin as soon as he shows signs that he may lose control of his behavior. Caregivers may do the following:
  
  
  • Speak to your child calmly and with respect. Caregivers will explain to your child what treatment is for and how he is expected to behave. They will also explain how restraints may be used. Puppets and other play therapy may be used to help a young child understand. Role-playing may be used to help an older child understand.
    
    
  • Listen to your child's concerns. For dental care or other medical treatments, a method called behavior guidance may help. The caregiver listens to the child's fears and takes steps to help relieve his anxiety (nervousness). This may be done by showing your child how the procedure will be done. Caregivers may also distract your child's attention from the procedure, such as by taking a short break.
    
    
  • Encourage your child to control his own behavior and praise him when he does. Caregivers may teach your child ways to avoid things that may cause him stress. For instance, if your child is in a mental health facility, he may be told to ignore the negative behaviors of other children.
    
    
  • Try to keep your child calm. Noise levels may be kept low. Muscle relaxation and art therapy may be used to help calm your child.
    
    
  • Explain what may occur if your child cannot calm himself. Caregivers will also help your child identify ways to avoid the use of restraints. This may be done using collaborative problem solving (CPS). This method helps you and your child learn what triggers may cause your child to act in an aggressive way. CPS may help prevent aggressive behavior before it happens.
    
    
  • Put your child in a time-out. A time-out removes your child from things that may cause him stress. During a time-out, your child may stay in an unlocked area for 30 minutes or less.
    
    
  • Use therapeutic or clinical holding. This is when a child is held by a caregiver or parent. The child is held until he calms down and regains control. Protective stabilization may also be used. This is when a caregiver or parent holds a child to allow a medical procedure to be done.
  
  
• Non-violent or non-self-destructive behavior management: Caregivers may observe your child more often to avoid the use of restraints. For instance, caregivers may watch your child to make sure he does not remove a feeding tube.

What must be done when physical and mechanical restraints are used?

• Caregivers will tell your child the type of restraint that may be used and the reason for it. They will also tell your child what he needs to do to avoid the use of restraints.
  
  
• When the restraint process begins, a caregiver will explain to your child what will happen. This caregiver protects the patient's head while other caregivers each manage an arm or leg. Whether your child is restrained on his back or stomach, he will be positioned so that he can breathe easily.
  
  
• Caregivers will monitor your child at all times while he is restrained. They will also do an assessment of your child every 15 minutes. This includes checking his vital signs, such as blood pressure, pulse (heart rate), and breathing. Caregivers will check to make sure the restraints are on your child correctly and that they are not too tight. Caregivers also will check whether your child needs food, water, medical care, or to use the toilet.
  
  
• A restraint order can last up to one hour for children younger than age nine. It can last two hours for those between 9 and 17 years old. When the restraint order ends, a caregiver will examine your child. If needed, the restraint order will be renewed.
  
  
• Restraint use will be stopped as soon as your child behaves as required by caregivers. This may include your child agreeing to act in a safe manner.

What must be done when chemical restraints are used?

• Caregivers need to know what medicines your child currently takes. Caregivers will make sure these medicines are safe to take along with medicines used for chemical restraint.
  
  
• Medicines used for chemical restraint are commonly offered to your child in pill form first. If your child refuses, medicines may be given as a shot or in an IV. An IV is a small tube put into a vein to give medicines or liquids.
  
  
• After the medicine is given, your child will be constantly monitored. Vital signs will be checked often until the medicine wears off.
  
  
• If sedation or general anesthesia is used for dental treatment, informed consent from the parent is needed. Sedation is medicine that helps reduce anxiety. General anesthesia is medicine that puts your child to sleep.

What must be done when environmental restraints are used?

• Caregivers will make sure the room used for seclusion is calm and safe. There should be windows with unbreakable glass so caregivers can monitor your child. There should be no exposed wiring, nails, or screws that may be used as weapons.
  
  
• Your child may keep personal objects if they do not increase the risk of harm to your child or caregivers. These objects may include clothing.
  
  
• Your child will be observed constantly by caregivers. This may be done in person or with a video camera.
  
  
• Caregivers will review the need for seclusion every two hours. Seclusion will end as soon your child behaves as caregivers have requested. This may include stopping violent behavior that puts others at risk.

Does your child need to agree to the medical use of restraints?

Trained caregivers usually decide when the use of restraints is needed. Caregivers will always tell your child what is going to happen before they apply restraints. Caregivers often try to get a child's consent for the use of restraint. Your child may have a behavioral health advance directive. This document describes how you or your child wants his care or restraint to be handled when he acts violently.

What must caregivers do after restraints are removed?

• Within 24 hours, caregivers will meet with you and your child to talk about the restraint event. They will discuss why restraint was needed and how restraint use could have been avoided. They will also discuss how restraint use may be avoided in the future. For instance, a safety plan may be created. This plan describes ways to avoid triggers, prevent conflicts, and strengthen coping skills. Caregivers may teach parents and other family members ways to help your child control his aggression.
  
  
• During this meeting, caregivers will ask if your child's physical and mental needs were met while restrained. If needed, a mental health caregiver will help your child cope with the restraint event. Your child may be encouraged to talk to people he hurt with his aggressive behavior.

How should you be involved when restraints are considered or used for your child?

As your child's parent or guardian, you will be told right away why restraint of your child is needed. A parent's informed consent is always preferred and is sometimes required before restraints can be used. Caregivers will:

• Tell the family when restraints are used. Caregivers will explain to the family the rules on the use of restraints.
  
  
• Ask family members about any physical disability that may increase your child's risk if restraints are used. Caregivers may also ask about past health care, other health problems, or physical abuse. They may ask about ways to help your child control his behavior.
  
  
• Ask family members to help calm your child and help him understand how he can avoid being restrained.
  
  
• Ask family members to act as sitters to help observe a child for problem behaviors. For instance, sitters can help prevent a child from removing a feeding tube. This can help avoid the use of restraints.
  
  
• Involve the family in the discussion that takes place after the use of restraints.

What are the risks of using restraints?

• When restrained, your child will not be able to do his normal daily tasks. Restraint use may damage your child's skin and may cause him to have trouble breathing. It may cause a pulmonary embolism (blood clot in the lung) or heart rhythm problems. After being restrained, your child may have flashbacks or nightmares. Rarely, an injury from restraint use can lead to death.
  
  
• The medicines used for chemical restraint may cause your child to feel sleepy and have nausea (upset stomach) and vomiting (throwing up). He may have muscles aches, nose bleeds, and an increased need to urinate. Medicines may cause drooling and may not work well with other medicines your child takes. Your child may have movements that he cannot control such as hand tremors (shaking). Certain medicines can decrease how well your child breathes. Your child may also be at risk for seizures (convulsions) and loss of consciousness. Talk with your child's caregiver if you have questions or concerns about the medical use of restraints.

Where can I find more information about the medical use of restraints?

If your child has been placed in restraints, you or your child may feel frustrated, angry, or sad. These feelings are normal. It may help to find out all you can about the use of restraints. For more information, contact:

• Joint Commission on Accreditation of Healthcare Organizations
  One Renaissance Blvd.
  Oakbrook Terrace , IL 60181
  Phone: 1- 630 - 792-5000
  Web Address: http://www.jointcommission.org
  

Care Agreement

Your child has the right to safe care and to be treated with respect when restraints are used. Restraints should not cause your child pain or other harm. You have the right to help plan your child's care. To help with this plan, you must learn about your child's health condition, how it may be treated, and when restraints may be needed. You can then discuss treatment options with caregivers. Work with them to decide what care may be used to best treat your child.