George Zukotynski, PhD, BCBA-D
Department of Aging and Disability Services
George.Zukotynski@dads.state.tx.us
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NADD for emphasizing support of ID and mental
health
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State Office Staff of DADS SSLC
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Thirteen Directors of Behavior Health Services
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Direct Support
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Our individuals
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Note: None of the information provided necessarily
represents the views of DADS, Texas, or DOJ
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Describe an integrated approach to reduce
restraints in a statewide system of supported
living centers
Delineate the differences between crisis
intervention restraint, medical restraint, and
protective mechanical restraint for self-injurious
behavior and reduction strategies.
Describe the six core strategies for reducing
restraint and seclusion (National Association of
State MH Program Directors).
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13 Supported Living Centers
Supporting 3391 individuals
Ranges in age and functioning level
Two Centers for alleged MR offenders
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DOJ Settlement Agreement
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◦ Scheduled Monitoring
◦ Section C on Restraints
◦ Impacts on policies, documentation,
implementation
◦ Impacts on total quality of programs
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Crisis Intervention
Restraints
•Protection from imminent danger
•Physical; prone/supine prohibited
•Mechanical
•Chemical
•Special IDT when more than three
in a rolling 30 days
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Protective Mechanical
Restraints for SIB
Mechanical restraint
applied to prevent the
danger of imminent
danger due to SIB
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Medical or Dental Restraint
Absolutely necessary for
procedure
Absolutely necessary for the
prevention of undoing of
treatment (medical healing)
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For restraints that are not emergency a
restraint plan is required
◦ Instructions to staff on the application of restraint
◦ For crisis intervention it includes behavioral
descriptions of imminent danger
◦ Instructions on how to remove restraint
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For each restraint plan there is a plan for
restraint reduction
◦ PBSP reinforcing functional replacement behavior
◦ A fading schedule for protective mechanical
◦ Healing condition has resolved
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SIX CORE
STRATEGIES
DOJ
SETTLEMENT
LEADERSHIP
GROUP
AGREEMENT
RESTRAINT
REDUCTION
STATE
POLICES AND
RULES
SENATE BILL
41
TRAUMA
INFORMED
CARE
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2005
2007
2012
• Six Core Strategies to Reduce the Use of Seclusion and Restraint
• Texas Seclusion and Restraint Reduction Leadership Group
• Hogg Foundation Sponsors Training and Consultation on
Trauma Informed Care at two Centers for Alleged Offenders
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DATA
LEADERSHIP
WORK
FORCE
COMSUMER
DEBRIEFING
PREVENTION
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2009
2011
2012
• DOJ Settlement Agreement
• Senate Bill 41 Prohibits Restraint in PBSPs
• Revised Restraint Policy: definitions, checklists,
restraint plans, release requirements
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2013
2014
•Texas Administrative Code: New
Restraint Rules
•Revised Restraint Policy: behavior and
biology; adjusted release time to
shorter intervals; processing plans
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Centers use standard
documentation checklists
to document crisis
intervention, medical, or
protective mechanical
restraint
Draft copies are reviewed
and finalized at the
Center
Data is typed into the
system
The data is placed in the
Dashboard
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This case study presented longitudinal aggregate data across 13 Centers
with a chronology of ecobehavioral changes (Ferlinger, 2008) from
2012-2014.
◦ Cultural factors: Six Core Strategies, Leadership Group, Trauma Informed Care
Training
◦ Governmental requirements: 2012 policy, Texas rules, 2014 policy
◦ DOJ Settlement Agreement
◦ A variety of trends are seen with some indicating decrease in restraint
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To date, there is only limited published research on restraint reduction
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Williams (2010), in a review of restraint reduction studies categorizes
five distinct approaches, several of which are in use in Texas
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Restraint fading for SIB
Staff Training
Assessment/modification of antecedent conditions
Modification of response contingent release criteria to a fixed-time release
Successful behavioral treatment
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Williams and Grossett (2011) set up organizational
requirements for mechanical restraint use: a behavior plan
must be developed to reduce restraint and a plan to reduce
injuries to self or others.
◦ Texas Administrative Code now requires a restraint plan and a PBSP to
reduce restraint and increase replacement behavior
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Luiselli (2009) in a review of restraint reduction lists the
following organizational strategies and clinical approaches
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Making criteria more stringent
Requiring more accurate and complete documentation
Performance improvement project
Staff training
Antecedent assessment and intervention
Fixed-time release
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Restraints versus supports
Mechanical restraint versus protective device
Medical procedures with medication vs
restraint
Fixed time release for crisis intervention
Least restrictive approach to crisis
Psychiatric emergency medication versus
chemical restraint
Research on restraint reduction
Research on de-escalation skills
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Ferlinger, D. (2008). Human services restraints: Its past and future. Intellectual and Developmental
Disabilities, 46, 154-165.
Huckshorn, K (2005). Six core strategies to reduce the use of seclusion/restraint. National Association
of State MH Program Directors. www.nasmhpd.org
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, 126-134.
Williams, D.E., (2010). Reduction and eliminating restraint of people with developmental disabilities
and severe behavior disorders: An overview of recent research. Research in Developmental
Disabilities 31,1142-1148.
Williams, D.E. & Grossett, D.L. (2011) Reduction of restraint of people with intellectual disabilities: An
organization behavior management t (OBM) approach. Research in Developmental Disabilities,
32, 2336-2339.
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