The Autism Society Event and Education Recordings Archive

A four-year initiative in Grafton’s Winchester Region seeking to minimize the use of physical restraint has resulted in sustainable success. This session will briefly describe the actions taken during the initiative and will review the practical strategies used to avoid physical restraints while maintaining safety in both classroom settings and group homes. The discussion will also focus on data demonstrating positive results for individual clients, employees and the organization as a whole. In some cases, individuals with Autism or other developmental disabilities also experience behavioral challenges such as physical aggression towards others and/or self injurious behavior.  The acts of aggression come in various degrees of intensity. One thing, however, remains consistent: the physical aggression is a form of communicating when no other means are available or effective. 

Grafton has served individuals with Autism and other developmental disabilities accompanied by challenging behaviors for over 50 years.  Throughout that time, we have used various de-escalation strategies. When other tools failed, however, physical restraint was called upon to maintain safety.   For example, in one month in 2003, we had 260 physical restraints for a total duration of 3800 minutes.  In 2004, to address this issue, Grafton’s Chief Executive Officer identified minimization of physical restraint as an organizational key performance indicator. Over the course of four years, Grafton has succeeded in substantially decreasing the use of physical restraint.  In the Winchester Region in fiscal year (FY) 2004 there were 2151 restraints, in FY2005 there were 1397, in FY2006 there were 348, in FY2007 there were 53, and in FY2008 there were only eight.  The population of the individuals we serve has not changed and our census has remained stable over the four years.         
        Graph illustrates the decline in physical restraints at Grafton.

In addition to increasing client safety, the initiative resulted in the reduction of client induced Workers’ Compensation claims.  We will present this data and outline how this result was achieved by the program team in close collaboration with Grafton’s risk management department.  Grafton has also been recognized with the Negley Award for achievement in risk management and Winchester’s success with this initiative is being published in an upcoming issue of the Journal of Applied Research in Intellectual Disabilities.

The presenters will begin this session by taking the participants through initial development of the initiative to minimize the use of physical restraint in Grafton’s Winchester facility. They will cover the key steps to success and will focus on the support and enthusiasm of Direct Support Professionals who work with our clients. 

The second part of this session will examine in great detail actual physical

restraint data and the various strategies used at Grafton to achieve positive outcomes.  Detail will be included on the following strategies used prior to escalation:

1.      Flexibility – Although we all know the importance of schedules and routines to our students, it is also necessary to remain flexible and understand that activities may not always happen according to schedule. If a student is having a particularly bad day or a disagreement arises over what the student wants to do, remain flexible and creative to allow for scheduled activities to take place in ways that aren’t necessarily spelled out on the schedule. As the student is more calm and involved in the activity, steer the schedule back on track.

2.      Praise – Always provide positive praise and feedback to students when they are doing well. Ensure they understand specifically for what they are being praised so they are able to make the connection from the praise to the activity.

3.      Engagement – Engage the students in meaningful tasks and activities. This will provide them with a sense of belonging in the situation and allow them to be involved in the work that is taking place. Students who are actively engaged and involved are not as likely to take part in negative behaviors.

4.      Choices – It is important for students to take an active role in making choices for themselves. Staff should allow for appropriate choices so that the student is able to have positive experiences with the choices they make. Making choices gives the students more control over their environment and gives them a sense of ownership over the activity.

5.      Distraction – Often a student will begin displaying negative behaviors when they are focused only on the activity or action that is causing their behavior, such as lack of access to an item or avoiding work or task at hand. If the staff is able to distract the student by asking them to choose another activity that serves the same skill or allows them to direct their focus to something else for a short period of time, it is likely that the student will let go of their focus on the activity or work that was causing their agitation.

6.      Cross-Dialogue – This is a skill that staff are able to work on that will give them the opportunity to get information to a student without directly implying or drawing direct attention to a negative behavior. Staff may speak to one another, within ear shot of the student, naming appropriate behaviors or activities that could calm the student or take the place of the inappropriate behavior that may be starting to escalate. The student is able to hear what he or she should be doing without being directly reprimanded for the activity and choose a replacement behavior on their own.

Detail will also be given on the following strategies used during an escalated situation:

1.      Relax – If the situation escalates, the staff should remain calm and relaxed and not allow themselves to get caught up in the adrenaline of the situation at hand. A calm and relaxed person makes better decisions and is able to focus on the safety of those around them.  

2.      Listen – Listen to what the student is trying to communicate. What are they hoping to gain from engaging in this behavior? By listening, the staff can take steps to mitigate the situation by understanding what the student wants.

3.      Extraordinary Blocking – Using blocking pads and bags is a way to ensure that everyone remains protected if the situation escalates to the student trying to hurt himself or others. Being proactive and using soft materials, the staff should be able to keep the student from causing injury.

4.      Breaks – If the staff is involved in a situation that has extended for a period of time, they should be sure to step in and give one another breaks. Taking frequent breaks keeps the staff from becoming too personally involved in the situation and keeps up their energy so they are able to prevent injury to the extent possible.

Case studies paired with data depicting clients with severe behavioral challenges will be used to guide the participants through the treatment planning and implementation process.  One case study, in particular, will illustrate strategies used that promote a culture of comfort and security.  It is the story of a young man who came from a facility that used extreme, aversive techniques. At Grafton, this same young man is treated with dignity and respect with a far more positive outcome. The discussion will cover the critical decisions made leading up to his enrollment at Grafton; how the initial treatment plan was developed; the specific training of the direct support professionals; obstacles that were overcome, and; ultimately how the individual’s life was changed.

The session will conclude with an emphasis on sustaining success.  It is not uncommon in any organization for an initiative to be introduced and to fairly quickly see positive results. However, the results lessen as enthusiasm and data analysis weakens. In Grafton’s Winchester Region, the initial success of this initiative has led to an overall change in culture. There is a new way of thinking, a new way of viewing challenging behavior, and a solid process for treatment planning all of which resulted in the sustained efficacy of this program.  

The primary learning from this session is that physical restraint is not the only answer. In fact, it is not even a viable option any longer. Other alternatives are just as effective and much safer. The success achieved during this initiative can be easily replicated at other schools and facilities serving individuals with Autism and we want to help others in the field to take learnings back to their organization, minimizing the use of physical restraint elsewhere. Please note that Grafton has presented on the progress of this initiative at the Autism Society of America conference the past two years with an overwhelmingly positive response.  During the past presentations the focus was on the initiative and the development of action steps and strategic planning to make the vision of avoiding physical restraints a reality.  This year we would like to go into greater detail regarding the actual strategies used in the classrooms and group homes on a daily basis that contributed to our new found culture.

Learning Objectives:

Presenters:

Kimberly L. Sanders, M.S.
President/Ukeru Systems
Grafton Integrated Health Network

Kim has worked with individuals with autism and other developmental disabilities for over 26 years. She has served in a variety of both hands-on and leadership roles at Grafton , beginning as a direct support professional. She is recognized as an innovator for assisting organizations move towards a restraint-free environment.

Crystal M. Ranker, B.S., M.S.
Teacher
Grafton

Crystal Ranker works with children with autism spectrum disorders and other developmental disorders. She currently teaches Special Education at Grafton in Winchester, VA, and holds a B.S. in Organizational Leadership and an M.S. in Strategic Leadership. Crystal is working toward the completion of her master's degree in Special Education.

Pamela A. Martin, B.S., ACBSW
Training Support Manager
Grafton

Pam has spent over 20 years supporting individuals with ASD’s and other developmental disabilities in community based settings. Currently, Pam is the Training Support Manager for Grafton’s Winchester Region, and also specializes in teaching community members about understanding and supporting individuals with ASD’s. She has a B.S. in Social Work.

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