Use of restrictive practices for challenging behaviour in a person with developmental disability

Any form of restrictive practice (eg physical, chemical or mechanical restraint, seclusion or containment) has legal implications. Use of restraint during an emergency should be a ‘last resort’, and only in response to a behaviour that might cause harm to the person or others. For more information, see Restrictive practices, the law, and the responsibility of the doctor.

Restrictive practices can be defined differently in each state and territory. Forms of restraint and considerations if used for challenging behaviour in a person with developmental disability outlines the main forms of restraint and considerations if they are used for challenging behaviour in a person with developmental disability.

Documentation must include the specific circumstances justifying the use of a restrictive practice, the form, frequency and duration of the restraint used, clinical indication, monitoring requirements and strategies to reduce the need for such measures.

After the person settles, the clinician should reassess the situation and look for a cause for the behaviour (see Initial assessment and support).

Table 1. Forms of restraint and considerations if used for challenging behaviour in a person with developmental disability
[NB1] [NB2]
Physical restraint
Physical restraint is the use or action of physical force to prevent, restrict or subdue movement of a person’s body, or part of their body, for the primary purpose of influencing their behaviour. Physical restraint does not include the use of a hands-on technique in a reflexive way to guide or redirect a person away from potential harm or injury, consistent with what could reasonably be considered the exercise of care towards a person.
Physical restraint has the potential to escalate a situation. It can pose a serious risk of harm (including death) to the person, and places others involved in the restraint at risk of harm. During physical restraint, airway management can be compromised, and the integrity of the skeletal structure and vital organs is at risk of harm. People with developmental disability may also have: increased risk of respiratory complications, including aspiration pneumonia risk of cervical spine instability (eg Down syndrome, 22q11.2 deletion syndrome) decreased respiratory reserve (eg caused by lower muscle tone, impaired posture, movement disorders). The use of physical restraint can also erode the therapeutic rapport between the person and those providing support, which in turn can impede the implementation of educational and other support strategies by those enacting the restraint.
Mechanical restraint
Mechanical restraint is the use of a device to prevent, restrict or subdue a person’s movement for the primary purpose of influencing a person’s behaviour, but it does not include the use of devices for therapeutic or nonbehavioural purposes. General practitioners should be alert for situations where a device prescribed for therapeutic purposes is being used ‘off label’ for the control of behaviour in a person with developmental disability (eg splints used outside of recommended period of therapy, electric wheelchair control being disconnected).
Seclusion
Seclusion is understood to be the sole confinement of a person in a room or a physical space at any hour of the day or night where voluntary exit is prevented or not facilitated, or it is implied that voluntary exit is not permitted. If seclusion is proposed to be part of a behaviour support plan, the person must be observed and provided access to food, drink and toilet facilities. Seclusion is not to be confused with ‘Therapeutic Time Out’, in which a person is placed in a low-stimulus environment for the explicit purpose of supporting them to calm themselves. ‘Therapeutic Time Out’ will not ordinarily involve social isolation, and will usually include access to preferred activities, music or other preferred stimuli.
Chemical restraint
Chemical restraint is the use of medication or a chemical substance for the primary purpose of influencing a person’s behaviour. It does not include the use of medication prescribed by a medical practitioner for the treatment of, or to enable treatment of, a diagnosed psychiatric disorder, physical illness or medical condition. While some form of sedation might be necessary to contain a dangerous situation, it should only be used as a temporary measure and should not become part of routine behavioural management. There is a paucity of evidence for safe doses of drugs for managing acute behavioural disturbance in people with developmental disability. Considerations include: barriers to monitoring for adverse effects (eg communication or cognitive difficulty) comorbidities drug interactions knowledge and skills of those providing support and monitoring for potential adverse effects (eg parents and staff in community residential services are unlikely to have formal training in monitoring for, recognising and responding to adverse effects).
Environmental restraint
Environmental restraint refers to any restriction of a person’s free access to all parts of their environment, including objects (eg possessions, household items) or activities.
Note: NB1: Restrictive practices can cause long-term harm or even death, and have legal implications; use of restraint should be ‘last resort’, and only considered in response to behaviour that might cause harm to the person or others. The use of any restraint should be documented in a behaviour support plan authorised under state and commonwealth regulations, and those implementing such strategies should be provided with training in their use, monitoring and reporting. The use of restraints should be regularly reviewed, and only used for the shortest possible time to ensure the safety of the person with disability or others. NB2: Definitions of restraint are based on those outlined by the National Disability Insurance Scheme (NDIS) Quality and Safeguards Commission.