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2014 13: 313 originally published online 30 October 2013Clinical Case Studies Serra R. Langone, James K. Luiselli, Denise Galvin and Jessica Hamill

Aggression-Contingent Physical Restraint (Protective Holding) in a Child With AutismEffects of Fixed-Time Release Fading on Frequency and Duration of

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Article

Effects of Fixed-Time ReleaseFading on Frequency and Durationof Aggression-Contingent Physical

Restraint (Protective Holding) in aChild With Autism

Serra R. Langone1, James K. Luiselli1, Denise Galvin1,

and Jessica Hamill1

Abstract

We report the case of an 11-year-old boy with autism who displayed aggressive behavior andrequired aggression-contingent physical restraint (protective holding) to protect peers andteachers from injury. During a baseline phase, teachers implemented the boy’s behavior support

plan and applied protective holding according to a behavior-contingent release (BCR) criterionin which they maintained physical contact with him until he was “calm” for a minimum of 30consecutive seconds. In the intervention phase, baseline procedures remained in effect, but the

teachers terminated protective holding with the boy according to a fixed-time release (FTR)criterion that was independent of his behavior during protective holding and faded (decreased)systematically over time. In contrast to BCR, FTR fading was associated with less exposure to

and fewer applications of protective holding. Post-intervention and follow-up results revealedthat protective holding was no longer required. We discuss the clinical implications of thesefindings.

Keywords

physical restraint, autism, aggression, restraint reduction, fixed-time release fading

1 Theoretical and Research Basis for Treatment

Physical restraint is sometimes required with children and adults who have developmental disabili-

ties; display challenging behaviors such as aggression, self-injury, and property destruction; and are

unresponsive to less restrictive intervention procedures (Harris, 1996; Luiselli, 2011; Reed, Luiselli,

Miller, & Kaplan, 2013). Concerning the acceptable use of physical restraint, virtually all regula-

tory agencies and professional organizations specify that it be reserved solely for behaviors that are

harmful to self, others, and the environment (American Psychological Association, 1994;

Association of Professional Behavior Analysts, 2010; Ryan, Robbins, Peterson, & Rozalski, 2009).

As for the focus of intervention, physical restraint is frequently applied to manage crisis situations

1May Institute, Randolph, MA, USA

Corresponding Author:

James K. Luiselli, May Institute, 41 Pacella Park Drive, Randolph, MA 02368, USA.

Email: [email protected]

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314 Clinical Case Studies 13(4)

and behavior “emergencies” (Reed, DiGennaro Reed, & Luiselli, 2013). In addition, physical

restraint can be a planned method of behavior support that is combined with antecedent control,

positive reinforcement, skill building, and other function-based procedures (Federal Statutes,

Regulations, and Policies Governing the ICF/MR Program, 2003).

It is important to acknowledge that physical restraint has several limitations. For example, the

procedure can be difficult to implement and easily misapplied. Improper implementation of physical restraint is particularly concerning due to the risk of injury (Hill & Spreat, 1987; Spreat,

Lipinski, Hill, & Halpin, 1986; Williams, 2009). Furthermore, physical restraint is sometimes

positively reinforcing (Favell, McGimsey, & Jones, 1978; Magee & Ellis, 1988), thereby increas-

ing the behavior it follows. Another factor is that many care-providers do not approve of physical

restraint (Cunningham, McDonnell, Easton, & Sturmey, 2003). Among staff who must imple-

ment physical restraint, poor acceptability can negatively impact procedural fidelity which, in

turn, compromises intervention effectiveness. Finally, some service settings may not have the

personnel and financial resources needed to provide extensive physical restraint training with

staff (Lennox, Geren, & Rourke, 2011).

Acknowledging the preceding limitations, several strategies can reduce and eliminate physi-cal restraint (Luiselli, 2009; Sturmey & McGlynn, 2003; Williams, 2010). For example, Luiselli,

Kane, Treml, and Young (2000) and Luiselli, Dunn, and Pace (2005) introduced antecedent con-

trol procedures that prevented or greatly curtailed challenging behaviors, which had required

physical restraint as a planned intervention. Restraint fading has also been successful by chang-

ing from a continuous to intermittent schedule of application (Lerman, Iwata, Shore, & DeLeon,

1997). From an organizational or systems-level perspective, decreased physical restraint has

been reported through mandatory behavioral consultation (Donat, 1998), administrative policy-

change (Singh, Singh, Davis, Latham, & Ayers, 1999), and performance improvement initiatives

that included intensified staff training, alternatives to restraint, increased clinical supervision,

and systematic utilization review (Sanders, 2009).

Another approach to reducing and eliminating physical restraint is termed fixed-time release

or FTR (Luiselli, 2008; Luiselli, Pace, & Dunn, 2006; Luiselli, Treml, Kane, & Young, 2004).

Typically, care-providers implement physical restraint according to a behavior-contingent release

(BCR) criterion in which restraint is terminated when a person is “calm” (e.g., absence of strug-

gling and resisting) for a predetermined length of time (e.g., 2 min). Unfortunately, the duration

of physical restraint can be prolonged if the BCR criterion is not rapidly achieved. By contrast,

FTR has care-providers stop physical restraint as soon as a set duration elapses independent of a

person’s behavior during restraint. In Luiselli et al. (2004), the average duration of physical

restraint applications with a 12-year-old girl decreased from 5.6 min with BCR to 3.1 min with

FTR. Targeting three children (11-14 years old), Luiselli et al. (2006) reduced physical restraint

from averages of 14.2, 5.1, and 11.2 min with BCR to 3.8, 1.4, and 3.0 min with FTR, respec-tively. These studies also revealed that when compared to BCR, the frequency of physical restraint

either remained the same or decreased with FTR. Thus, FTR reduces the total amount of time a

person experiences physical restraint and may have the corresponding reductive effect on how

frequently the procedure is applied.

Fixed-time release from protective holding has also been effective by gradually reducing the

FTR criterion. In treating a 13-year-old boy with autism, Luiselli (2008) had classroom teachers

initially apply physical restraint contingent on the boy’s aggression and at a FTR criterion of 60

s. Fading was then introduced by reducing the FTR criterion to 30 s, 15 s, and 7 s. Upon achiev-

ing FTR-7 s, physical restraint was eliminated by having the teachers stand behind the boy as if

to implement restraint, touch his shoulders, and instruct him to “sit down.” In addition to replicat-ing previous studies that decreased total time exposed to physical restraint (Luiselli, 2008;

Luiselli et al., 2006; Luiselli et al., 2004), the results of Luiselli (2008) showed that FTR fading

can further reduce restraint duration as well as eliminate restraint entirely.


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Langone et al. 315

In the present case study, we evaluated the effects of FTR fading on frequency and duration of

physical restraint with a child who had autism and aggressive behavior. Our therapeutic objec-

tives were to reduce physical restraint applications to the lowest duration possible while monitor-

ing collateral changes in restraint frequency. Hence, we report another potentially effective

strategy for reducing and eliminating physical restraint of people who have developmental dis-

abilities and require intensive interventions for treating high-risk challenging behaviors (Luiselli,2011; Reed, Luiselli, Miller, & Kaplan, 2013).

2 Case Introduction

Danny was an 11-year-old boy who had been diagnosed with autism at two years of age. He

spoke in 2-4 word phrases and receptively could follow most 1-2 step instructions. Danny was

able to read many words and short sentences as well as match the corresponding pictures to sen-

tences, identify numbers 1-100, and tell time on a digital clock. He had not received formal intel-

lectual testing.

Danny lived at home with his parents. He attended a specialized school for children and youthwith developmental disabilities each weekday from 8:30 a.m. to 3:00 p.m. His classroom at the

school was comprised of five other students, a primary teacher, and two teacher assistants. All of

the teachers conducted instruction with Danny according to his Individualized Educational

Program (IEP). He had a daily schedule of instructional activities that addressed communication,

pre-academic, self-help, and leisure skills.

3 Presenting Complaints

Danny presented with aggressive behavior that included hitting, kicking, head-butting, grabbing,

hair-pulling, and biting. His aggression was primarily directed toward classroom staff, but some-

times against peers as well. His aggressive behavior had injured teachers, disrupted instructional

activities, and made it difficult to promote social interactions between Danny and classmates.

4 History

Danny had been displaying aggression at variable frequency several years preceding the study.

At times, his aggressive behavior consisted of a single response such as hitting or kicking a

teacher who was sitting beside him. On other occasions, aggression occurred as an “episode” in

which he exhibited several consecutive responses in rapid succession. Many times, Danny exhib-

ited repeated aggression while actively pursuing one or more teachers.

Before the study, teachers reacted to aggressive behavior by physically blocking Danny’sresponses and redirecting him back to the ongoing activity. The teachers also followed a behavior

support plan (described below) comprised of antecedent and consequence procedures.

Unfortunately, the behavior support plan was only marginally effective as Danny continued to

aggress toward peers and teachers several times daily.

5 Assessment

Direct Measurement

Throughout the study, teachers implemented protective holding when Danny exhibited an aggres-

sive episode by (a) walking or running toward them or a peer and (b) making physical contact in

the form of a hit, kick, head-butt, grab, hair pull, or bite. Teachers recorded frequency of aggres-

sive episodes and the corresponding protective holds on an incident report form that traveled


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with Danny to and from his scheduled activities. These data were summed as the total frequency

of protective holds each day.

The teachers also documented the duration (minutes) of each protective hold by recording the

time (to the nearest minute) that they initiated and terminated physical contact with Danny. These

data were summed as the average minutes per protective hold each day (cumulative daily dura-

tion of protective holds/frequency of protective holds).For 21% of protective holds that were implemented during the study, two teachers assessed

interobserver agreement (IOA) by independently completing an incident report form. Using the

protocol reported by Kleinmann et al. (2009), an agreement between teachers was recorded when

they documented the same date, time, and duration (+/− 10 s) of the protective holds. There was

100% agreement between the teachers.

Functional Behavioral Assessment

Preceding the study, the clinical director at the school and the primary classroom teacher conducted

functional behavioral assessment (FBA; Cipani & Schock, 2011) to identify antecedent and conse-quence influences on aggressive episodes. The FBA entailed first observing Danny during class-

room activities, noting interactions and situations that were associated with aggressive episodes.

Next, the clinical director interviewed the teachers to solicit their opinions about behavior function.

The third component of FBA was reviewing antecedent-behavior-consequence (A-B-C) data

(Bijou, Peterson, & Ault, 1968) that had been recorded for several weeks in the classroom.

6 Case Conceptualization

The results of FBA suggested that Danny frequently displayed an aggressive episode when he was

required to complete non-preferred activities and at times when he requested objects that could not

be given to him or they had to be temporarily removed. Accordingly, aggressive episodes were

determined to be both tangible and escape motivated. That is, we hypothesized that Danny had a

learning history in which his aggressive behavior had been reinforced by care-providers providing

him access to preferred objects and withdrawing non-preferred activities contingently.

On the basis of FBA, the clinical director and teachers developed a multi-procedure behavior

support plan. First, the teachers provided Danny with differential positive reinforcement when he

participated in and completed instructional activities without displaying aggression. Positive

reinforcement consisted of verbal praise (e.g., “Good, Danny, you opened your book.”) and

access to objects such as playing with toys. The behavior support plan also specified that teachers

control antecedent conditions that appeared to be associated with aggressive episodes.

Specifically, they ensured that Danny was not in close proximity to peers, presented “lowdemand” instructional activities as often as possible, and delayed activity termination if he dis-

played aggression and other disruptive behavior. As indicated previously, the teachers blocked

and redirected aggressive responses.

With the behavior support plan in effect several months preceding the study, aggressive epi-

sodes continued at an unacceptable level. The school’s clinical team then determined that protec-

tive holding should be evaluated with the purpose of immediately stopping Danny from repeated

aggressive responses that were causing injuries, disrupting activities, and posing a safety risk to

teachers and other students (Luiselli, 2011; Reed, Luiselli, Miller, & Kaplan, 2013 ).

7 Course of Treatment and Assessment of Progress

The study conformed to a quasi-experimental design with an initial baseline phase in which

teachers followed a BCR criterion and an intervention phase in which the teachers followed a


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Langone et al. 317

FTR criterion and a FTR fading protocol. The behavior support plan described earlier was in

effect during baseline and intervention phases. Within intervention, the only manipulation was

decreasing the FTR criterion, thereby controlling external factors that might have influenced

outcome.

Baseline (28 Days)

The teachers had been taught to implement protective holding following a rigorous program in

physical management (see Lennox et al., 2011, for a description of such training). The clinical

team at the school approved application of protective holding with Danny and routinely super-

vised the teachers. Danny’s parents also provided informed, written consent. When implement-

ing protective holding, two teachers simultaneously stood to Danny’s side, grasped his arms, and

gently guided him to the floor. The teachers then maintained their side-to-side position while

extending their other hand against Danny’s leg to stabilize any movement.

During the baseline phase, teachers stopped holding Danny when he achieved a BCR criterion

of 30 consecutive seconds without struggling, moving his body, and vocalizing. In effect, theBCR criterion was an indication that Danny was “calm” before teachers withdrew their physical

contact with him. Under this condition, the minimum duration of time Danny could spend in a

protective hold was 30 s. A protective hold could continue for as much time as it required Danny

to achieve the 30 s criterion.

Intervention (208 Days)

Baseline conditions remained in effect during the intervention phase, except that teachers fol-

lowed a FTR criterion instead of the BCR criterion. Now, they terminated protective holding with

Danny when a set-duration of time elapsed independent of his behavior during the hold. The

initial FTR criterion was 2 min-30 s, which was the average protective hold duration in baseline.

Subsequently, the FTR criterion was reduced over consecutive days to 2 min-10 s (18 days), 1

min-50 s (18 days), 1 min-30 s (19 days), 1 min-10 s (23 days), 50 s (20 days), 30 s (9 days), 10 s

(35 days), and 5 s (36 days). The protocol for lowering the FTR criterion was based on visual

inspection of the protective holding frequency data and trend analysis showing less than 1 protec-

tive hold per week during 2 to 3 consecutive weeks.

Figure 1 shows that in the baseline phase, there was an average of 1.1 protective holds each

day lasting an average of 2.3 min per hold. Protective hold duration in baseline ranged from 30 s

to 15.1 min. The daily frequency of protective holding decreased contemporaneously during

intervention with the systematic reduction in duration of protective holding through FTR fading.

The data in Figure 1 reveal further that by conclusion of the study, Danny no longer required protective holding (Weeks 1-5). In total, Danny was exposed to 1 hr and 19 min of protective

holding with the BCR criterion in effect during the baseline phase. In the final condition of the

intervention phase with a FTR-5 s criterion, his total exposure to protective holding was 15 s.

8 Complicating Factors

As explained earlier, implementing physical restraint is a complicated process that must consider

potential negative effects such as misapplication, injury, and procedurally induced problem

behavior. In the present case, the classroom teachers had been thoroughly trained in protective

holding, were closely supervised, and demonstrated exemplary intervention integrity (DiGennaroReed & Codding, 2011). Neither the teachers nor Danny sustained bodily harm and there were

no imminent safety risks. In addition, we did not witness unanticipated behavioral concerns that

were associated with protective holding during application or other situations in the school day.




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9 Access and Barriers to Care

Danny had regular attendance at school which enabled intervention to progress without interrup-

tion. The consistency of intervention likely contributed to the positive results and durable main-

tenance effects. There were no managed care considerations or third-party financial constraints

because the study was conducted in a special education setting. Notably, Danny’s parents sup-

ported his intervention plan and consented to protective holding as a necessary behavior manage-

ment procedure. Certainly, some parents may not approve similar methods of physical

intervention, thereby curtailing implementation in high-risk clinical cases.

10 Follow-Up

Protective holding frequency and duration were reported for 4 consecutive months approximately

6 months following the study. During this period, teachers implemented four protective holds

with Danny, an average of one protective hold per month. The FTR criterion had been maintained

at 5 s—thus, Danny’s total exposure to protective holding at follow-up amounted to 20 s. As a

result of less frequent aggression and physical restraint, teachers reported that Danny was more

compliant during instructional activities and interacted more positively with peers.

11 Treatment Implications of the Case

We found that protective holding of a child with autism gradually decreased and was eventu-

ally eliminated subsequent to fixed-time release fading. In that these results support previous

clinical studies (Luiselli, 2008; Luiselli et al., 2006; Luiselli et al., 2004), it appears that FTR

0

0.5

1

1.5

2

2.5

B C R - : 3 0

F T R - 2 : 3 0

F T R - 2 : 1 0

F T R - 1 : 5 0

F T R - 1 : 3 0

F T R - 1 : 1 0

F T R - : 5 0

F T R - : 3 0

F T R - : 1 0

F T R - : 0 5

1 W e e k

2 W e e k s

3 W e e k s

4 W e e k s

5 W e e k s

F r e q u e n c y a n d D u r a t i o n

Protective Holds: Average Daily Frequency

Protective Holds: Average Duration Per Hold

Intervention: Fixed-Time Release Fading

Phase Conditions

BL

Figure 1. Average frequency of protective holds per day and average duration (minutes) per protectivehold during baseline (BCR) and intervention (FTR fading) phases.Note. BCR = behavior-contingent release; FTR = fixed-time release.




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Langone et al. 319

is an empirically supported procedure for reducing the total time a person experiences physi-

cal restraint. As well, frequency of protective holding may also decrease with FTR although

the mechanism responsible for this effect is unclear. For example, manipulating duration

should not influence the frequency of behavior that produces protective holding, unless

restraint is positively reinforcing (Favell et al., 1978; Magee & Ellis, 1988). At this time,

further research is needed to clarify the relationship between protective holding frequencyand duration.

Fixed-time release fading is a deliberate process that must be carefully monitored to ensure

that practitioners adhere to the gradually decreasing release criteria. We reiterate that when com-

pared to BCR, slowly reducing the duration of protective holding will expose a person to less

physical intervention and risk of injury. It is possible, of course, that frequency of protective

holding could increase with FTR fading, in which case the strategy may have to be abandoned in

favor of other restraint-reduction methods (Reed, Luiselli, Miller, & Kaplan, 2013 ; Sturmey &

McGlynn, 2003).

As a clinical case study, these results cannot be attributed unequivocally to FTR fading. For

example, frequency of protective holding may have decreased with lengthier implementation ofthe BCR criterion or possibly the FTR criterion could have been lowered abruptly without fading

it systematically. In terms of research tactics, the relative effectiveness of BCR and FTR could

have been compared by introducing and withdrawing the two release criteria in a reversal-type

design (Kazdin, 2011). However, such an analysis was contraindicated because we wanted to

prevent long-duration protective holds that had been recorded with Danny during the initial base-

line (BCR) phase.

12 Recommendations to Clinicians and Students

Clinicians and students alike should be fully appraised about physical restraint practices, training

requirements, regulatory guidelines, and evaluative methodologies (Lennox et al., 2011; Luiselli,

2011; Reed, Luiselli, Miller, & Kaplan, 2013 ; Ryan et al., 2009). Whenever possible, protective

holding procedures should be avoided and only considered when challenging behaviors are

harmful, non-responsive to less restrictive interventions, and likely to continue without addi-

tional treatment. If protective holding is clinically justified, it should be implemented as one

component of a comprehensive behavior support plan like the one illustrated in this study. Care-

providers must also contemplate restraint-reduction and elimination strategies early in the treat-

ment process.

In summary, we recommend FTR fading as one of several procedures that can effectively

decrease frequency and duration of protective holding with people who have developmental dis-

abilities. Ultimately, the therapeutic objective should be to eliminate physical restraint and indoing so, improve a person’s social adjustment and quality of life.

Authors’ Note

This study was conducted at the May Center for Child Development, Woburn, Massachusetts. The authors

acknowledge the classroom teachers for participating in the study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or

publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.




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Author Biographies

Serra R. Langone, MS, BCBA, MEd, is a Clinical Director at the May Center for Child Development,

Woburn, Massachusetts.

James K. Luiselli, EdD, ABPP, BCBA-D, is a Senior Vice President of Applied Research, Clinical

Training, and Peer Review at May Institute, Randolph, Massachusetts. He also serves as a director of train-

ing for the institute’s predoctoral internship and postdoctoral fellowship programs in clinical psychology.

Denise Galvin, BS, is a Senior Teacher at the May Center for Child Development, Woburn, Massachusetts.

Jessica Hamill, MEd, is a Director of Education and Educational Administrator at the May Center for Child

Development, Woburn, Massachusetts.

Documents

Clinical Case Studies-Autism