There are probably few more emotive topics in children's care settings than the use of physical intervention, or restraint. Understandably so, because, as we have seen from various journalists' investigations and public enquiries, it can be used abusively and, in some cases, children have died.
It can be traumatic for children and, sometimes, distressing for carers too.
It appears to be a statement of uncontroversial truth to say that children should only be restrained when absolutely necessary. In children's homes this is, essentially, when a child is likely to harm themselves or someone else and not to ensure a child complies with adult instructions (the guidelines are different in schools, where it can be used to remove a disruptive pupil from a classroom, and there are different rules again in secure homes, secure training centres and so on).
The use of physical intervention to stop children hurting themselves or someone else should, in my view, be entirely unquestionable. If I witnessed a toddler about to put his hand in a fire or walk out into the road, no one would bat an eyelid if I pulled them back or picked them up and moved them to somewhere safe. In fact, I imagine most people would agree it would be neglectful for me not to do this.
I am sure too that most responsible parents would intervene if they believed their older children were about to hurt themselves or someone else.
Of course, to reduce the need for physical intervention is not just about "de-escalation techniques" during the incident itself, but all that we do to look after a young person which helps them feel safe, regulated and contained. Over time this should, hopefully, mean there are less of the unsafe behaviours which might require a restraint to stop.
I have had numerous experiences of children and young people appearing to quite deliberately do things which they knew meant I would have to restrain them: standing in the middle of the road, attempting to put ligatures around their necks, attacking me – and many more examples.
Indeed, a young person I used to look after told me, as an adult, that she would wait for me to come on shift before "kicking off" because she knew I would, and could, restrain her. I also have a very vivid memory of a 14-year-old girl screaming at me: "Why didn't you f*cking restrain me". She felt I should have done this to stop her from absconding and, under the circumstances, she was right. Unfortunately, but understandably, she took this as evidence that I did not really care about her.
It may be uncomfortable, but if we are to reduce the need for physical restraint, we will not be able to do so unless we are willing to think about why being restrictively held seems to meet a need, consciously or not, for some young people and they will provoke restraint in order to ensure that need is met. Laura Steckley's excellent research paper has already explored some of these issues.
There are, of course, no absolutes here and no single reason or need. The young person who waited for my arrival before provoking a restraint, would talk about feeling like she was "falling apart" and "shattering" – she needed to feel like she was being, physically, held together. It is extremely unlikely this is a need which could be met by words alone.
The girl who was angry I did not restrain her knew she was unable to keep herself safe. She did not need someone who tried to talk her out of running away and she did not need someone "educating" her about the risks she was taking when she knew that better than anyone because she was experiencing them. What she desperately needed, and wanted, was someone who cared enough to actually stop her.
When attempting to understand what a young person's need is, it is always worth considering what they may have missed out on at an earlier developmental stage. For example, a parent does not just contain a toddler through thinking and empathetic responses or even through hugs. A parent may well pick up a dysregulated two or three-year-old, even though the toddler might protest and fight, and hold them close in a quite restrictive way.
This helps the infant feel safe, because they learn their rage can be managed and does not have to be catastrophic.
It is not the case, in this situation, that if the parent could hit on exactly the right empathetic words, however well they named the infants anxiety, this would be sufficient. The physical act of close holding is what is required. Learning that one is not omnipotent is important and small children who do not learn this will become frightened of themselves and are likely to be dysregulated most of the time. Some young people in care may not have had this early experience of their anger and rage being withstood and contained – so they might need, and push for, physical intervention.
The picture may be complicated further, some children might provoke restraint because they are, unconsciously, re-enacting earlier traumatic experiences. If this is what is happening, then ideally you would want to avoid physical intervention, but you might not be able to. Some, or all, of these processes may be going at different times, or simultaneously, for an individual child.
We stand a much higher chance of reducing the amount of restraints required for an individual young person if we can understand the need they are communicating – because then we stand a chance of working out how that need can be met without restraint.
What if the young person really needs to be hugged closely for a long period of time? How many carers (and organisations) would be willing to do this? We may also have to accept that some young people might go through periods where they need to be restrained regularly because nothing else will quite meet the need.
To think about, and manage, these issues properly requires carers who have a high level of understanding – not just of the children they look after, but themselves too. Carers need to have an awareness of their own processes – including their feelings of anger or powerlessness – which can lead to using physical intervention unnecessarily.
This requires a significant level of training and, more crucially, genuine clinical supervision in which staff can honestly explore the use of restraint. How many carers would feel able to say: "I was really worked up by then, I think I held him too tightly", or "On reflection, there was no need for me to restrain her, but I was so frustrated"? If there is not space for this type of discussion, without carers and staff feeling they need to cover their back, then the possibility of inappropriate, or even abusive, use of restraint increases.
However, not doing something can have as many consequences as doing something and, for some young people, if they are not restrained when really they need to be, the consequences might not just be physical harm, but emotional and psychological harm too.
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