Child and Family Services Policy > Section V - Services to Children in Substitute Care

PHILOSOPHY:

All children who are recipients of services from Child Welfare Services are entitled to and shall be treated with dignity and respect, in a culture that promotes healing and provides each child the support needed to manage his or her own behavior. This policy is inclusive and applies to all children in custody or care of DHHS Child Welfare Services and those whose placements are directly overseen by DHHS Child Welfare Services in Maine Caring Families, family foster care and kinship care. This policy is in addition to existing state regulations, rules, and policies relating to behavior support and management.

1. Definitions:

Mechanical Restraint: Mechanical restraint is the immobilization of a recipient’s arms, legs or entire body by the use of an apparatus that is not a medical protective devise. It is the position of DHHS Child Welfare Services that mechanical restraint should only take place in a hospital under a doctor’s care and supervision.

Chemical Restraint: Chemical restraint is the use of medication, administered involuntarily, for the purpose of immobilizing an individual who is in imminent danger of self-injury or harm to others. It is the position of DHHS Child Welfare Services that mechanical restraint should only take place in a hospital under a doctor’s care and supervision. All other chemical interventions should be therapeutic in nature. The use of medication in a time of increased psychosis or aggression is not a restraint, but appropriate use of medication as long as the goal in not physical immobilization.

Manual Restraint: Manual restraint is the use of recognized certified physical restraint methods such as Mandt or TCI to hold a recipient in a non-stressful position until the recipient is able to control his or her own behavior. It is the position of DHHS Child Welfare Services that manual restraint should not be used, except on an emergency basis in treatment foster care, Maine Caring Families, family foster care or kinship care. Children whose behavioral issues are significant to require restraint should be placed in a hospital or residential setting. Child welfare staffs may use physical restraint on an emergency basis if they have received the appropriate training. An emergency is defined as a situation where there is risk of imminent harm or danger to the child or others.

Physical restraint of a child that results in lying face down on the floor while pressure is applied to the back is prohibited. The Department prohibits restraint for all children in any position which restricts the free movement of the diaphragm or chest so as to interrupt normal breathing and speech. Any body position that restricts the airway or that interferes with the muscular or mechanical means of getting air into and out of the body could prove fatal and is prohibited. A combination of conditions, mental and physical, including the use of certain medications, can place individuals at particular risk in this situation.

Seclusion: Seclusion is the involuntary placement in a room that is locked or held closed and from which exit is denied. It is the position of DHHS Child Welfare Services that locked seclusion should only take place in a hospital under a doctor’s care and supervision.

Isolation: Isolation is the involuntary placement of a child in a timeout/safe room to separate the child from others or from an environment where there was potential of harm to the child or others. Staff must observe and monitor the child. The door cannot be locked or held closed and the child may not be denied exit. It is the position of DHHS Child Welfare Services that isolation may not be used in treatment foster care, Maine Caring Families, family foster care or kinship care. Isolation may be used in residential or hospital settings with appropriate safeguards.

Time out: Time out is the voluntary placement of a recipient in a quiet non-stressful area and should not be confused with isolation. Isolation/safe rooms may be used for this purpose, but the recipient cannot be denied exit from the room.

2. Principles:

The principle regulating behavior support and management is clearly defined in the Rights of Recipients of Mental Health Services who are Children in Need of Treatment and licensing regulations for Private Non-Medical Institutions and Residential Child Care Facilities. All child welfare staff should receive training in these areas. All agencies that operate under contract with DHHS Child Welfare Services are required to follow these regulations. The following policy is intended to clarify the use of restrictive behavioral management in placements supervised by the Department which include Maine Caring Families, family foster care and kinship care. The policy is also intended to document the requirements of contracted treatment foster care and residential providers.

DHHS Child Welfare Services prohibits the use of restrictive behavioral an intervention in placements that the Department directly supervises for children in its custody or care. These placements include Maine Caring Families (one type of treatment foster care), family foster care and kinship care or fictive kin placements. Restrictive behavioral interventions include mechanical restraint, chemical restraint, seclusion and isolation as defined above. Of these interventions only manual restraint may be used on an emergency basis in Maine Caring Families, family foster care, kinship care and fictive kin placements.

A child identified through assessment as being in need of restrictive behavioral management interventions requires a more restrictive level of treatment than can be provided by contracted treatment foster care, Maine Caring Families, family foster care, kinship care and fictive kin placements. These children shall be placed without delay in contract residential treatment programs or hospitals, which are equipped to provide restrictive behavioral interventions.

Restrictive behavioral management interventions are utilized to maintain health and safety in situations where less restrictive measures are ineffective. The use of these interventions must be based on the assessed needs of the individual child. When a client experiences a restrictive behavioral management intervention, the first question should be whether the use of the intervention could have been avoided. Each restrictive behavioral management intervention should be viewed as an opportunity to explore new methods to support the child in managing his or her behavior. Following any behavior intervention the child should be provided the opportunity to process the event with staff. Each restrictive behavior management intervention should be thoroughly documented and reported to the Child Welfare Service caseworker with clear justification for the use of the specific intervention. Treatment plans should be flexible and adjusted often to respond each child’s needs.

The child, family, guardian, and GAL where appointed, should be educated regarding staff use of behavior interventions. All team members, including the child when developmentally appropriate, shall receive the written summary of this policy. This includes biological parents, adoptive parents, foster parents, residential staff, guardian ad litem, and other team members. All team members shall receive a copy of the child’s treatment plan, which should include any behavioral techniques that will be used as part of treatment.

All behavior plans shall be based on the results of an assessment developed by licensed clinical staff. Children and families should be asked what has worked best to de-escalate aggressive behavior for that child in the past. The plan shall identify strategies to help the person de-escalate behaviors and specify the interventions that may and may not be used. Any type of restrictive behavioral management intervention shall not be use in response to property damage and only be employed when absolutely necessary to protect the child from injury to self or others, and only after less restrictive measures have proven to be ineffective. Restrictive behavioral interventions are never to be used as punishment, discipline, coercion and retaliation or for the convenience of staff.

A behavioral support and management plan should include:

a.Strategies that will help the child de-escalate their behavior and prevent harassing, violent or out of control behavior

b.Specify the behavioral interventions that may and may not be used

c.Be modified as necessary

d.Is developed and signed by the child (when appropriate), his/her parents, legal guardian and provider staff.

3. Policies and procedure for those children in placements directly supervised by CWS, which includes Maine Caring Families, Family Foster Care, Kinship and Fictive Kin placements.

A.Only on an emergency basis is manual restraint permitted in Maine Caring Families, family foster homes, kinship placements and fictive kin placements. Isolation is not permitted. An emergency is defined as a situation where there is risk of imminent harm or danger to the child or others. Such emergency manual restraints shall be discontinued as soon as possible and in limited to the following maximum time periods per episode:

15 minutes for children nine and younger

30 minutes for children age ten and older.

B.At no time may emergency restraint be used as a form or punishment, disciplined, to gain compliance for the convenience of foster, kinship parents or staff. If emergency restraint continues for longer than the above time periods, the foster parents or staff must immediate contact the Community Based Mobile Crisis Team and request a crisis assessment. The foster parent or staff may continue the restraint until the crisis team arrives and during the assessment. The crisis team will conduct an assessment to determine if the client should be placed in a more restrictive level of care, such as a hospital setting, or what other steps can be taken.

C.Child Welfare staff should be informed within 24 hours of any emergency restraint that has taken place in the above placements. After hours foster parents can notify the Department by calling the Child Protective Intake Unit (1-800-452-1999). If the child has a legal guardian, they shall also be informed within one business day. Since the Department does not employ restrictive behavioral management interventions in placements it supervises, the child’s caseworker shall be immediately advised of this report so that decisions can be made regarding emergency debriefing, immediate physical and emotional well being of those involved and who else need to be notified (e.g. parents, Guardian Ad Litem, etc.). Child Welfare staff should respond consistent with the custodial responsibly of the Department. In absence of policy guidance or supervisory direction, the reasonable person rule applies.

D.Foster parents or support staff are required to submit the approved DHHS Restraint Report form which shall include the following:

a.An assessment of the precipitating cause or reason for the behavior interventions.

b.Documentation of the methods of emergency restraint used, and the length/duration of the intervention

c.An explanation of the less restrictive interventions tried prior to the behavioral intervention and why such measures were not successful

d.An assessment of the impact/effectiveness of the treatment plan and how it may need to be modified to prevent the use of behavioral interventions in the future.

e.The names of the foster parents, kinship parents or support staff involved.

E.The child must be given a chance to process the emergency restraint. This processing should be part of the client’s treatment, if possible. Clinical records should document the child concerns, his or her reflection on the effectiveness of the intervention and level his or her of understanding of the process.

F.For any behavior intervention that takes longer than one hour or which causes injury to the client or staff, the child’s team must schedule a debriefing to review the emergency restraint by the next business day. The debriefing shall identify the antecedent behaviors that lead to the intervention and use this information to modify the treatment plan.

G.All restraint forms will be faxed to DHHS Child Welfare Central Office. Central Office staff will fax a copy to the caseworker and Program Administrator/Assistant Program Administrator in the District office. The information will be entered into the approved database. At the end of each month will produce a report documenting the use of emergency restraint of children in the custody and care of the Department for the review and analysis by the Senior Management Team.

H.A report is to be made to Central Intake of any restraint resulting in physical signs of injury or if the child is reporting they were hurt, or suffering resultant or persistent pain. The Institutional Abuse Unit will investigate where there is a physical injury apparent.

4. Policies and Procedures for those Children placed with Contracted Agencies in both Treatment Foster Care and Residential Care

- Treatment Foster Care:

A.Only on an emergency basis is manual restraint permitted in Treatment Foster Care provided by agencies under contract with CWS. Isolation is not permitted. An emergency is defined as a situation where there is risk of imminent harm or danger to the child or others. Such emergency manual restraints shall be discontinued as soon as possible and in limited to the following maximum time periods per episode:

15 minutes for children nine and younger

30 minutes for children age ten and older.

B.The reporting requirements are the same for emergency restraint in Treatment Foster Care as in Residential Services as documented below.

- Residential Services

A.The terms Isolation and Seclusion are used interchangeably in the various regulations governing behavioral management. Seclusion following the definition of a setting/room where exit is denied is not permitted in residential facilities. Isolation is permitted in children’s residential facilities that hold a mental health license. A client may be lead/escorted involuntarily to a designated room that meets licensing regulations. A lock cannot be used to hold the door, but the door may be shut while the child is in isolation. The child must be monitored randomly but at least every 15 minutes by qualified staff. The door must allow visibility into the room if shut. No child under the age of five (5) shall be isolated outside the view of a caregiver. Isolation shall be limited to thirty minutes. During the isolation the child must be randomly given a chance to remain calm and leave isolation. If staff feel continued isolation is warranted, the program supervisor must physically assess the child and the need for continued isolation. All uses of isolation shall be documented in the client’s treatment plan.

B.Manual Restraints are permitted only in children’s licensed mental health residential facilities. All residential staff must be trained in a recognized and approved restraint technique and implement the techniques with fidelity. At no time may restraint be used as a form of punishment, discipline, to gain compliance or for the convenience of staff. If physical restraint continues for more than thirty minutes, provider staff must call the Community Based Mobile Crisis Team and request a crisis assessment. The provider may continue the restraint until the crisis team arrives and during the assessment. The crisis team will conduct an assessment to determine if the client should be placed in a higher level of care, such as a hospital setting, or what other steps can be taken.

B.Child Welfare staff should be informed within one business day of all uses of manual restraint. If the child has a legal guardian, they shall also be informed within one business day. Provider staff are required to submit the approve restraint report form that includes

f.An assessment of the precipitating cause or reason for the behavior interventions.

g.Documentation of the methods used (restraint or isolation), and the length/duration of the intervention

h.An explanation of the less restrictive interventions tried prior to the behavioral intervention and why such measures were not successful

i.An assessment of the impact/effectiveness of the treatment plan and how it may need to be modified to prevent the use of behavioral interventions in the future.

j.The names of the staff involved and the supervisor who authorized the behavior intervention.

C.The child must be given a chance to process all behavior interventions. This processing should be part of the client’s treatment. Clinical records should document the child concerns, his or her reflection on the effectiveness of the intervention and level his or her of understanding of the process.

D.For any behavior intervention that takes longer than one hour or which causes injury to the client or staff, the provider shall schedule a debriefing to review the behavioral intervention by the next business day. Child welfare staff shall be informed of the meeting and given the option to attend. The debriefing shall identify the antecedent behaviors that lead to the intervention and use this information to modify the treatment plan.

E.All restraint forms will be faxed to DHHS Child Welfare Central Office. Central Office staff will fax a copy to the caseworker and Program Administrator or Assistant Program Administrator in the District office. The information will be entered into the approved database. At the end of each month will produce a report documenting the use of manual restraint of children in the custody and care of the Department for the review and analysis by the Senior Management Team.

F.A report is to be made to Central Intake of any restraint resulting in physical signs of injury or if the child is reporting they were hurt, or suffering resultant or persistent pain. The Institutional Abuse Unit will investigate where there is a physical injury apparent.

Current Regulations on Behavioral Support and Management of Children

CWS Regulations:

•Consent for Non Routine Medical Procedures (SecV.1-5, Pages 3-5 covers therapeutic holding and rebirthing)

CBHS Regulations:

•Rights of Recipients of Mental Health Services who are Children in Need of Treatment (applied to all children served in residential mental health faculties)

•Regulations Governing Emergency Interventions and Behavioral Treatment for People with Mental Retardation and Autism (Applied to all children with Mental Retardation and Autism)

Licensing Regulations: Please note that these regulations will be updated and reissued in the next year.

•Rules for Licensure of PNMI Residential Child Care Facilities (Sec. 4B-4, Pages17-19 and Sec. 6D, Pages 79-83)

•Rules for the Licensure or Child Placing Agencies (Sec. 23F-2, Pages 34-35)

•Rules for Licensure of Emergency Shelters for Youth (Sec. B-3, Pages 14-17)

•Rules for Licensure of Shelters for Homeless Children (Sec. B-5, Pages 8-10)

•Rules Providing for Licensure of Family Foster Homes for Children (Sec. 9-D, Pages 13 and 14, also applies to Treatment Foster Homes)

Dept. of Corrections Regulations:

•Behavioral Management Systems (DOC Regulations Chapter 15)

Dept. of Education Regulations:

•Regulations governing timeout rooms, therapeutic restraints and aversion

in public schools and approved private schools (DOE Regulations Chapter 33)

“Pending the results of a review and revision of Ch. 33, 2009-10 the use of any restraint that restricts the free movement of the diaphragm or chest or that restricts the airway so as to interrupt normal breathing or speech of students is prohibited. All school personnel who may restrain or assist with a restraint shall be notified of this prohibition. During the course of every restraint, a student’s breathing and speech shall be monitored to protect against airway stress.”

•Maine Special Education Regulations (DOE Regulations Chapter 101, Pages 90-98)

V. D-11. Behavior Support Management

V. D-11. Behavior Support Management