Black Boxing Restraints: The Need for Full Disclosure and Consent

Abstract

In this article we discuss the necessity of fully informing patients and their families of what constitutes physical interventions and their attendant risks under the established principles and obligations of informed consent. After a brief review of the elements of informed consent and the nature of the duty to advise patients and their families of treatment risks, we argue that physical interventions are an unvalidated treatment for aggressive and violent behavior and should be used only as a safety intervention. We focus our discussion on the informed consent issues for school aged children, adolescents, and emancipated minors and contend that if restraints are used they must pose less risk than the behavior they are trying to alleviate. We also opine that if restraints are misused by mental health or child welfare treatment settings, then their misuse may be considered a subject of a patient maltreatment, abuse, criminal or civil action. A central thesis of the article is that informed consent must be seen as an integral and dynamic process of treatment. We recommend strategies that gain parental permission and child assent, that view informed consent as a dynamic and individualized process that aids and supports the therapeutic relationship, and that stress the importance of simplicity and clarity.

Policies Matter: Closing the Reporting and Transparency Gaps in the use of Restraint, Seclusion, and Time-Out Rooms in Schools

“…The documentation and reports would be shared immediately with parents and school administrators, as well as school divisions, and ultimately with central educational authorities (e.g., ministries of education in the provinces/territory), where it would be analyzed to reduce and prevent reoccurrence, and then publicized at an aggregate level in order to create accountability and oversight. Follow-up debriefings and a re-evaluation/and or development a student's individualized education plan would also be required (Butler, 2019;Gagnon et al, 2017;Lebel et al, 2012;Mohr & Nunno, 2011).…”

Restraint and seclusion use in U.S. School settings: Recommendations from allied treatment disciplines.

“…Each episode of R&S should receive careful review and scrutiny with the goal of preventing future use. Restraint and seclusion data at the local, state, and national level should be regularly reported and annual aggregate data should be publicly disseminated to better understand the extent of use and training and resource needs (Mohr & Nunno, 2011).…”

“…If R&S are used in a treatment program, the facility has a professional duty to obtain informed consent from the youth and the youth's family. Even children as young as 6 or 7 can and should be part of the process when a procedure carries a risk to their physical or emotional health (Mohr & Nunno, 2011). Consent and assent can be denied, and there should be contingencies developed in the event of denied consent or assent.…”

“…Consent and assent can be denied, and there should be contingencies developed in the event of denied consent or assent. However, informed consent is dynamic and can be obtained at one point in time but may not be relevant at another (Mohr & Nunno, 2011). For example, parental consent can be obtained at the beginning of the first grade but not be relevant during the fourth grade because the child's developmental and physical status is likely to have changed and therefore presents a different set of conditions that modify the risks involved in R&S. Informed consent should be revisited every time there is a substantial change in the child's individual crisis or behavioral support plan and ⁄ or every time R&S is used (Mohr & Nunno, 2011).…”

“…Restraint and seclusion are emergency safety measures of last resort and should only be used in response to behavior that is considered violent, out of control, or imminently dangerous to the self or others. Risk for adverse effects and abuse increases when R&S is (a) used in lieu of less risk-laden, more effective therapeutic, trauma-sensitive, noncoercive prevention and intervention strategies and environments to manage agitation or aggression; (b) intermingled with treatment or educational goals, discipline, and punishment; or (c) exceeds the foreseeable risks associated with the behavior it is attempting to contain (Mohr & Nunno, 2011; Nunno, 2009).…”