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States Continue to Overwhelmingly Allow Restraint and Seclusion

The use of restraint, restrictive interventions, and seclusion techniques are not only controversial, there is also little research that indicates they are effective. Instead, they may result in injury and trauma for both people with intellectual and developmental disabilities (IDD), and those implementing the techniques.

Restraint: “Interventions restricting movement; generally falls into three categories: physical, mechanical, and chemical. Physical restraint: Prevents free movement by applying force to a person’s body. Mechanical restraint: A type of physical restraint but introduces tools such as straps, belts, and helmets to restrict free movement. Chemical restraint: Chemical restraint uses pharmacological means to control a person’s behaviors and movement outside of any standard treatment for their psychiatric or medical condition.

Restrictive interventions: ‘Limit an individual’s movement; a person’s access to other individuals, locations or activities, or restrict participant rights. Restrictive interventions also include the use of other aversive techniques (not including restraint or seclusion) that are designed to modify a person’s behavior’

Seclusion: ‘The involuntary confinement of a person in a room or an area where the person is physically prevented from leaving’” (Friedman & Crabb, 2018, p. 172)

The purpose of this study was to explore if and how states permitted use of restraint, restrictive interventions, and seclusion in their Medicaid HCBS waivers, which are the largest funding stream of long term services and supports (LTSS) for people with IDD. To do so, we examined Medicaid HCBS waivers for people with IDD from across the nation in fiscal year (FY) 2015.

Findings revealed the majority of waivers allowed restraint (78.4%) and restrictive interventions (75.7%) in FY 2015 (see figures). Meanwhile, only about a quarter of states (24.3%) permitted seclusion.

States That Permit Restraint

States That Permit Interventions

States That Permit Seclusion

Relationships with Mental and Behavioral Health Services

Since one of the arguments in favor of these harmful techniques is that they address serious aggressive behavior, as part of this analysis, we also explored if there was a relationship between states permitting intervention usage and provision of behavioral therapy and crisis services spending.

Findings revealed those states that prohibit restraint, restrictive intervention, and seclusion projected spending more on behavioral health services per person than those states that permit the use of each of these techniques (see figure).

Average Behavioral Health Spending Per Person By Intervention

Moreover, there was also a relationship between these techniques and provision of crisis services. States that prohibit restraint, restrictive intervention, and seclusion also projected spending less on crisis services per person than those states that permit the use of each of these techniques (see figure).

Average Crisis Spending Per Person By Intervention

It seems a better mental and behavioral health infrastructure would result in a reduced need for these aggressive intervention techniques. However, more research is needed to determine if “states’ provision of mental health services results in less need for interventions, or if a lack of interventions results in the need for more mental health services” (Friedman & Crabb, 2018, p. 183). Regardless of the directionality of the relationship, there needs to be a greater prioritization of mental and behavioral health services for people with IDD and less use of these harmful and problematic techniques.