Forcing the issue

The recent controversy over the death of David “Rocky” Bennett
while being held face-down by staff in his psychiatric unit has
prompted yet another call to review the use of physical restraint.
Similar deaths in prisons and police cells as well as in
psychiatric settings have raised serious questions about the safety
of different restraint methods.

Children’s services are not immune to such scandals and inquiries,
particularly in residential homes. In 1992, the Warner Report
recommended that the government issue full guidance for staff on
control, restraint and physical contact with children in
residential care, backed up with training materials.¹

However, it is debatable whether this “full guidance” has ever been
achieved. Ten years after Warner, a UN committee concluded that
children’s rights were still being breached, in particular the
right not to be subjected to cruel, inhuman and degrading
treatment.² The UNCommittee on the Rights of the Child
called for the UK to review the use of restraint and solitary
confinement for children in all settings.

So what is current policy and practice in restraint within English
children’s services? A recent review by the National Children’s
Bureau has painted a picture of inconsistency and
fragmentation.

Some stated principles are common across all services: physical
restraint should be used only as a “last resort”, it should be
applied using minimum force for the shortest possible time, and
restraint should not be used as a punishment. But apart from these
basic rules, there is little consistency across services. The same
child displaying the same behaviour in different settings cannot
expect the same response. For example, a child who verbally abuses
staff inside a children’s home cannot justifiably be restrained
because there is no risk of injury or damage to property. However,
she could be manhandled out of a classroom by teachers if they
judge her behaviour a threat to the “good order” of the
school.

Each sector operates under different guidance about restraining
children, from the criteria when restraint can be used to the
techniques that are acceptable and the monitoring of
incidents.

Social care
Regulations in the Children Act 1989 govern the way looked-after
children can be restrained. Restraint is justified only “to prevent
a child harming himself or others or from damaging property. Force
should not be used for any other purpose, nor simply to secure
compliance with staff instructions”.

In practice, there have been difficulties in interpreting these
rules, particularly in relation to vulnerable children attempting
to abscond. Does such behaviour constitute a risk of harm?
Clarification was issued in 1993 and 1997, but this has been
criticised for adding to the confusion. The position of foster
carers remains particularly unclear, as the techniques that staff
can use to restrain children in their care are left to the
discretion of local authorities and providers. Managers may invent
their own model or purchase a training package from private
companies.

The vagueness of this approach leaves both carers and children
exposed. Staff may fear litigation if they interpret the guidance
wrongly, and instead hide behind “no touch” policies. In the
meantime, children are confused about where they stand and are
disempowered as a result. Staff are required to record instances of
restraint and these records are open to scrutiny, but there is no
requirement to report the use of restraint at a national
level.

Education
Here, the picture is very different. The Education Act 1996
stipulates that staff can use reasonable force to stop pupils
committing an offence, causing personal injury or damage to
property, or “engaging in any behaviour prejudicial to the
maintenance of good order and discipline at the school or among any
of its pupils”. This is clearly a lower threshold than that for
looked-after children. Each head teacher has responsibility for
implementing the guidance, and this includes authorising staff to
use restraint. However, there is no requirement for staff to
receive training and methods of restraint are left to their
discretion. This has led one critic to suggest the guidance
breaches the UN convention in its failure to protect children from
physical violence.³

A recent review from the Department for Education and Skills showed
the implementation of the guidance had been patchy, and many
schools and local education authorities (LEAs) were unclear about
their responsibilities.⁴ The monitoring process was
particularly weak. Although schools were recording incidents as
directed, this information was not uniformly sent to LEAs. Nor was
there any system for analysing the data on a local or national
basis.

Health
There is no government guidance specifically on the restraint of
children in health settings. However, the Royal College of Nursing
and the British Medical Association have issued advice, recognising
that children may need to be restrained not just because of risky
behaviour but also to administer essential treatment.⁵
These documents describe considerations for good practice, but they
do not constitute official guidance.

The lack of regulation means that restraint in health settings may
go unnoticed. There is no formal requirement to record incidents or
any system of external scrutiny and, as a result, children are
unprotected from potential harm.

The secure estate
Practice within young offenders institutions, secure training
centres and local authority secure children’s homes is enormously
diverse, even though their residents are likely to display broadly
similar behaviour.

Young offenders institutions use the control and restraint method
developed within adult prisons. This is a pain-compliant system
whereby pressure is applied to joints, for example in the form of
arm locks or leg locks, and where the prisoner may also be
subjected to prone restraint – being held face-down on the floor.
Criteria for using restraint are based on the problem behaviour
itself rather than on any risk it may pose, while judgements that a
child is “recalcitrant” or “potentially disruptive” may trigger the
use of force. Children refer to control and restraint as being
“twisted up” and several documented injuries have resulted.

In contrast, in secure training centres the use of pain and prone
restraint is expressly forbidden. Instead, staff have a hierarchy
of “holds” to restrict the child’s movement which they use only
where behaviour is posing a risk.

Secure children’s homes work in the same way as other children’s
homes, although with the added criterion that they can use
restraint if there is a credible risk of escape.

The Youth Justice Board is developing a common code of practice to
address these disparities.

The case for change
Does it matter that children can be subjected to such a range of
responses, given the diverse nature of their needs? It would not be
easy to develop a universal method of restraint suitable for all
children, from grabbing a toddler who is running into the street to
restraining a 17 year old to prevent them committing an assault.
Also, research evidence is lacking. We know little about the safety
and effectiveness of different methods, the impact of restraint on
children and staff, or even the incidence of restraint in the
UK.

There have been attempts to introduce change. The British Institute
of Learning Disabilities has addressed the problem by developing a
policy framework setting out the elements of good practice. At
government level, Northern Ireland and Wales are drafting guidance
on restraint, while Scotland is tackling the disparities within
care standards to ensure a more “joined-up” approach. In England,
although restraint is not mentioned, the Children Bill aspires to
place children and their families at the heart of service
provision, with all agencies working closely towards common
outcomes including a tighter focus on child protection.

But are these separate efforts enough? The UK government has failed
to respond to the UN committee’s concern that children in our
society are being subjected to cruel, inhuman or degrading
treatment through the use of physical restraint. Surely this is a
fundamental issue that risks undermining the rhetoric?

The success of a policy must be judged by its impact on the most
vulnerable. A recent consultation with looked-after children
undertaken by England’s children’s rights director Roger Morgan
showed that the experience of restraint was commonplace. It also
left children feeling distressed, hurt and vengeful. Whatever the
guidance suggests, restraint was perceived as a punishment and as
abusive – a source of particular bitterness for children who had
been removed from parents because of the latter’s alleged abusive
behaviour. Many saw physical intervention as a common means of
securing compliance rather than as a last resort to prevent damage
or injury. Several children described injuries occurring through
inexperienced use of restraint. Perhaps most worryingly, the
children felt there was nothing they could do. They were at the
mercy of adults and had no redress.

The least we can do is to initiate an urgent debate about whether
using restraint and inflicting pain are appropriate ways to treat
children.

Di Hart is principal officer in the children’s
residential care unit at the National Children’s Bureau.

References

⁶ British Medical Association, “Consent, Rights and
Choices in Health Care for Children and Young People”,
BMJ, 2001