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Question and Challenge to Dr. Ronald Federici and his Supporters

April 25, 2011

As always, the following posting is an indication of my opinion and understanding of the issues I discuss.

Recently, Valle Oberg, a passionate supporter of Dr. Ronald Federici’s intervention for internationally adopted children with serious behavior problems, as outlined in his book, Help for the Hopeless Child, commented on another article in this blog, defending Dr. Federici and particularly the method of prone restraint described in his book, which she reported having used for up to four to six hours at a time (I am not clear on whether he explicitly okayed or advised this, but she stated she thought it was safe to do this as long as his instructions were followed).  After several lengthy exchanges, she declined to comment further and I respect her right not to do so. However, I would like to repeat the same question and challenge I offered to Ms. Oberg., to Dr. Federici and/or other supporters of his. Again, my intent is not to pull anyone away from Dr. Federici but rather, to bring to light what current policy and position statements with regard to the use of restraints say and to ask if they are aware of any current policy and position statements I may have missed that state that the prone restraint procedure recommended by Dr. Federici is in accordance with such guidelines.

Ms. Oberg is now accusing me of citing “articles and not experience”. You bet I am, although it would be more accurate to say evidence and not experience. Personal experiences and anecdotes are not evidence. The articles I am citing contain scientific evidence. Personal experience contains bias and cannot be generalized to all children in that population, as she attempts to do, based only on her own experience and those people she knows. Please understand that I am not singling Ms. Oberg out here — all human beings have bias. It is an inescapable part of the human condition that no one, regardless of “expertise” or experience is exempt from, myself included which is why I don’t invoke my personal experience working with children with very serious behavior problems as evidence for anything.  Anecdotes can be used to illustrate a point and I have done that, but they are not to be used as a substitute for scientific evidence. The scientific method, while not perfect, does control for biases that personal experience cannot.

Years and years of experience by people who dismiss the need for scientific evidence can amount to years and years of confirmation bias, meaning that they could be even more off base than someone with only a small amount of or even no experience. There’s a saying that the easiest person to fool is oneself. The policy and position statements I review here are based on evidence that has overturned the old way of doing things when it comes to heavy-handed interventions used with children including restraints for control, which are becoming a thing of the past for people who have kept up to date on the latest evidence.

Some of the main current policy and position statements on the use of restraints in institutional settings can be found on SAMHSA’s wbsite. Policy and Position Statements in this PDF include those by:

  • American Nurses Association
  • American Psychiatric Nurses Association
  • Federation for Families for Children’s Mental Health
  • NAMI
  • National Association of State Mental Health Program Directors
  • National Mental Health Association
  • Pennsylvania: Restraints, Seclusion and Exclusion in State Mental Hospitals and Restoration Center.

I invite people to review these guidelines, which state the following:

  • Restraints represent treatment failure and are to be used only as an option of last resort with the least restrictive methods being applied first.
  • Restraints should only be used when there is an immediate threat to the physical safety to self or others. Once the threat has passed, restraints should not be used (for example, a child yelling “I hate you” is not a valid reason to use a restraint or if a child backs down and ceases being violent, restraints should not be used).
  • Staff need to be trained in behavioral interventions that in most cases can successfully prevent a situation from escalating to violence in the first place, and hence, eliminate the need for restraints.
  • These guidelines contain strict time limits on restraints. For example, the Federation for Families for Children’s Mental Health guidelines state:

There should be no instances of seclusion or restraints that last more than a few minutes (i.e., 15 minutes). If they do, the child should have ready (on demand) access to food, water, bathroom facilities, and be allowed to make a phone call to a predetermined, trusted, family member, professional, or support  person. Any child who is secluded for more than 15 minutes should be provided with appropriate and safe learning materials and instruction.

  • Restraints should not be used as a means to control the environment of the child. For example, NAMI guidelines state:

In current practice, physical restraints are sometimes imposed on a patient involuntarily for control of the environment (curtailing individual behavior to avoid the necessity for adequate staffing or clinical interventions); coercion (forcing the patient to comply with the staff’s wishes); or punishment (staff punishing or penalizing patients). NAMI rejects these as legitimate reasons to impose restraints.

  • Only licensed professionals specifically trained in the use of restraint may administer restraints
  • Here is what the Pennsylvania guidelines say about prone restraint (p. 57):

All of the above preexisting risk factors are exacerbated when the patient is placed in a face down position and/or when “hands are held behind the back” holds or restraints are employed.
___ When the patient is held or restrained in a face down (prone) position, lungs are compressed and breathing may become labored. The more pressure that is applied to the person’s torso, the more compression is increased.
___ Placing a pillow, blanket, or other item under or over the patient’s face as part of a restraint or holding process, especially when the patient is in a prone position, may result in suffocation.

[point of clarification: I am not saying Federici does all these things — I had thought that would be understood since I never stated that he did, but apparently I am being misquoted on this, so I will make this explicit – note that it says in a face down position AND/OR hands behind the back, but that does not mean I am stating Federici uses the hands behind the back position — he does not]

Note that these policies and procedures were written for institutional settings where highly trained and experience staff are on hand. If the policies are this strict in these settings, what does that say about parents who are left alone with their children and do not follow these policies, but instead, place a child in a prone restraint for hours at a time? Nowhere in any of these policies could I find any statements that they did not apply to internationally adopted children who were adopted when they were older and spent time in institutions. The APSAC Task Force Report provides some very specific statements against “attachment”, coercive restraint, and other similar therapies. Unfortunately, however, proponents of such interventions seem to somehow feel that they are above or exempt from such conclusions and nothing bad will happen if they use them, much like an adolescent who engages in risky behavior. I sincerely hope it doesn’t take another death of a child for them to wake up and see the evidence, but even then, it may not phase them.

The white paper on prone restraints by PCMA that I wrote about in an earlier posting has similar recommendations and although this paper is in favor of prone holds, the authors note that “certain types of prone holds are very unsafe” including lying on or straddling the torso in any way. Their reason for this is, even if the person has no intention of putting any pressure on the person’s torso, if the restrainer becomes fatigued, this could inadvertently happen.

My challenge to Dr. Federici’s supporters is for them to show me any current guidelines that state that:

  • It is okay to place a child in a prone restraint for hours at a time.
  • It is okay to use prone restraints on a child who is being defiant, but not presenting an immediate physical threat (for example, a child yelling “I hate you” or refusing to obey the parent)
  • It is okay to follow through with restraint even if a child backs down and promises to change his/her behavior.
  • It is okay to place a pillow under the child’s head during prone restraint
  • It is okay for people who have not themselves received official training and certification in the use of prone restraints to restrain a child, as long as they have been trained by a therapist who has had experience working with this population in a residential treatment facility.
  • It is okay to go right to prone restraints, when less invasive methods have not first been tried.

If such a position and policy statement exists, I would be very interested in reading it.

Additionally by way of an update, about a year ago I asked Dr. Federici to list hospitals or residential facilities that currently use the prone restraint method described in his book. On Ron Federici’s Blog, there was as posting in his name entitled Ronald Federici Replies to Monica Pignotti that responded to my question. One of the institutions listed in that posting is Regional Institute for Children in Maryland. However, having looked into the matter, it appears that the state of Maryland has banned prone restraints in Maryland schools and residential facilities. I’m not sure I’m understanding how Regional Institute could be currently using prone restraints if they are banned, as it appears to be a school for teens with behavior problems. Have I missed something?

Here is a very informative PowerPoint that describes Maryland’s restraint elimination initiative.

Additionally, a Maryland-based organization, TACT2 Professional Crisis Intervention that trains in the use of restraints and crisis intervention, decided to discontinue training in prone restraint entirely in 2008.  They state on their website:

Due to very legitimate concerns regarding positional asphyxia, a number of states have banned the use of prone restraints in the past 5 years, and more states are moving in that direction in 2008-09.

Even when well-designed and well-executed, prone restraints contain an inherent potential for danger, as they place youth in a face down position which could possibly compromise breathing. When agencies have enough well-trained and supervised staff, they can respond quickly and intelligently to emotional and physiological concerns before they become emergencies. Unfortunately, the reality is that too many agencies and too many staff fail to meet these conditions. Across the nation, youth care agencies are often understaffed, and because of high turnover, utilize inexperienced and poorly trained individuals. Staff are frequently uninformed of health conditions which might impact the safety of a restraint, or in the heat of the moment, lose the professional perspective needed to make safe and therapeutic decisions.

Given these realities, we have decided to voluntarily remove the prone restraint from the TACT-2 program, effective July 1, 2008.

This is very typical of the types of changes that are happening in organizations all over the United States that once used prone restraint, but are no longer using it for reasons described so succinctly by TACT2. Nevertheless, Ronald Federici and his supporters continue to insist that the prone restraint method, described in his book is completely safe, even when used for hours at a time, as long as it is done as he instructs and as long as the parents are trained by a qualified therapist (however, as far as I could tell, there are no specifics on what constitutes a qualified therapist other than the person needs to have training and experience working in residential facilities with populations similar to the one he described). I remain concerned and unconvinced regarding this matter.

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