Therapeutic Schools, Therapeutic Programs
and Outdoor Behavioral Health Programs
The National Association of Schools and Programs
126 North Marina, Suite 3
Prescott, AZ 86301
to the NATSAP Principles
of Good Practice
The following Guidelines and Practice
of Behavioral Management have been unanimously adopted
the Board of Directors of the National Association of Therapeutic
Schools and Programs as basic practice standards ascribed
to by member therapeutic programs and schools.
of Behavioral Management
When dealing with at-risk, troubled, oppositional, acting
out, maladaptive and/or defiant youth, the program staff might
be required to employ behavior support management techniques
to foster adaptive, appropriate and pro-social behavior and
assure the safety of the individual youth, other program participants
and/or the staff. Such techniques start with the establishment
of written guidelines, rules and expectations of appropriate
and pro-social behavior. When a program participant's behavior
is in opposition the written rules and guidelines and places
him/herself and/or others in harms way, additional behavior
management techniques may be utilized. Those behavior support
management techniques range from verbal persuasion to physical
Hence, a school or program concerned with the safety of its
program participants must advocate and practice a policy of
behavioral support management that should:
1.1 practice behavior support management techniques designed
to foster pro-social behavior. Such techniques are utilized
not exclusively for the purpose of behavioral control. Behavioral
support techniques include respondent and operant conditioning,
shaping, extinction, redirection and social modeling with
both primary and secondary reinforcement integrated within
the programming. Such techniques can be used appropriately
to reduce excessive negative behavior and promote pro-social
behavior and development;
1.2 employ the least intrusive method possible to assure
the safety of all parties concerned (i.e. the individual
child, other program participants and staff);
1.3 when possible, assure that less intrusive interventions
have been offered to the child before more restrictive methods
1.4 when faced with the necessity of applying such interventions,
protect as much as possible, the dignity and privacy of
the program participant.
2.0 The Continuum of Behavior Management
Fundamentally, the continuum of behavioral support management
techniques and interventions can be divided into three general
categories: 1) behavioral management interventions that foster
adaptive and pro-social behavior; 2) de-escalation procedures
when the child becomes agitated (see 4.0); and 3) special
treatment procedures when the program participant's intensity
and duration is such that de-escalation techniques, including
brief physical holdings, are no longer effective to bring
the behavior under control (see 5.0).
3.0 Behavior Support Management Techniques
Designed to Foster Pro-Social Behavior
Behavior support management techniques are therapeutic interventions
utilized to foster pro-social and discourage maladaptive behavior
within the program participants.
A school or program employing behavior support techniques
3.1 develop and implement written policies that govern
the use of behavior support techniques;
3.3 fully inform program participants and his/her family
regarding the behavior support system at the time of admission.
(i.e. level system, pre-determined consequences for certain
adaptive and maladaptive behaviors);
3.4 group consequences must be approached with great care
and an effort not to infringe on individual's appropriate
care. A written policy should describe the appropriate use
of group consequences and describe limits on such consequence;
3.5 specify procedures and interventions that are prohibited.
At a minimum, the following are prohibited:
3.5.1 procedures that deny a nutritionally adequate diet.
3.5.2 physically abusive punishment.
3.5.3 any behavior support intervention that is implemented
by another program participant without the expressed consent
of a staff member
3.5.4 any behavior support management intervention that
is contrary to local, state and/or national licensing or
accrediting bodies, should school or program be so licensed
3.5.6 application of consequences that are not in accordance
with the program participant's rights.
4.0 De-Escalation Interventions
De-escalation techniques are a part of the organization's
overall behavior support policy and procedures, but are specifically
delineated as those interventions that are designed to de-escalate
agitated behavior that, if unchecked by the staff and/or the
program participant, may rise to the level of being a danger
to self, others, destruction of property or serious disruption
of the therapeutic environment. Hence, the purpose of de-escalation
interventions is to reduce maladaptive and agitated behavior
and replace it with pro-social behavior. The skilled practice
and application of de-escalation techniques are the most effective
way to prevent the use of special treatment procedure.
De-escalation Technique should include Verbal Interventions
(Example: Extensive training on the following topics should
be in place.
a) Staff members need to mentally prepare. Remain calm,
become aware of what the person is saying and doing, feel
respect for person not the behavior.
b) Share your observations and listen to what is being
c) Identify what is causing the issue and/or feeling.
d) Assist the person with developing more productive avenues
to express feeling.
A school or program, employing de-escalation interventions,
should incorporate the following elements into their behavioral
4.1 Whenever appropriate, least restrictive behavioral
de-escalation interventions should be used.
4.2 Policy and procedure protocols delineate the a) type
of behavior interventions utilized, b) what contextual circumstances
call for what type of behavioral interventions and c) the
duration and methods employed in the de-escalation process.
Examples for the use of least restrictive to most restrictive
intervention could be:
- Category I interventions might include teaching interventions,
benign response reduction techniques such as verbal directives,
prompts, redirection, contingent observation.
- Category II interventions might include over-correction,
quiet time, time-out, and positive practice. Category III
interventions might include novel, non-standard or experimental
4.3 Policies and procedure govern the use of time-out.
4.3.1 The time-out protocols should distinguish between
a self-directed time-out and a staff-directed time-out.
Timeout should also be included in a tiered approach.
Examples of Time-Out Procedures:
1. A program participant, returning from a group therapy
session, is visibly agitated and is requesting a time-out.
The individual is placed in an open-door time-out room and
instructed that he may return to the regular, scheduled
activity when he feels that he has regained adequate behavior
and emotional control. After the program participant is
requesting to re-join the regular activity, the staff assesses
the program participant whether or not the program participant
has sufficiently de-escalated to return to the regular group
activity. Should the program participant not be ready, the
staff directs the program participant to take additional
time to regain control and composure.
2. Prior to a group therapy session, a program participant
is requesting a self-directed time-out. The program participant
has a pattern of avoiding group therapy because she does
not want to be exposed to her peers' feedback about her
behavior. The staff denied the program participant request
for a self-directed time-out because it is clinically contraindicated
and encouraged the program participant to attend the group.
3. A program participant is demonstrating agitated
behavior, but is not requesting a self-directed time-out.
As part of a progressive de-escalation protocol, the staff
is directing the program participant to take a time-out
in the open-door time out room. The staff member stands
in the open door to prevent the individual from leaving
the time-out room. Periodically, the staff will assess the
individual as to whether or not he has gained sufficient
behavioral control to return to the regularly scheduled
activity. If the staff decides, following an assessment
of the program participant, that he should not rejoin the
regular scheduled activity and prevents him from leaving
the time-out room by physically blocking the exit for more
than 30 minutes, the time-out procedure has risen to the
level of a special treatment procedure.
4.4 Policies and procedure should govern the use of brief
physical holding interventions.
4.4.1 Brief physical holdings may only be utilized under
the following conditions:
220.127.116.11 Danger to self (i.e. attempting to or in
the process of head banging, punching the wall, attempting
to swallow a "sharp," scratching or carving in
an attempt to cause damage, etc.).
18.104.22.168 Danger to others (i.e. attempting to or
endangering others by slapping, kicking, biting, etc.).
22.214.171.124 Substantial destruction of facility/staff/others
property (i.e. damaging furniture, computer equipment,
NOTE: Programs should check with their individual licensing
agency when considering the above examples.
4.4.2 Therapeutic holds should not exceed 30 minutes. If
a program participant, placed in a therapeutic hold, is
unable to regain control within 30 minutes and the procedure
needs to be extended beyond the 30 minutes, the therapeutic
hold then rises to the level of a special treatment procedure.
a) An individual is shouting obscenities at his peers.
The peers are visibly agitated. The individual is not
responding to verbal request from the staff. The individual
is offered a staff directed time-out. The individual refuses
to walk to the time-out area but escalates with obscenity
and threats of violence. The Staff attempt to physically
escort the individual to the time out area. In the process,
the individual is punching a staff member. As a result,
the individual is placed in a therapeutic hold. Within
10 minutes, the individual is calm and released from the
therapeutic hold - this is not a special treatment procedure.
b) Should the child require a therapeutic hold for
more than 30 minutes in order to regain control, the therapeutic
hold will rise to the level of a special treatment procedure.
4.5 Brief physical holds are never used as punishment.
4.6 Therapeutic holds are documented in the program participant's
5.0 Special Treatment Procedures
Special Treatment Procedures refer to a specific
class of behavioral interventions that restrict the free movement
of a child by mechanical or physical means for a prolonged
period of time when the child becomes a danger to self and/or
others, is destructive of property, or is a serious disruption
to the therapeutic environment. Specifically, those interventions
are referred to as seclusion, restraint, or more than 30 minutes
of a physical hold.
Seclusion is a procedure where the individual is
restricted to a small space, such as a time-out room, without
the ability to leave the room, i.e. the individual is blocked
from exiting either by a locked-door or by a staff standing
in the door and preventing the program participant from leaving
the room for more than 30 minutes.
A Restraint procedure occurs when a mechanical
device such as leather belts, posy belts, strait jackets,
hand cuffs, or other devices are used to restrict the free
movement of an individual or whenever a program participant
is placed in a physical hold exceeding 30 minutes.
Those NATSAP members, who employ special treatment procedures,
must be licensed or accredited by state and/or national regulatory
organizations that specifically address the use of said procedures.
However, any NATSAP member program may resort to physical
restraint in order to remove a participant to a more restrictive
level of care in the event of imminent threat of serious injury
to the program participant or others. All NATSAP programs
must have specific policy, procedures, and training to respond
to such emergent situations.
6.0 Risk Management and Performance Improvement
6.1 Physical holdings, restraint and seclusion can be
high risk and problem prone. The organization should collect
data on the use of brief physical holding interventions
and special treatment procedures in order to monitor and
improve performance of processes that involve risk or may
result in sentinel events.
7.0 Informed Consent
7.1 Parents/guardians and students/residents are informed,
at the time of admission regarding behavior management interventions
including physical holding and special treatment procedures.
Elements of Guideline:
- Upon admission, the family and program participant
are informed about the general conditions under which behavior
management techniques are utilized, including physical holdings,
seclusion and/or restraint. A written consent is obtained
for the parent/guardian, and if applicable, by the program
participant for the use of these interventions.
- As part of the admission process, the staff presents
the parent/guardian with a written, general explanation
of behavior management policies and procedures, including
the use of physical holdings, seclusion and/or restraint.
- Parent/Guardian signature(s) are obtained for the
use of those interventions. Students/residents are equally
informed about these interventions and are encouraged to
sign the consent form. They may refuse to sign the form
but parental/guardian written consent will permit the application
of those interventions.
8.0 Staff Training and Competence
8.1 Staff is trained and competent in the use of the behavior
support policy and procedures.
8.2 Staff is trained and competent to minimize the use
of intrusive behavior intervention such as physical holdings,
seclusion and/or restraint.
Elements of Guideline:
a) The organization educates, assesses and documents
the competence of staff in minimizing the appropriate use
of physical holdings, seclusion and/or restraint and, before
they participate in any use of said interventions, are also
educated and trained in their safe use.
b) In order to minimize the use of these procedures,
all direct care staff as well as any other staff involved
in the use of said interventions receive ongoing training
in and demonstrate an understanding:
- of the underlying causes of threatening behaviors
exhibited by the program participants;
- of the possibility that a program participant may
exhibit an aggressive behavior that is related to a medical
condition and not related to his or her emotional condition,
for example, threatening behavior that may result from delirium
in fever and hypoglycemia;
- of how a staff's own behaviors can affect the behaviors
of the program participant;
- of the use of de-escalation, mediation, self-protection
and other techniques, such as time-out,
- recognizing signs of physical distress in individuals
who are being held, restrained, or secluded.
c) Staff charged with monitoring or initiating the
holdings, seclusion and/or restraint procedure receive the
training and demonstrate the competence to assess the program
participant throughout these procedures.
Glossary of Terms
Brief Physical Holding: A non-violent
physical intervention restricting the movement of a youth,
or restricting the movement of normal function of a portion
of the youth's body as described in agency-approved training
methods, by forcefully and involuntarily depriving the youth
of free liberty to move about. Simple physical redirection
which does not cause pain, such as hand on the back or briefly
holding the upper arm or clasping of the hand, should not
be considered a physical restraint. Brief Physical Holdings
may not exceed 30 minutes in duration. If a program participant
requires holding for more than 30 minutes, said procedure
has risen to the level of a Special Treatment Procedure.
Special Treatment Procedure: A specific
class of behavior interventions restrict the free movement
of a child by mechanical or physical means for a prolonged
period of time, and/or a physical holding that exceeds 30
minutes in duration in response to threats or actions of self
harm, harm towards others, destruction of property, and serious
disruption of the therapeutic environment. Specifically, those
interventions are referred to as seclusion and mechanical
restraint and/or physical holdings for more than 30 minutes
Seclusion: A procedure where the
individual is restricted to a small space, such as a time-out
room, without the ability to leave the room, i.e. the individual
is blocked from exiting either by a lock-door or by a staff-restricting
exit for more than 30 minutes. That is to say, that a procedure
where the individual is prevented from exiting a confined
space for 29 or less minutes, is not a seclusion procedure.
Mechanical restraint: A procedure
where a mechanical device such as leather belts, posy belts,
strait jacket, hand cuffs, and other devices are used to restrict
the free movement of an individual. Therapeutic holds (see
4.4) that are longer then 30 minutes in duration, are also
considered restraint procedures.
Time-Out: Time-out procedures are
those classes of interventions in which the program participant
is offered a time away from the regular scheduled activity
in order to gather himself and/or re-establishing the locus
of control within him/her, in an attempt to de-escalate agitated
behavior and/or to prevent a serious disruption of the therapeutic
environment. When possible, time-out interventions are conducted
away from stimuli that may contribute to the escalation of
maladaptive behavior and/or reduce the probability for serious
disruption to the therapeutic environment. Time outs in excess
of 30 minutes should be classified as seclusion.
Self Directed Time-Out: A procedure
where the program participant is requesting a time-out in
effort of regain control and/or composure, sensing or knowing
that he/she is agitated and desiring some time to de-escalate.
The program participant should be given adequate time to do
so. At any time during a self-directed time-out, when it becomes
evident that the continuation of the self-directed time-out
becomes clinically contraindicated, the procedure is terminated
by the staff.
Staff Directed Time-Out: A time-out
procedure where the program participant is restricted, for
30 minutes or less, from leaving an unlocked room or area.
A procedure where the individual is restricted for 30 minutes
or more in the time-out area is a special treatment procedure
(see definition). A staff directed time-out procedure may
not deny the program participant from daily, adequate nutritional
intake and deprive him/her from regular eliminating.
Comprehensive Accreditation Manual for
Behavioral Health Care of the Joint
Commission on Accreditation of Health Care Organization (JCAHO)
1999-2000, 2001-2002. Chicago, IL.
Core Standards of the Office of Licensure
of the Utah Department of Human Services.
Corded, S., and Gair, D.S.: Freedom Within
Limits. Proceedings of the Fourth Annual Children's Advocacy
Conference. Boston, New England Children's Mental Health Task
Force. (A U.S. Public Health Service Document, 1978.
Dorr, D.: The Need to Understand Discipline.
In The Psychology of Discipline. Edited by Dorr, F., Zax,
M., Bonner, J. New York, International Universities Press,
Gair, D.S.: Limit-setting and Seclusion in
Psychiatric Hospitals. Psychiatric Opinion. 17:15-19, 1980.
Guthrell, T.: Observations and the Theoretical
Basis for Seclusion of the Psychiatric Resident. Am I Psychiatry
Spitz, R.A.: No and Yes. New York,
International Universities Press, 1957.
2005, Woodbury Reports, Inc. All Rights Reserved.
(This article may not be reproduced without written approval
of the publisher.)