What is Seclusion and Restraint & Why should I care??
Supporting Student Behavior:  Standards for the Emergency  Use of Seclusion and Restraint   Awareness Training Muskegon Ar...
Andrew <ul><li>11 years old </li></ul>Died from traumatic asphyxia and chest compression.  Face-down restraint  with arms ...
Angie <ul><li>7 years old </li></ul>Stopped breathing after being placed  in prone restraint position.  Death being ruled ...
Chase <ul><li>17 years old </li></ul>Asphyxiation by a prone restraint   He was restrained for refusing to stop talking an...
Chris <ul><li>13 years old      </li></ul>Asphyxiation by prone restraint   He was restrained 4 times … in  his  last 24 h...
Edith <ul><li>15 years old </li></ul>Restraint Asphyxia –  She was looking at a family photograph  when a male aide instru...
Gareth <ul><li>15 years old   </li></ul>Died of asphyxiation by a prone restraint   Restrained by three staff members on h...
Isaiah <ul><li>17 years old </li></ul>Four youths witnessed his death.  Students say staff sat on him for three hours unti...
Jonathan <ul><li>13 years old </li></ul>Restrained in a van while staff were running errands.  Though he was clearly havin...
Mark <ul><li>14 years old </li></ul>Asphyxiation while being forcibly restrained by 3 staff in a prone position
Sakena <ul><li>18 years old   </li></ul>Suffocation during face down restraint with staff member laying across her back.
Travis <ul><li>13 years old </li></ul>The autopsy indicated he died because of the face-down on the ground restraint. Rest...
Omega <ul><li>17 years old </li></ul>He died after being restrained by staff in prone position with arms behind his back. ...
Robert <ul><li>12 years old   </li></ul>Asphyxiation while restrained after a dispute about his…  missing teddy bear He wa...
Reality <ul><li>142 deaths in the US from 1988 – 1998 due to S/R, reported by the Hartford Courant  (Weiss et al, 1998) </...
Reality <ul><li>50 to 150 deaths occur in the US each year due to S/R estimated by the Harvard Center for Risk Analysis   ...
The Research <ul><li>Over 85% of restraints, management, seclusion, begin with students refusing to follow a staff directi...
Part One Introduction
TERMS   <ul><li>What is restraint? </li></ul><ul><li>What is physical management? </li></ul><ul><li>What is physical assis...
Physical Restraint <ul><li>Physical Restraint  is the application of physical force by one or more individuals that reduce...
What is Physical Assistance <ul><li>Physically assisting someone who is accepting of your help) e.g., putting on your coat...
What is physical management? <ul><li>Physically forcing someone to do something against their will (e.g., forcibly taking ...
What is a physical escort? <ul><li>Physical Escort  is the touching or holding a student with a minimum use of contact for...
What is mechanical restraint? Mechanical Restraint is the use of any device, article, garment, or material attached or adj...
What is seclusion? <ul><li>Seclusion  means the confinement of a student alone in a secured room or other space from which...
What is time-out? <ul><li>Timeout  means a behavior management technique in which a student, for a limited and specified t...
What is an emergency? <ul><li>Emergency  is a situation in which a student’s behavior poses imminent risk to the safety of...
What is a Emergency Safety Intervention? <ul><li>Emergency Safety Intervention  is the use of seclusion or restraint to de...
What is Prone Restraint? <ul><li>Prone Restraint  is the restraint of a person face down.  </li></ul>PROHIBITED IN STATE G...
What is supine restraint? <ul><li>Supine Restraint  is the restraint of a person face up.  </li></ul>
State Board of Education Policy on Seclusion and Restraint <ul><li>On December 12, 2006 the State Board of Education adopt...
Context for the Policy <ul><li>Referent group created  by Superintendent of Public Instruction – May 2004. </li></ul><ul><...
The  Supporting Student Behavior: Standards for the Emergency Use of Seclusion and Restraint (Supporting Student Behavior)...
The  Supporting Student Behavior  document is rooted in best practices and drafted in the belief that: <ul><ul><li>the mos...
Legal Context of the Policy <ul><li>Policy is not meant to conflict with or limit corporal punishment statute.  </li></ul>...
State Board of Education Policy on Positive Behavior Support <ul><li>Each school district in Michigan will implement a sys...
Impact of School-wide PBS on  Seclusion and Restraint <ul><li>Implementation of a school-wide system will ensure that secl...
Continuum of School-wide PBS
Are classroom response cost systems contributing to defiance and aggression?   <ul><li>Response to Intervention </li></ul>...
Training on Policy <ul><li>Awareness Training-  Needed for broad educational community including pre-service and substitut...
TRAINING <ul><li>Training Framework  </li></ul><ul><ul><li>A comprehensive training framework includes:  </li></ul></ul><u...
Training Components <ul><ul><li>All training must include:  </li></ul></ul><ul><ul><ul><li>􀁸  proactive practices and stra...
Comprehensive Training for Key Identified Personnel <ul><li>C. Comprehensive Training for Key Identified Personnel  </li><...
TRAINING CONTINUED <ul><li>instruction in the use of seclusion and restraint;  </li></ul><ul><li>􀁸  identification of even...
Part Two Standards for  Seclusion and Restraint
Definitions <ul><li>Seclusion </li></ul><ul><ul><li>Last resort emergency safety intervention </li></ul></ul><ul><ul><li>G...
Justification for Use <ul><li>Seclusion: </li></ul><ul><ul><li>Must be used only under emergency situations and if essenti...
Corporal Punishment <ul><li>Deliberate infliction of physical pain by hitting, paddling, spanking, slapping, or any other ...
Limitations <ul><li>Seclusion not to be used for: </li></ul><ul><ul><li>Staff convenience </li></ul></ul><ul><ul><li>Disci...
Prohibited Practices <ul><li>Seclusion: </li></ul><ul><ul><li>Corporal punishment </li></ul></ul><ul><ul><li>Depriving bas...
Use of Physical Force under the  Corporal Punishment Statute <ul><li>In maintaining order and control, a person may use ph...
Procedures for Use <ul><li>Seclusion and Safety: </li></ul><ul><ul><li>Use trained key personnel </li></ul></ul><ul><ul><l...
<ul><li>Seclusion: </li></ul><ul><li>Proportionate and sensitive to student’s: </li></ul><ul><ul><li>Severity of behavior ...
Duration <ul><li>Seclusion: </li></ul><ul><ul><li>No longer than needed to allow student to regain control </li></ul></ul>...
Debriefing <ul><li>Seclusion: </li></ul><ul><ul><li>Followed by debriefing with the parent and student to explore </li></u...
Emergency Intervention Plan (EIP) for Seclusion <ul><li>Trigger =  a pattern of behavior requiring the use of seclusion oc...
<ul><li>Trigger = a pattern of behavior requiring the use of restraint  </li></ul><ul><li>Documented steps for EIP: </li><...
EIP for Restraint (continued) <ul><ul><li>Gain informed consent based upon an explanation of: </li></ul></ul><ul><ul><ul><...
Documentation and Reporting <ul><li>Seclusion: </li></ul><ul><ul><li>Document each use of seclusion and reason for use </l...
Data Collection System <ul><li>Seclusion data must include: </li></ul><ul><ul><li>Frequency </li></ul></ul><ul><ul><li>Rel...
SCENARIO #1 <ul><li>Johnnie brings a restricted item to school- e.g., Pokie Man cards. Johnnie’s teacher asks for the card...
SCENARIO # 2 <ul><li>You ask a Johnny to leave the room and go to the time-out area. John tells you to go to h-ll. I’m not...
Scenario # 3 <ul><li>Johnny hates to go to gym. Halfway down the hall he flops on the floor and refuses to move. The staff...
Scenario # 4 <ul><li>You have told Johnny he can’t go out for recess until his work his done. The bell for recess rings an...
Scenario # 5 <ul><li>Staff are working with Johnny and he throws his materials on the floor. Staff tell him to pick it up....
Scenario # 6 <ul><li>Johnny’s teacher uses a red light classroom management system. John violates a class rule and the tea...
Scenario * 7 <ul><li>In the pre-school class, Johnny is having problems sitting at circle. Consequently, the teacher uses ...
Scenario # 8 <ul><li>Johnny keeps leaving music class so the teacher assistant holds him and keeps him from leaving the ac...
Scenario # 9 <ul><li>Johnny hits another student in class. He continues to hit the student. The teacher holds Johnny with ...
Other Potential Scenarios  <ul><li>Coming in from recess </li></ul><ul><li>Removing a hat </li></ul><ul><li>Denying Access...
Is It Restraint ?
Acceptable Use of Restraint in Schools <ul><ul><li>Restraint of a student most often refers to a set of proven techniques ...
Functional Behavior Assessment & Behavior Intervention Planning <ul><li>Getting a real grasp:  </li></ul><ul><ul><ul><li>P...
Functional Behavioral Assessment <ul><li>What purpose does the behavior serve for the student? </li></ul><ul><li>How can y...
In Other Words <ul><li>“ Why is this person engaging in this behavior in this setting at this time?” </li></ul><ul><li>Gor...
Is it a Behavior Intervention  Plan (BIP)? <ul><li>If the BIP focuses on what happens  after  a behavior occurs, it is a B...
Positive Support ?
Comprehensive Training In Restraint Is Important for Schools <ul><li>De-escalation techniques emphasized </li></ul><ul><li...
THE REVISED SCHOOL CODE (EXCERPT)  Act 451 of 1976  <ul><li>380.1312 “Corporal punishment” defined; infliction of corporal...
THE REVISED SCHOOL CODE <ul><ul><li>Sec. 1312.  </li></ul></ul><ul><ul><li>(1) As used in this section, “corporal punishme...
THE REVISED SCHOOL CODE <ul><ul><li>(a) To restrain or remove a pupil whose behavior is interfering with the orderly exerc...
Risks <ul><li>Restraints can be a dangerous method of intervention.  </li></ul><ul><li>The Child Welfare League of America...
Risks <ul><li>One of the leading causes of deaths during restraint is “asphyxia” which is a restriction of the person’s ab...
Risks <ul><li>Any restraint that restricts the free movement of the chest or diaphragm may restrict breathing and contribu...
Risks <ul><li>Students may also have risk factors such as medical conditions that exacerbate the risks of restraints.  </l...
Risks <ul><li>The child’s treatment or programming should focus on other methods of addressing behavior, such as PBS. </li...
Signs of Physical Distress <ul><li>A student who is highly agitated and is being restrained is under a great deal of physi...
Signs of Physical Distress <ul><li>Circulatory </li></ul><ul><li>Extremities are cold to the touch </li></ul><ul><li>Blue ...
Signs of Physical Distress <ul><li>Respiratory </li></ul><ul><li>Rapid, shallow breathing </li></ul><ul><li>Panting, grunt...
Signs of Physical Distress <ul><li>Neurological </li></ul><ul><li>Confusion, disorientation </li></ul><ul><li>Seizure </li...
Signs of Physical Distress <ul><li>Gastrointestinal </li></ul><ul><li>Vomiting </li></ul><ul><li>Compliant of constipation...
Signs of Physical Distress <ul><li>Musculo-Skeletal </li></ul><ul><li>Joint swelling </li></ul><ul><li>Complaint of pain <...
Resources <ul><li>Personal Emergency Intervention Training </li></ul><ul><ul><li>Devereux Institute of Clinical Training a...
PBS <ul><li>Covers 4 areas: </li></ul><ul><ul><ul><li>Systems change </li></ul></ul></ul><ul><ul><ul><li>Environmental alt...
Questions and Answers
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P R E V E N T I N G T H E U S E O F E X C L U S I O N A N D R E S T R A I N T

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P R E V E N T I N G T H E U S E O F E X C L U S I O N A N D R E S T R A I N T

  1. 1. What is Seclusion and Restraint & Why should I care??
  2. 2. Supporting Student Behavior: Standards for the Emergency Use of Seclusion and Restraint Awareness Training Muskegon Area Intermediate School District Presented by Steven Vitto, M.A., Behavioral Specialist, M.A.I.S.D. Certified Crisis Prevention Trainer (CPI) Certified Therapeutic Crisis Intervention Trainer (TCI) Certified State of Michigan PBS Coach and Trainer Certified Balanced & Restorative Justice Trainer (BARJ)
  3. 3. Andrew <ul><li>11 years old </li></ul>Died from traumatic asphyxia and chest compression. Face-down restraint with arms crossed over chest.
  4. 4. Angie <ul><li>7 years old </li></ul>Stopped breathing after being placed in prone restraint position. Death being ruled a homicide  
  5. 5. Chase <ul><li>17 years old </li></ul>Asphyxiation by a prone restraint He was restrained for refusing to stop talking and not following instructions . According to an autopsy he died after suffocating on his own vomit.
  6. 6. Chris <ul><li>13 years old   </li></ul>Asphyxiation by prone restraint He was restrained 4 times … in his last 24 hours
  7. 7. Edith <ul><li>15 years old </li></ul>Restraint Asphyxia – She was looking at a family photograph when a male aide instructed her to hand over the &quot;unauthorized&quot; personal item. The dispute escalated into a face-down floor restraint
  8. 8. Gareth <ul><li>15 years old </li></ul>Died of asphyxiation by a prone restraint Restrained by three staff members on his 4th day at the facility
  9. 9. Isaiah <ul><li>17 years old </li></ul>Four youths witnessed his death. Students say staff sat on him for three hours until he passed out and died.
  10. 10. Jonathan <ul><li>13 years old </li></ul>Restrained in a van while staff were running errands. Though he was clearly having difficulties breathing they continued running their errands… for another 1½ hours .
  11. 11. Mark <ul><li>14 years old </li></ul>Asphyxiation while being forcibly restrained by 3 staff in a prone position
  12. 12. Sakena <ul><li>18 years old </li></ul>Suffocation during face down restraint with staff member laying across her back.
  13. 13. Travis <ul><li>13 years old </li></ul>The autopsy indicated he died because of the face-down on the ground restraint. Restrained 1½ hours.   Denied request for asthma meds.
  14. 14. Omega <ul><li>17 years old </li></ul>He died after being restrained by staff in prone position with arms behind his back. June 3, 2007
  15. 15. Robert <ul><li>12 years old </li></ul>Asphyxiation while restrained after a dispute about his… missing teddy bear He was restrained for 10 minutes, face down on the floor. The staffer who restrained the boy left him lying, unresponsive, on the floor
  16. 16. Reality <ul><li>142 deaths in the US from 1988 – 1998 due to S/R, reported by the Hartford Courant (Weiss et al, 1998) </li></ul><ul><li>111 fatalities over 10 years in New York facilities due to restraints (Sundram, 1994 as cited by Zimbroff, 2003) </li></ul><ul><li>At least 16 children (<18 y.o.) died in restraints in Texas programs from 1988 – 2002, reported by local media (American-Statesman, May 18, 2003 ) </li></ul><ul><li>At least 14 people died and at least one has become permanently comatose while being subjected to S/R from July 1999 to March 2002 in California (Mildred, 2002 ) </li></ul>
  17. 17. Reality <ul><li>50 to 150 deaths occur in the US each year due to S/R estimated by the Harvard Center for Risk Analysis (NAMI, 2003) </li></ul><ul><li>Federal Office of the Inspector General identified 42 of 104 (42%) SR deaths from 08/99 – 12/04 were not reported. (OIG, 2006) </li></ul>
  18. 18. The Research <ul><li>Over 85% of restraints, management, seclusion, begin with students refusing to follow a staff direction. </li></ul><ul><li>How staff deal with this noncompliance plays a big part in whether the student’s behavior diffuses or escalates. </li></ul><ul><li>There is no research supporting the use of forced compliance as a behavioral change strategy. </li></ul><ul><li>There is a significant increase in children with ODD, ADHD, ASD, Social Maladjustment, Down Syndrome in our schools. </li></ul><ul><li>Staff need to be trained in how to deal with oppositional, defiant and aggressive behavior. </li></ul><ul><li>Most staff have little training in this area. </li></ul>
  19. 19. Part One Introduction
  20. 20. TERMS <ul><li>What is restraint? </li></ul><ul><li>What is physical management? </li></ul><ul><li>What is physical assistance? </li></ul><ul><li>What is a physical escort? </li></ul><ul><li>What is mechanical restraint? </li></ul><ul><li>What is seclusion? </li></ul><ul><li>What is time-out? </li></ul><ul><li>What is an emergency? </li></ul><ul><li>What is imminent danger? </li></ul>
  21. 21. Physical Restraint <ul><li>Physical Restraint is the application of physical force by one or more individuals that reduces or restricts a student’s freedom of movement. Physical restraint of a student may only be used for the purpose of providing safety and support. </li></ul>RESTRICTIONS IN STATE GUIDELINES
  22. 22. What is Physical Assistance <ul><li>Physically assisting someone who is accepting of your help) e.g., putting on your coat) </li></ul>
  23. 23. What is physical management? <ul><li>Physically forcing someone to do something against their will (e.g., forcibly taking something away from someone, physically making someone do a task) </li></ul>RESTRICTIONS IN STATE GUIDELINES
  24. 24. What is a physical escort? <ul><li>Physical Escort is the touching or holding a student with a minimum use of contact for the purpose of directing movement from one place to another. </li></ul>RESTRICTIONS IN STATE GUIDELINES
  25. 25. What is mechanical restraint? Mechanical Restraint is the use of any device, article, garment, or material attached or adjacent to the student's body, which the student cannot easily remove, and that restricts freedom of movement PROHIBITED IN STATE GUIDELINES
  26. 26. What is seclusion? <ul><li>Seclusion means the confinement of a student alone in a secured room or other space from which the student is physically prevented from leaving. </li></ul>RESTRICTIONS IN STATE GUIDELINES
  27. 27. What is time-out? <ul><li>Timeout means a behavior management technique in which a student, for a limited and specified time, is placed in an environment where access to positive reinforcement is unavailable. Timeout should not be confused with seclusion because in a timeout setting a student’s movement is not physically restricted. </li></ul>
  28. 28. What is an emergency? <ul><li>Emergency is a situation in which a student’s behavior poses imminent risk to the safety of an individual student or to the safety of others. An emergency requires an immediate intervention. </li></ul>RESTRICTIONS IN STATE GUIDELINES
  29. 29. What is a Emergency Safety Intervention? <ul><li>Emergency Safety Intervention is the use of seclusion or restraint to de-escalate student behavior that poses an imminent risk to the safety of an individual student and others. </li></ul>RESTRICTIONS IN STATE GUIDELINES
  30. 30. What is Prone Restraint? <ul><li>Prone Restraint is the restraint of a person face down. </li></ul>PROHIBITED IN STATE GUIDELINES
  31. 31. What is supine restraint? <ul><li>Supine Restraint is the restraint of a person face up. </li></ul>
  32. 32. State Board of Education Policy on Seclusion and Restraint <ul><li>On December 12, 2006 the State Board of Education adopted “Supporting Student Behavior: Standard for the Emergency Use of Seclusion and Restraint”. </li></ul>
  33. 33. Context for the Policy <ul><li>Referent group created by Superintendent of Public Instruction – May 2004. </li></ul><ul><li>Group included parents, advocates, educators, policy makers & service providers. </li></ul><ul><li>Group charge: </li></ul><ul><ul><li>Develop standards for the use of seclusion and restraint; </li></ul></ul><ul><ul><li>Recommend substantive strategic directives; and </li></ul></ul><ul><ul><li>Recommend implementation to State Board of Education </li></ul></ul>
  34. 34. The Supporting Student Behavior: Standards for the Emergency Use of Seclusion and Restraint (Supporting Student Behavior) document <ul><ul><li>▪ summarizes how a positive behavior support approach uses proactive strategies to reduce or eliminate the use of seclusion and restraint; </li></ul></ul><ul><ul><li>▪ defines the terms “seclusion” and “restraint”; </li></ul></ul><ul><ul><li>▪ outlines procedures for emergency use of seclusion and restraint; and </li></ul></ul><ul><ul><li>▪ provides a framework for training. </li></ul></ul>
  35. 35. The Supporting Student Behavior document is rooted in best practices and drafted in the belief that: <ul><ul><li>the most effective strategies for supporting positive student behavior begin with meaningful instruction provided by highly trained professionals in a safe environment which promotes dignity for all students; </li></ul></ul><ul><ul><li>school-wide systems of positive behavioral support to address challenging behavior will increase instructional time for all; and </li></ul></ul><ul><ul><li>seclusion or restraint should be used only in an emergency and require </li></ul></ul><ul><ul><li>diligent assessment, monitoring, documentation, and reporting by trained personnel. </li></ul></ul>
  36. 36. Legal Context of the Policy <ul><li>Policy is not meant to conflict with or limit corporal punishment statute. </li></ul><ul><li>Policy is not law. </li></ul>
  37. 37. State Board of Education Policy on Positive Behavior Support <ul><li>Each school district in Michigan will implement a system of school-wide positive behavior support (PBS) strategies. (Adopted September 12, 2006) </li></ul>
  38. 38. Impact of School-wide PBS on Seclusion and Restraint <ul><li>Implementation of a school-wide system will ensure that seclusion and restraint are used only as a last resort method. </li></ul><ul><ul><li>Encourages learning by building relationships; </li></ul></ul><ul><ul><li>Teaches skills/rules/expectations; </li></ul></ul><ul><ul><li>Identifies replacement behaviors that interfere with learning; </li></ul></ul><ul><ul><li>Makes problem behavior less effective; </li></ul></ul><ul><ul><li>Makes desired behavior more functional and adaptive. </li></ul></ul>
  39. 39. Continuum of School-wide PBS
  40. 40. Are classroom response cost systems contributing to defiance and aggression? <ul><li>Response to Intervention </li></ul><ul><li>Are we using evidenced based classroom behavior management systems at the universal level? Are classroom response cost systems evidenced based? Is there a balance, better yet, an overbalance of Positive Incentives and Feedback for Desired Behavior? </li></ul><ul><li>When universal consequences (e.g., Classroom Response Cost System) are not effective, or when they trigger an escalation of behavior, do we differentiate our approach? </li></ul><ul><li>Are we over-relying on classroom response cost systems to manage student behaviors? </li></ul>
  41. 41. Training on Policy <ul><li>Awareness Training- Needed for broad educational community including pre-service and substitute teachers. </li></ul><ul><li>Comprehensive Training- Needed for key personnel identified by district to ensure trained personnel are available for emergency response. </li></ul>
  42. 42. TRAINING <ul><li>Training Framework </li></ul><ul><ul><li>A comprehensive training framework includes: </li></ul></ul><ul><ul><ul><li>􀁸 awareness training for the broader educational </li></ul></ul></ul><ul><ul><ul><li>community, including pre-service training for all </li></ul></ul></ul><ul><ul><ul><li>teachers; </li></ul></ul></ul><ul><ul><ul><li>􀁸 awareness training for substitute teachers; and </li></ul></ul></ul><ul><ul><ul><li>􀁸 comprehensive training for key identified personnel </li></ul></ul></ul>
  43. 43. Training Components <ul><ul><li>All training must include: </li></ul></ul><ul><ul><ul><li>􀁸 proactive practices and strategies that ensure the dignity of students; </li></ul></ul></ul><ul><ul><ul><li>􀁸 conflict resolution; </li></ul></ul></ul><ul><ul><ul><li>􀁸 mediation; </li></ul></ul></ul><ul><ul><ul><li>􀁸 social skills training; </li></ul></ul></ul><ul><ul><ul><li>􀁸 de-escalation techniques; </li></ul></ul></ul><ul><ul><ul><li>􀁸 positive behavior support strategies; </li></ul></ul></ul><ul><ul><ul><li>􀁸 techniques to identify student behaviors that may trigger emergency safety </li></ul></ul></ul><ul><ul><ul><li>situations; </li></ul></ul></ul><ul><ul><ul><li>􀁸 related safety considerations, including information regarding the increased </li></ul></ul></ul><ul><ul><ul><li>risk of injury to students and staff when seclusion or restraint is used; </li></ul></ul></ul><ul><ul><ul><li>􀁸 instruction in the use of seclusion and restraint; </li></ul></ul></ul><ul><ul><ul><li>􀁸 identification of events and environmental factors that may trigger </li></ul></ul></ul><ul><ul><ul><li>emergency safety situations; and </li></ul></ul></ul><ul><ul><ul><li>􀁸 instruction on the State Board of Education policy on Supporting Student Behavior: The Emergency Use of Seclusion and Restrain </li></ul></ul></ul>
  44. 44. Comprehensive Training for Key Identified Personnel <ul><li>C. Comprehensive Training for Key Identified Personnel </li></ul><ul><ul><li>A Local Educational Agency (LEA) will identify sufficient key personnel to ensure that trained personnel are available for an emergency situation. Before using seclusion or restraint with students, key identified personnel who may have to respond to an emergency safety situation must be trained in: </li></ul></ul><ul><ul><ul><li>􀁸 proactive practices and strategies that ensure the dignity of students; </li></ul></ul></ul><ul><ul><ul><li>􀁸 conflict resolution; </li></ul></ul></ul><ul><ul><ul><li>􀁸 mediation; </li></ul></ul></ul><ul><ul><ul><li>􀁸 social skills training; </li></ul></ul></ul><ul><ul><ul><li>􀁸 de-escalation techniques; </li></ul></ul></ul><ul><ul><ul><li>􀁸 positive behavior support strategies; </li></ul></ul></ul><ul><ul><ul><li>􀁸 techniques to identify student behaviors that may trigger emergency safety </li></ul></ul></ul><ul><ul><ul><li>situations; </li></ul></ul></ul><ul><ul><ul><li>􀁸 related safety considerations, including information regarding the increased risk of injury to students and staff when seclusion or restraint is used; </li></ul></ul></ul>
  45. 45. TRAINING CONTINUED <ul><li>instruction in the use of seclusion and restraint; </li></ul><ul><li>􀁸 identification of events and environmental factors that may trigger emergency safety situations; </li></ul><ul><li>􀁸 instruction on the State Board of Education policy on Supporting Student Behavior: The Emergency Use of Seclusion and Restraint ; </li></ul><ul><li>􀁸 description and identification of dangerous behaviors; </li></ul><ul><li>􀁸 methods for evaluating the risk of harm to determine whether the use of seclusion or restraint is warranted; </li></ul><ul><li>􀁸 types of seclusion; </li></ul><ul><li>􀁸 types of restraint; </li></ul><ul><li>􀁸 the risk of using seclusion and restraint in consideration of a student’s known and unknown medical or psychological limitations; </li></ul><ul><li>􀁸 instruction in the use of seclusion and restraint; </li></ul><ul><li>􀁸 the effects of seclusion and restraint on ALL students; </li></ul><ul><li>􀁸 how to monitor the physical signs of distress; and </li></ul><ul><li>􀁸 how to obtain medical assistance. </li></ul>
  46. 46. Part Two Standards for Seclusion and Restraint
  47. 47. Definitions <ul><li>Seclusion </li></ul><ul><ul><li>Last resort emergency safety intervention </li></ul></ul><ul><ul><li>Gives opportunity to regain control </li></ul></ul><ul><ul><li>Student is confined in room or other space & prevented from leaving </li></ul></ul><ul><ul><li>Continuous adult observation required </li></ul></ul><ul><li>Restraint </li></ul><ul><ul><li>Emergency intervention </li></ul></ul><ul><ul><li>Gives opportunity to regain control </li></ul></ul><ul><ul><li>Direct physical contact that prevents or significantly restricts the student’s movement </li></ul></ul>
  48. 48. Justification for Use <ul><li>Seclusion: </li></ul><ul><ul><li>Must be used only under emergency situations and if essential </li></ul></ul><ul><ul><li>Emergency situations include behavior that: </li></ul></ul><ul><ul><ul><li>Poses imminent risk to the safety of the individual student </li></ul></ul></ul><ul><ul><ul><li>Poses imminent risk to the safety of others </li></ul></ul></ul><ul><li>Restraint: </li></ul><ul><ul><li>Must be used only under emergency situations and if essential </li></ul></ul><ul><ul><li>Emergency situations include behavior that: </li></ul></ul><ul><ul><ul><li>Poses imminent risk to the safety of the individual student </li></ul></ul></ul><ul><ul><ul><li>Poses imminent risk to the safety of others </li></ul></ul></ul><ul><ul><ul><li>Fits the corporal punishment statute </li></ul></ul></ul>
  49. 49. Corporal Punishment <ul><li>Deliberate infliction of physical pain by hitting, paddling, spanking, slapping, or any other physical force as a means of discipline. </li></ul><ul><li>Person employed by, engaged as a volunteer or contractor may use reasonable physical force as necessary to maintain order and control in a school or school related setting for the purpose of providing an environment that is conducive to safety and learning. </li></ul>
  50. 50. Limitations <ul><li>Seclusion not to be used for: </li></ul><ul><ul><li>Staff convenience </li></ul></ul><ul><ul><li>Discipline or punishment </li></ul></ul><ul><ul><li>As a substitute for less restrictive interventions </li></ul></ul><ul><ul><li>As a substitute for training in CPI and PBS </li></ul></ul><ul><li>Restraint not to be used for: </li></ul><ul><ul><li>Staff convenience </li></ul></ul><ul><ul><li>Discipline or punishment </li></ul></ul><ul><ul><li>As a substitute for less restrictive interventions </li></ul></ul><ul><ul><li>As a substitute for training in CPI and PBS </li></ul></ul>
  51. 51. Prohibited Practices <ul><li>Seclusion: </li></ul><ul><ul><li>Corporal punishment </li></ul></ul><ul><ul><li>Depriving basic needs </li></ul></ul><ul><ul><li>Child abuse </li></ul></ul><ul><ul><li>Seclusion of preschool children </li></ul></ul><ul><ul><li>Intentional application of a noxious substance or physical stimuli resulting in physical pain or extreme discomfort </li></ul></ul><ul><li>Restraint: </li></ul><ul><ul><li>Corporal punishment </li></ul></ul><ul><ul><li>Depriving basic needs </li></ul></ul><ul><ul><li>Child abuse </li></ul></ul><ul><ul><li>Mechanical and chemical restraint </li></ul></ul><ul><ul><li>Intentional application of a noxious substance or physical stimuli resulting in physical pain or extreme discomfort </li></ul></ul><ul><ul><li>Prone restraint </li></ul></ul>
  52. 52. Use of Physical Force under the Corporal Punishment Statute <ul><li>In maintaining order and control, a person may use physical force upon a student: </li></ul><ul><ul><li>To restrain or remove a pupil whose behavior is interfering with the orderly exercise and performance of school functions if the pupil has refused to comply </li></ul></ul><ul><ul><li>For self-defense or defense of another </li></ul></ul><ul><ul><li>To prevent a student from inflicting harm on self </li></ul></ul><ul><ul><li>To quell a disturbance that threatens physical injury </li></ul></ul><ul><ul><li>To obtain possession of a weapon or other dangerous object </li></ul></ul><ul><ul><li>To protect property </li></ul></ul>
  53. 53. Procedures for Use <ul><li>Seclusion and Safety: </li></ul><ul><ul><li>Use trained key personnel </li></ul></ul><ul><ul><li>Watch for physical distress </li></ul></ul><ul><ul><li>Medical assistance if needed </li></ul></ul><ul><ul><li>Continuously observe </li></ul></ul><ul><ul><li>Document observations </li></ul></ul><ul><li>Restraint and Safety: </li></ul><ul><ul><li>Use trained key personnel </li></ul></ul><ul><ul><li>Watch for physical distress </li></ul></ul><ul><ul><li>Seek medical assistance if needed </li></ul></ul><ul><ul><li>Continuously observe </li></ul></ul><ul><ul><li>Document observations </li></ul></ul>
  54. 54. <ul><li>Seclusion: </li></ul><ul><li>Proportionate and sensitive to student’s: </li></ul><ul><ul><li>Severity of behavior </li></ul></ul><ul><ul><li>Developmental and chronological ages </li></ul></ul><ul><ul><li>Size </li></ul></ul><ul><ul><li>Physical, medical and psychiatric condition </li></ul></ul><ul><ul><li>Gender </li></ul></ul><ul><ul><li>Personal history, including history of physical or sexual abuse </li></ul></ul><ul><li>Restraint: </li></ul><ul><li>Proportionate and sensitive to student’s: </li></ul><ul><ul><li>Severity of behavior </li></ul></ul><ul><ul><li>Developmental and chronological ages </li></ul></ul><ul><ul><li>Size </li></ul></ul><ul><ul><li>Physical, medical and psychiatric condition </li></ul></ul><ul><ul><li>Gender </li></ul></ul><ul><ul><li>Personal history, including history of physical or sexual abuse </li></ul></ul>Procedures for Use (continued)
  55. 55. Duration <ul><li>Seclusion: </li></ul><ul><ul><li>No longer than needed to allow student to regain control </li></ul></ul><ul><ul><li>Elementary = no more than 15 minutes </li></ul></ul><ul><ul><li>Middle / High School= no more than 20 minutes </li></ul></ul><ul><ul><li>If more time is needed, add support staff and document to explain time extension </li></ul></ul><ul><li>Restraint: </li></ul><ul><ul><li>No longer than needed to allow student to regain control, but generally no longer than 10 minutes </li></ul></ul><ul><ul><li>If more time is needed, add support staff and document to explain time extension </li></ul></ul>
  56. 56. Debriefing <ul><li>Seclusion: </li></ul><ul><ul><li>Followed by debriefing with the parent and student to explore </li></ul></ul><ul><ul><ul><li>Triggers </li></ul></ul></ul><ul><ul><ul><li>Whether behavior will occur again </li></ul></ul></ul><ul><ul><ul><li>What, if any, follow-up is needed </li></ul></ul></ul><ul><li>Restraint: </li></ul><ul><ul><li>Followed by debriefing with the parent and student to explore </li></ul></ul><ul><ul><ul><li>Triggers </li></ul></ul></ul><ul><ul><ul><li>Whether behavior will occur again </li></ul></ul></ul><ul><ul><ul><li>What, if any, follow-up is needed </li></ul></ul></ul>
  57. 57. Emergency Intervention Plan (EIP) for Seclusion <ul><li>Trigger = a pattern of behavior requiring the use of seclusion occurs or is reasonably anticipated </li></ul><ul><li>Documented steps for EIP: </li></ul><ul><ul><li>Detail the emergency plan </li></ul></ul><ul><ul><li>Ask if a known medical condition contraindicates seclusion </li></ul></ul><ul><ul><li>List possible alternative, pros and cons of each </li></ul></ul><ul><ul><li>Periodic review </li></ul></ul><ul><ul><li>Trained personnel </li></ul></ul>
  58. 58. <ul><li>Trigger = a pattern of behavior requiring the use of restraint </li></ul><ul><li>Documented steps for EIP: </li></ul><ul><ul><li>Detail the emergency plan </li></ul></ul><ul><ul><li>Ask if a known medical condition contraindicates restraint </li></ul></ul><ul><ul><li>Conduct peer review by knowledgeable staff </li></ul></ul>Emergency Intervention Plan (EIP) for Restraint
  59. 59. EIP for Restraint (continued) <ul><ul><li>Gain informed consent based upon an explanation of: </li></ul></ul><ul><ul><ul><li>Emergency restraint </li></ul></ul></ul><ul><ul><ul><li>Possible discomforts and risks </li></ul></ul></ul><ul><ul><ul><li>Possible alternative strategies, pros and cons of each </li></ul></ul></ul><ul><ul><ul><li>Answers to questions </li></ul></ul></ul><ul><ul><ul><li>Freedom to withdraw consent </li></ul></ul></ul><ul><ul><li>Periodic review </li></ul></ul><ul><ul><li>Trained personnel </li></ul></ul><ul><ul><li>Tell / show student circumstances when restraint would occur </li></ul></ul>
  60. 60. Documentation and Reporting <ul><li>Seclusion: </li></ul><ul><ul><li>Document each use of seclusion and reason for use </li></ul></ul><ul><ul><li>Document in writing and report immediately to building administrator </li></ul></ul><ul><ul><li>Verbally report to parent/guardian immediately or ASAP </li></ul></ul><ul><ul><li>Provide written report to parent within 24 hours </li></ul></ul><ul><li>Restraint: </li></ul><ul><ul><li>Document each use of seclusion and reason for use </li></ul></ul><ul><ul><li>Document in writing and report immediately to building administrator </li></ul></ul><ul><ul><li>Verbally report to parent/guardian immediately or ASAP </li></ul></ul><ul><ul><li>Provide written report to parent within 24 hours </li></ul></ul>
  61. 61. Data Collection System <ul><li>Seclusion data must include: </li></ul><ul><ul><li>Frequency </li></ul></ul><ul><ul><li>Relationship to suspension, expulsion and drop-out rates </li></ul></ul><ul><ul><li>ID of appropriately trained key personnel and levels of education, training and knowledge </li></ul></ul><ul><ul><li>A schedule for reporting and analyzing data by MDE (to be determined) </li></ul></ul><ul><li>Restraint data must include: </li></ul><ul><ul><li>Frequency </li></ul></ul><ul><ul><li>Relationship to suspension, expulsion and drop-out rates </li></ul></ul><ul><ul><li>ID of appropriately trained key personnel and levels of education, training and knowledge </li></ul></ul><ul><ul><li>A schedule for reporting and analyzing data by MDE (to be determined) </li></ul></ul>
  62. 62. SCENARIO #1 <ul><li>Johnnie brings a restricted item to school- e.g., Pokie Man cards. Johnnie’s teacher asks for the cards. Johnny curtly say’s “No way” The teacher reiterates, “Give me the cards” John refuses. The teacher physically takes the cards away. </li></ul>Physical Management
  63. 63. SCENARIO # 2 <ul><li>You ask a Johnny to leave the room and go to the time-out area. John tells you to go to h-ll. I’m not going anywhere. The staff physically manage John to the “time-out” room and then hold the door </li></ul>Physical Escort
  64. 64. Scenario # 3 <ul><li>Johnny hates to go to gym. Halfway down the hall he flops on the floor and refuses to move. The staff pull him by his feet, and pick him up and carry him to the Gym </li></ul>Physical Escort
  65. 65. Scenario # 4 <ul><li>You have told Johnny he can’t go out for recess until his work his done. The bell for recess rings and Johnny gets up and starts to go outside even though his work is incomplete? The teacher blocks the door and physically keeps Johnny from going out. </li></ul>Physical Restraint
  66. 66. Scenario # 5 <ul><li>Staff are working with Johnny and he throws his materials on the floor. Staff tell him to pick it up. Johnny refuses. Staff use hand over hand and force Johnny to pick up the materials. </li></ul>PHYSICAL MANAGEMENT
  67. 67. Scenario # 6 <ul><li>Johnny’s teacher uses a red light classroom management system. John violates a class rule and the teacher tells him to move his clip from green to yellow. Johnny says “no.” The teacher moves the clip. Johnny gets mad and moves the clip back. The teacher tells Johnny to return to his seat. He refuses. The teacher physically moves Johnny to his seat. </li></ul>PHYSICAL MANAGEMENT
  68. 68. Scenario * 7 <ul><li>In the pre-school class, Johnny is having problems sitting at circle. Consequently, the teacher uses a seatbelt to keep Johnny in his seat. </li></ul>MECHANICAL RESTRAINT
  69. 69. Scenario # 8 <ul><li>Johnny keeps leaving music class so the teacher assistant holds him and keeps him from leaving the activity. </li></ul>PHYSICAL RESTRAINT
  70. 70. Scenario # 9 <ul><li>Johnny hits another student in class. He continues to hit the student. The teacher holds Johnny with a basket wrap. Johnny resists and she physically moves him to the office conference room. Johnny is screaming and yelling and the teacher closes the door to keep Johnny from leaving </li></ul>Physical Restraint Physical Escort Seclusion
  71. 71. Other Potential Scenarios <ul><li>Coming in from recess </li></ul><ul><li>Removing a hat </li></ul><ul><li>Denying Access to Compute </li></ul><ul><li>Refusing to go to an activitry </li></ul>
  72. 72. Is It Restraint ?
  73. 73. Acceptable Use of Restraint in Schools <ul><ul><li>Restraint of a student most often refers to a set of proven techniques used by school personnel during extraordinary circumstances in order to secure the safety of the child and/or those persons who cannot otherwise escape harm. </li></ul></ul>Unacceptable Use of Restraint in Schools <ul><ul><li>The holding of a student for any length of time with a purpose or intent other than providing safety, comfort or support should be considered as avoidable and a misapplication of restraint. Physically restraining a student as a means of discipline, to force compliance, or for the convenience of a caregiver is an unacceptable practice. </li></ul></ul>
  74. 74. Functional Behavior Assessment & Behavior Intervention Planning <ul><li>Getting a real grasp: </li></ul><ul><ul><ul><li>Positive </li></ul></ul></ul><ul><ul><ul><li>Pro-active </li></ul></ul></ul><ul><ul><ul><li>Skill-based - not punitive </li></ul></ul></ul>
  75. 75. Functional Behavioral Assessment <ul><li>What purpose does the behavior serve for the student? </li></ul><ul><li>How can you determine the answer? </li></ul><ul><ul><li>Watch the student, ask people, look at records and patterns </li></ul></ul><ul><ul><li>When does the behavior happen? </li></ul></ul><ul><ul><li>Where does the behavior happen? </li></ul></ul><ul><ul><li>Who is there? </li></ul></ul><ul><ul><li>What happens after the behavior? </li></ul></ul>
  76. 76. In Other Words <ul><li>“ Why is this person engaging in this behavior in this setting at this time?” </li></ul><ul><li>Gordon Paul, 1967 </li></ul>
  77. 77. Is it a Behavior Intervention Plan (BIP)? <ul><li>If the BIP focuses on what happens after a behavior occurs, it is a Behavior Management Plan. </li></ul><ul><li>If the BIP focuses on what happens before a behavior occurs, it is a Behavior Intervention Plan. </li></ul>
  78. 78. Positive Support ?
  79. 79. Comprehensive Training In Restraint Is Important for Schools <ul><li>De-escalation techniques emphasized </li></ul><ul><li>Risk of injury to students is reduced </li></ul><ul><li>Risk of injury to staff is reduced </li></ul><ul><li>Restraint should be respectful and enable student to regain self-control </li></ul>
  80. 80. THE REVISED SCHOOL CODE (EXCERPT) Act 451 of 1976 <ul><li>380.1312 “Corporal punishment” defined; infliction of corporal punishment by employee, volunteer, or contractor; exercise of necessary reasonable physical force; liability; violation; deference given to reasonable good-faith judgments; development, implementation, and enforcement of code of student conduct; model list of alternatives to use of corporal punishment; authority permitting corporal punishment void. </li></ul>
  81. 81. THE REVISED SCHOOL CODE <ul><ul><li>Sec. 1312. </li></ul></ul><ul><ul><li>(1) As used in this section, “corporal punishment” means the deliberate infliction of physical pain by hitting, paddling, spanking, slapping, or any other physical force used as a means of discipline. </li></ul></ul><ul><ul><li>(2) Corporal punishment does not include physical pain caused by reasonable physical activities associated with athletic training. </li></ul></ul><ul><ul><li>(3) A person employed by or engaged as a volunteer or contractor by a local or intermediate school board or public school academy shall not inflict or cause to be inflicted corporal punishment upon any pupil under any circumstances. </li></ul></ul><ul><ul><li>(4) A person employed by or engaged as a volunteer or contractor by a local or intermediate school board or public school academy may use reasonable physical force upon a pupil as necessary to maintain order and control in a school or school-related setting for the purpose of providing an environment conducive to safety and learning. In maintaining that order and control, the person may use physical force upon a pupil as may be necessary for 1 or more of the following: </li></ul></ul>
  82. 82. THE REVISED SCHOOL CODE <ul><ul><li>(a) To restrain or remove a pupil whose behavior is interfering with the orderly exercise and performance of school district or public school academy functions within a school or at a school-related activity, if that pupil has refused to comply with a request to refrain from further disruptive acts. </li></ul></ul><ul><ul><li>(b) For self-defense or the defense of another. </li></ul></ul><ul><ul><li>(c) To prevent a pupil from inflicting harm on himself or herself. </li></ul></ul><ul><ul><li>(d) To quell a disturbance that threatens physical injury to any person. </li></ul></ul><ul><ul><li>(e) To obtain possession of a weapon or other dangerous object upon or within the control of a pupil. </li></ul></ul><ul><ul><li>(f) To protect property. </li></ul></ul><ul><ul><li>(5) A person employed by or engaged as a volunteer or contractor by a local or intermediate school board or public school academy who exercises necessary reasonable physical force upon a pupil, or upon another person of Supporting Student Behavior: Standards for the Emergency Use of Seclusion and Restraint Michigan Department of Education 20 </li></ul></ul>
  83. 83. Risks <ul><li>Restraints can be a dangerous method of intervention. </li></ul><ul><li>The Child Welfare League of American (CWLA) estimates that between 8 to 10 children die each year due to restraints with numerous others suffering various injuries from bumps and bruises to broken bones (not just in schools). </li></ul><ul><li>Also emotional injuries to the students </li></ul>
  84. 84. Risks <ul><li>One of the leading causes of deaths during restraint is “asphyxia” which is a restriction of the person’s ability to breathe. </li></ul><ul><li>It is referred to as restraint associated or positional asphyxia and sometimes called “Sudden Death Syndrome.” </li></ul><ul><li>Restraint associated occurs during the process of restraining a person in a manner that causes difficulty with breathing in and out. This leads to insufficient oxygen in the blood which leads to a disturbed heart rhythm which leads to death. </li></ul>
  85. 85. Risks <ul><li>Any restraint that restricts the free movement of the chest or diaphragm may restrict breathing and contribute to positional or restraint associated asphyxia. </li></ul><ul><li>Research shows that “prone restraints” or “floor restraints” are the most dangerous and most likely to cause asphyxia because they involve placing the child face down on the floor which puts pressure on the child’s ribs, chest. </li></ul>
  86. 86. Risks <ul><li>Students may also have risk factors such as medical conditions that exacerbate the risks of restraints. </li></ul><ul><li>Students with asthma, epilepsy or heart conditions can be more prone to have adverse reactions, including death, with certain types of restraints. </li></ul><ul><li>Obese students and students taking certain medications may also be more prone to adverse reactions with certain types of restraints. </li></ul>
  87. 87. Risks <ul><li>The child’s treatment or programming should focus on other methods of addressing behavior, such as PBS. </li></ul><ul><li>If restraints are used, it is very important that safety measures to protect the child and the person restraining the child are implemented. </li></ul><ul><li>Safety measures include training, monitoring and reporting. </li></ul>
  88. 88. Signs of Physical Distress <ul><li>A student who is highly agitated and is being restrained is under a great deal of physical stress. For this reason, staff must be thoroughly aware of the possible indications of physical distress and injury. </li></ul><ul><li>A very dangerous risk to students during the implementation of restraint procedures is restraint-related Positional Asphyxia. </li></ul><ul><li>Positional Asphyxia also termed “Restraint Asphyxia” occurs when the position of a person’s body interferes with that person’s ability to breathe, resulting in death. </li></ul><ul><li>Improperly applied restraints techniques, particularly in the prone position, increase the risk of asphyxia. </li></ul><ul><li>Staff must avoid force and pressure on the student’s back, chest, and diaphragm. </li></ul>
  89. 89. Signs of Physical Distress <ul><li>Circulatory </li></ul><ul><li>Extremities are cold to the touch </li></ul><ul><li>Blue tinge to nail beds and/or area around mouth </li></ul><ul><li>Bleeding </li></ul><ul><li>Flushed or ashen face </li></ul>
  90. 90. Signs of Physical Distress <ul><li>Respiratory </li></ul><ul><li>Rapid, shallow breathing </li></ul><ul><li>Panting, grunting </li></ul><ul><li>Blue tinge to nail beds and/or area around the mouth </li></ul><ul><li>Nasal flaring </li></ul><ul><li>Absence of / difficulty breathing </li></ul>
  91. 91. Signs of Physical Distress <ul><li>Neurological </li></ul><ul><li>Confusion, disorientation </li></ul><ul><li>Seizure </li></ul><ul><li>Vomiting </li></ul><ul><li>Difficulty breathing </li></ul><ul><li>Unconsciousness </li></ul><ul><li>Unequal pupil size </li></ul><ul><li>Complaint of heaches </li></ul>
  92. 92. Signs of Physical Distress <ul><li>Gastrointestinal </li></ul><ul><li>Vomiting </li></ul><ul><li>Compliant of constipation </li></ul><ul><li>Diarrhea </li></ul>
  93. 93. Signs of Physical Distress <ul><li>Musculo-Skeletal </li></ul><ul><li>Joint swelling </li></ul><ul><li>Complaint of pain </li></ul><ul><li>Redness / Bruising </li></ul><ul><li>Deformity of limb or joint </li></ul>
  94. 94. Resources <ul><li>Personal Emergency Intervention Training </li></ul><ul><ul><li>Devereux Institute of Clinical Training and Research </li></ul></ul><ul><li>Nonviolent Crisis Intervention Training </li></ul><ul><ul><li>Crisis Prevention Institute </li></ul></ul><ul><li>Coalition Against Institutionalized Child Abuse </li></ul><ul><ul><li>www.caica.org </li></ul></ul><ul><li>“ Same Old Sad Song” – Smokie Norful </li></ul>
  95. 95. PBS <ul><li>Covers 4 areas: </li></ul><ul><ul><ul><li>Systems change </li></ul></ul></ul><ul><ul><ul><li>Environmental alteration </li></ul></ul></ul><ul><ul><ul><li>Skill instruction </li></ul></ul></ul><ul><ul><ul><li>Behavioral consequence </li></ul></ul></ul><ul><li>Group process to evaluate and address all four areas. </li></ul><ul><li>Resources on PBS on website and www.edlawrc.com . </li></ul>
  96. 96. Questions and Answers

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