1. 10 Areas of Danger and Concern
10a
Areas of Danger
and Concern
Introduction
10
Physical action including restraint carries risks. These include the possibility of serious
physical and psychological trauma and even death. Such situations could result in
criminal or civil proceedings or fatal accident inquiries. Disciplinary action may
result from some situations.
Although serious injuries and deaths have been reported in the UK, there is still a
lack of appropriate research to provide clear guidance. There is well founded and
widespread concern about certain aspects of practice. So far, these have focused
on the following:
10b Neck holds
Holding a child by the neck risks asphyxiation (suffocation) or restricting the blood flow
to the brain. It carries the risk of death. You should never use any form of neck
hold.
10c Obstructing Mouth or Nose
Children spitting or biting while being restrained are legitimate concerns for staff. Your
welfare should be suitably protected and your concerns should be looked at by
occupational health services. While you may understandably wish to cover the
childʼs mouth to protect yourself from spitting or biting, you must never do so.
10d Prone restraint
The term prone restraint simply means to hold a child ʻface downʼ, when on the ground,
usually with their head to one side. There are many versions of this procedure.
Risks associated with prone restraint can be reduced if the procedure used has a
minimum effect on breathing and the health of the child is good (Graham 2002).
However, the procedure may carry unacceptable risks if pressure is placed on the
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2. 10 Areas of Danger and Concern
childʼs torso or hips or the health of child gives cause for concern. Health concerns
may include obesity, asthma or other respiratory problems (Day 2002).
• Restraining children in a prone position carries a higher risk of serious harm than
other holds done correctly, and as such should always be treated as a final option.
• Restraining children in a prone position is more likely than other forms, such as
standing or seated restraints, to be seen by them as a punishment or as abuse.
• Service providers should only approve the restraining of children in a prone
position when an assessment of risk shows that this is the least restrictive action
necessary to achieve a safe outcome for all involved.
10e Seated holds
There are many seated holds with different names in different systems and approaches to
restraint. The research suggests that these techniques are seen by service users as
less intrusive than prone restraint (McDonell et al. 1993).
However, seated holds are not without risk. ʻHyperflexionʼ, where the individual is
bent forward at the waist while seated, can severely restrict breathing and you must
never use it. Hyperflexion is also dangerous if it happens in a kneeling position
(Paterson and Leadbetter 1998).
10f Supine restraint
Supine simply means ʻface upʼ when on the ground, and there are again many varieties of
this procedure. It is sometimes suggested that supine restraint is safer than prone
restraint but it may be associated with risks of a different type. It carries the risk
of choking or inhaling vomit (Morrison et al 2001). Staff need to be aware of this
danger.
10g Basket holds
Basket holds again exist in several versions involving combinations of one or two
people with the staff and children involved variously standing or sitting. Though
bad outcomes have been reported, the risks associated with basket holds can be
reduced.
Two variations give cause for concern. Firstly, if you are doing a basket hold in
a seated position the child must not be bent forward, as this will interfere with
breathing. Secondly, staff can fall accidentally across a childʼs back (into a prone
position) but continue to hold on. A basket hold should never be continued under
these circumstances.
Sometimes staff pull a childʼs hands across their chest from behind, and it is less
risky practice to hold the childʼs hands down to their hips – this should be done
without pulling the arms back, as compressing a childʼs abdominal area will
compress the diaphragm and interfere with their ability to breathe.
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3. 10 Areas of Danger and Concern
10h Pain compliance
Pain compliance is not an acceptable practice in child care. Getting a child to go along
with what you say by inflicting pain exists in a number of forms. These include, for
example, deliberately using pressure across a joint or the use of pressure points.
Pain increases the power professionals have over vulnerable people and so the
possibility of abuse. At the same time the use of pain reduces the chance of
building up a therapeutic relationship (Paterson et al. 2004). As a result, its use in
child care is not acceptable.
10i Medication
Children may be receiving medication for a range of physical or psychological disorders.
Some forms of medication may increase the risk of a child experiencing problems
after a restraint. All risk assessments should take account of the possible side
effects of medication both generally and in the context of restraint (Hughes and
Van Dusen 1993).
10j Conclusion
It is service providers and not those who provide training in physically restraining
children who are ultimately responsible for making sure that the methods used are
appropriate and safe in their residential establishments. Their decisions will be
guided by considering a wide range of issues, for example the needs of children
who are accommodated and the nature of the services provided. However, all
service providers should be working with their training providers towards reducing
or getting rid of those procedures associated with a higher risk of problems
discussed here. Individual staff remain personally responsible for their actions in
individual situations.
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