E. Emergency Behavior Interventions
Many trauma-informed care trainings promote specific strategies including self-care approaches, peer-provided services, arts programs, and comfort rooms to enhance healing and as to provide a means to avoid the use of restraint and seclusion. Generally, if a trauma response is triggered, allowing time, space, and support can help re-establish self-regulation.
In Texas, the Administrative Code offers the following guidelines on utilizing Emergency Behavior Interventions, such as restraints and seclusion, on children in General Residential Operations and Residential Treatment Centers. These guidelines are summarized in the chart which follows.
1. Restraint/Seclusion May Only Be Used:
• As last resort
26 Tex. Admin. Code § 748.2455(a)(1) and (2); 26 Tex. Admin. Code § 749.2055(a)(1) and (2); 26 Tex. Admin. Code § 748.2551(a); and 26 Tex. Admin. Code § 749.2151
• After less restrictive and more positive measures have been tried and failed
26 Tex. Admin. Code § 748.2455(a)(1) and (2); 26 Tex. Admin. Code § 749.2055(a)(1) and (2); 26 Tex. Admin. Code § 748.2551(a); and 26 Tex. Admin. Code § 749.2151(a)
• Only in an emergency situation or to administer intra-muscular medication or other physician prescribed medication
26 Tex. Admin. Code § 748.2455(a)(2); 26 Tex. Admin. Code § 749.2055(a)(2); 26 Tex. Admin Code § 748.43(22); and 26 Tex. Admin. Code § 749.43(25) (Definition of emergency situation)
• When immediately necessary
26 Tex. Admin. Code § 748.43(20); 26 Tex. Admin. Code § 749.43(23) (Definition of Emergency Behavioral Intervention (EBI); 26 Tex. Admin Code § 748.43(22); and 26 Tex. Admin. Code § 749.43(25) (Definition of emergency situation)
• To prevent imminent probable death or substantial physical injury
26 Tex. Admin. Code § 748.43(20); 26 Tex. Admin. Code § 749.43(23) (Definition of EBI); 26 Tex. Admin. Code § 748.43(22); 40 Tex. Admin. Code § 749.43(25) (Definition of emergency situation); 26 Tex. Admin. Code § 748.43(68); and 26 Tex. Admin. Code § 749.43(72) (Definition of substantial physical injury)
• Never as punishment, retaliation, means of compliance, convenience, or treatment
26 Tex. Admin. Code § 748.2463 and 26 Tex. Admin. Code § 749.2063
2. Types of Restraints That May Be Administered with Restrictions:
• Short personal restraint and personal restraint
26 Tex. Admin. Code § 748.2451(a)(1) and (2); 26 Tex. Admin. Code § 749.2051(a)(1) and (2); 26 Tex. Admin. Code § 748.43(51) and (65); and 26 Tex. Admin. Code § 749.43(52) and (69) (Definition of personal restraint and short personal restraint)
• Emergency medication
26 Tex. Admin. Code § 748.2451(a)(3); 26 Tex. Admin. Code § 749.2051(a)(3); 26 Tex. Admin. Code § 748.2753 (simultaneous use with another EBI); 26 Tex. Admin. Code § 749.2233 (simultaneous use with personal restraint); 26 Tex. Admin. Code § 748.43(21); and 26 Tex. Admin. Code § 749.43(24) (Definition of emergency medication)
• Seclusion
26 Tex. Admin. Code § 748.2451(a)(4); 26 Tex. Admin. Code § 748.2651; 26 Tex. Admin. Code § 748.43(63); 26 Tex. Admin. Code § 749.43(67) (Definition of seclusion); and 26 Tex. Admin. Code § 749.2051(b)
• Mechanical restraint
26 Tex. Admin. Code § 748.2451(a)(5) (only in Residential Treatment Centers); 26 Tex. Admin. Code § 748.2701; 26 Tex. Admin. Code § 748.2703; 26 Tex. Admin. Code § 748.2755 (simultaneous use with emergency medication); 26 Tex. Admin. Code § 748.43(39); 26 Tex. Admin. Code § 749.43(40) (Definition of mechanical restraint); and 26 Tex. Admin. Code § 749.2051(b)
3. Restraint/Seclusion May Only Be Administered by:
• A caregiver qualified in emergency behavior interventions
26 Tex. Admin. Code § 748.2453; 26 Tex. Admin. Code § 749.2053; (Requirements); 26 Tex. Admin. Code § 748.947; 26 Tex. Admin. Code § 749.947 (Annual training requirements)26 Tex. Admin. Code § 748.863(a); 26 Tex. Admin. Code § 749.863(a) (Pre-service training requirements); 26 Tex. Admin. Code § 748.930; and 26 Tex. Admin. Code § 749.930 (Training hours).
• Whose duties include the direct care, supervision, guidance, and protection of child
26 Tex. Admin. Code § 748.43(5) and 26 Tex. Admin. Code § 749.43(9)
4. A Child Must Be Released from a Restraint/Seclusion:
• Immediately if an emergency health situation arises
26 Tex. Admin. Code § 748.2553(1)(A), (2)(A), (4)(A), and (5)(A); 26 Tex. Admin. Code § 749.2153(1)(A) and (2)(A); 26 Tex. Admin. Code § 748.2603; and 26 Tex. Admin. Code § 749.2203
• Immediately once the danger is over
26 Tex. Admin. Code § 748.2553(2)(C) and 26 Tex. Admin. Code § 749.2153(2)(C)
• Once maximum time allowed is reached
26 Tex. Admin. Code § 748.2553(2)(E); 26 Tex. Admin. Code § 749.2153(2)(E); and 26 Tex. Admin. Code § 748.2553(2)(E) and (4)(D)
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Figure: 26 Tex. Admin. Code § 748.2553 |
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Type of Emergency Behavior Intervention |
The caregiver must release the child if any of the following apply: |
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(1) Short personal restraint |
(A) Immediately when an emergency health situation occurs during the restraint and the caregiver must obtain treatment immediately; or (B) Within one minute, or sooner if the danger is over or the emergency situation no longer exists. |
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(2) Personal restraint |
(A) Immediately when an emergency health situation occurs during the restraint. The caregiver must obtain treatment [for the child] immediately; (B) Within one minute of the implementation of a prone or supine transitional hold; (C) As soon as the child's behavior is no longer a danger to himself or others; (D) As soon as the medication is administered; or (E) When the maximum time allowed for personal restraint is reached. |
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(3) Emergency medication |
Not applicable. |
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(4) Seclusion |
(A) Immediately when an emergency health situation occurs during the seclusion and the caregiver must obtain treatment immediately; (B) As soon as the child's behavior is no longer a danger to himself or others; (C) No later than five minutes after the child begins exhibiting the regulated behaviors[187]; (D) When the maximum time allowed for seclusion is reached; (E) If the child falls asleep in seclusion, the caregiver must: (i) Unlock the door; (ii) Continuously observe the child until he awakens; and (iii) Evaluate his overall well-being; or (F) If the child is receiving emergency care services: (i) As soon as the child is no longer a danger to himself or others; (ii) Upon the arrival of a medical professional; or (iii) Upon assistance from law enforcement or the fire department. |
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(5) Mechanical restraint |
(A) Immediately when an emergency health situation occurs during the restraint and the caregiver must obtain treatment immediately; (B) As soon as the child's behavior is no longer a danger to himself or others; (C) No later than five minutes after the child begins exhibiting the regulated behaviors; (D) When the maximum time allowed for mechanical restraint is reached; or (E) If the child falls asleep in the mechanical restraint. In this situation, the caregiver must release the child from the restraint and continuously observe the child until he awakens and evaluate him. |
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Figure: 26 Tex. Admin. Code § 748.2801 |
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Types of Emergency Behavior Intervention |
The maximum length of time is: |
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(1) Short personal restraint |
One minute. |
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(2) Personal restraint |
(A) For a child of any age, 30 minutes; (B) A prone or supine personal restraint transitional hold may not exceed one minute. |
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(3) Emergency medication |
Not applicable. |
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(4) Seclusion |
(A) For a child under nine years old, one hour. (B) For a child nine years old or older, two hours. |
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(5) Mechanical restraint |
(A) For a child under nine years old, 30 minutes. (B) For a child nine years old or older, one hour. |
When restraining/secluding, a written order is required:
• By a licensed physician when administering emergency medications
26 Tex. Admin. Code § 748.2501(3) and 26 Tex. Admin. Code § 749.2101(3)
• By a licensed psychiatrist when administering mechanical restraints
26 Tex. Admin. Code § 748.2501(5)
• By a licensed psychiatrist, physician, or psychologist when administering successive restraints
26 Tex. Admin. Code § 748.2501(2); 26 Tex. Admin. Code § 749.2101(2)(A); 26 Tex. Admin. Code § 748.2751(3); and 26 Tex. Admin. Code § 749.2231(a)
• When using restraints simultaneously
26 Tex. Admin. Code § 748.2501(2); 26 Tex. Admin. Code § 749.2101(2)(A); 26 Tex. Admin. Code § 748.2753(a)(3) and (b); 26 Tex. Admin. Code § 749.2233(a) (Emergency medications with personal restraint); and 26 Tex. Admin. Code § 748.2755(a)(3) and (b) (Mechanical restraints with emergency medications)
• When maximum length of time allowed is exceeded
26 Tex. Admin. Code § 748.2805; however under 26 Tex. Admin. Code § 749.2283, time extension prohibited.
• Also see: 26 Tex. Admin. Code § 748.2505; 26 Tex. Admin. Code § 749.2105 (Content of written orders); 26 Tex. Admin. Code § 748.2507; 26 Tex. Admin. Code § 749.2107 (PRN orders); and 26 Tex. Admin. Code § 748.2807 (verbal orders to exceed maximum time allowed)
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Figure: 26 Tex. Admin. Code § 748.2501 |
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Type of Emergency Behavior Intervention |
Are written orders required to administer the intervention for a specific child? |
Who can write orders for the use of the intervention for a specific child? |
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(1) Short personal restraint |
NO. |
Not applicable. |
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(2) Personal restraint |
NO. However, successive restraints, a restraint simultaneous with emergency medication, and/or a restraint that exceeds the maximum time limit all require orders as specified in this subchapter. PRN orders are also permitted under 26 Tex. Admin. Code § 748.2507 of this title (relating to “Under what conditions are PRN orders permitted for a specific child?”). |
Not applicable. |
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(3) Emergency medication |
YES. |
A licensed physician. |
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(4) Seclusion |
YES, except written orders are not required when [professionals] provide emergency care services to the child placed in seclusion. |
A licensed psychiatrist, psychologist, or physician. |
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(5) Mechanical restraint |
YES. |
A licensed psychiatrist. |
A review of the use of emergency behavior intervention for a specific child is triggered when:
• Personally restrained four times in a seven-day period or more than 12 times in 30-day period or same child personally restrained more often than order allows.
26 Tex. Admin. Code § 748.2901(a)(2) and 26 Tex. Admin. Code § 749.2331(b)(2)
• Emergency medications used three times in a thirty-day period
26 Tex. Admin. Code § 748.2901(3) and 26 Tex. Admin. Code § 749.2331(3)
• Secluded more than twelve hours or three times in a seven-day period
26 Tex. Admin. Code § 748.2901(a)(4) (Note that this is not applicable to foster care placements.)
• Mechanically restrained more than three hours or three times in a seven-day period
26 Tex. Admin. Code § 748.2901(a)(5) (Note that this is not applicable to foster care placements.)
Restraint/Seclusion that is NOT allowed:
• Mechanical restraint may not be simultaneously used with seclusion or pursuant to PRN order
26 Tex. Admin. Code § 748.2757 and 26 Tex. Admin. Code § 748.2507(5)
• No chemical restraints
26 Tex. Admin. Code § 748.1119(1); 26 Tex. Admin. Code § 749.1021(1); 26 Tex. Admin. Code § 748.2451(b); 26 Tex. Admin. Code § 749.2051(b); 26 Tex. Admin. Code § 748.43(7); and 26 Tex. Admin. Code § 749.43(12) (Definition)
• Prone or supine restraints except for a transitional hold for 1 minute or less or as a last resort
26 Tex. Admin. Code § 748.2605(b); 26 Tex. Admin. Code § 749.2205(b) and (c); 26 Tex. Admin. Code § 748.2461(b)(1); 26 Tex. Admin. Code § 749.2061(b)(1); 26 Tex. Admin. Code § 748.2553(2)(B); 26 Tex. Admin. Code § 749.2153(2)(B); 26 Tex. Admin. Code § 748.2801(2)(B); and 26 Tex. Admin. Code § 749.2281(2)(B)
• Foster care placements may never administer chemical restraints, mechanical restraints, or seclusion.
Also see other relevant provisions:
• 26 Tex. Admin. Code § 748.1119 and 26 Tex. Admin. Code § 749.2051 (Techniques prohibited)
• 26 Tex. Admin. Code § 748.2303 and 26 Tex. Admin. Code § 749.1953 (May not use or threaten corporal punishment)
• 26 Tex. Admin. Code § 748.2307 and 26 Tex. Admin. Code § 749.1957 (Methods of punishment prohibited)
• 26 Tex. Admin. Code § 748.2605 and 26 Tex. Admin. Code § 749.2205 (Prohibited physical restraint techniques)
• 26 Tex. Admin. Code § 748.2705 (Types of mechanical & other restraint devices prohibited)