The Use of Coercive Measures in a Residential Treatment Setting for Children with Intellectual Disabilities: How Trauma-Informed Care Training Leads to a Change in Staff Attitude and Behavior

Children in residential treatment settings often exhibit challenging behavior that can result in the use of physical restraint and seclusion. These coercive measures can cause serious physical and emotional harm, especially to children who have prior experiences of abuse and neglect. Children with mild intellectual disabilities or borderline intellectual functioning (MBID) are at increased risk for exposure to adverse childhood experiences. For these vulnerable children especially, experiencing physical coercion can be retraumatizing and add new traumatic experiences. The prevention of coercive measures for children with MBID in residential treatment settings is therefore a priority. Trauma-informed care (TIC) aims to create safe, supportive environments that prevent re-traumatization and stimulate healing and resilience. While TIC implementation seems effective in reducing coercive measures in residential youth treatment settings, little is known about this effect in settings for children with MBID. In the current study we investigated whether TIC training impacted staff attitudes and behaviors regarding the application of coercive measures in a residential treatment setting for children with MBID. Staff participated in a seven-module learning curriculum on the principles of TIC. We used a verbal analysis approach to analyze incident reports on the use of seclusion and restraint using an a priori coding framework with six different subthemes. This approach allowed us to integrate both qualitative and quantitative components within a unified analytic framework. We compared incident reports that predated TIC training with reports filed after teams were trained. Results showed a general but modest positive shift towards more trauma-sensitive attitudes and responses in managing challenging behavior. We observed more collaboration, less repression, and a tendency to stay connected, even in times of distress and aggression. Regarding subthemes, significant positive shifts were identified for the themes Repression versus Collaboration, Responding to Challenging Behavior and Regulation of Stress Responses. No such shifts were observed for the subthemes Mechanisms of Behavior Change, Drivers of Challenging Behavior and Empathy and Connection. For all themes, room for improvement remained after training. The results indicate that TIC training is a necessary first step in TIC implementation but it is not sufficient for drastically reducing the use of coercive measures in residential treatment settings for children with MBID. We suggest that a translation from a change in perspective to a change in actions requires guided peer-to-peer reflection, coaching on the job and ongoing supervision.