Skip to main content
Children’s Long-Term Support (CLTS) Provider Handbook

Section 12: Restrictive Measures

Participant health, safety, and inclusion are at the center of the CLTS Program. This section defines restraints, outlines the CLTS Program position on the limited uses of restraints, provides alternatives to restrictive strategies, and lists the specific steps every CWA and provider must follow when considering restriction actions, including the emergency use of restraints.

Guiding principles

  • Every child has the right to trauma-informed, culturally responsive care.
  • All behavior, including dangerous behavior, has a purpose or meaning for the child.
  • Seclusion and isolation are never appropriate in a community setting for children.
  • Restrictive measures are a treatment failure, not a treatment modality.

Because children of color and people with disabilities are restrained at disproportionately higher rates, every use of restraint requires careful review and justification.

Best practices in positive behavior supports and de-escalation

When dangerous behavior is present, positive behavior supports must be used and documented in the participant file. Positive behavior supports offer an approach for developing an understanding of why a child or youth engages in the challenging and dangerous behavior. They focus on supporting them in a respectful, dignified, and person-centered manner through empowerment, choice, and connections to prevent the recurrence of behaviors with negative outcomes.

Positive behavior supports:

  • Try to understand the “why” of the behavior.
  • Keep the dignity of the child.
  • Focus on the child’s needs.
  • Empower the child.
  • Allow choices.
  • Teach skills.
  • Reduce the chances that the challenging and dangerous behavior will happen again.

Providers and members of the participant’s Deciding Together team can create a support plan to describe the things people can do to support the child if their behavior puts themself or others at risk. A behavior support plan (BSP) is a written document and may be as simple as an after-school routine or a more complex, full plan addressing a broader range of situations where the child and family could use positive behavior supports. Not all children who have a disability need a behavior support plan. But when needed, behavior support plans can help give parents and caregivers important tools.

For children with complex behavioral needs, a full BSP may be needed. The support planning process should involve the child’s entire team and include:

  • Medical evaluation to rule out physical or medical concerns.
  • Deciding which factors are related to the behavior.
  • Identifying the reasons or functions for the behavior (the “why” of the behavior).
  • Identifying how to prevent, deescalate, and respond to the behavior.
  • A plan to develop other coping skills.

The BSP is unique to the child and provides an easy-to-follow plan for the people and providers who support the child. A BSP should:

  • Define the behavior of concern.
  • Describe prevention strategies.
  • Describe de-escalation strategies.
  • Describe response strategies.

If a provider receives a BSP they should review it with any staff who will be supporting the participant.

Restrictive measures

Restrictive measures can mean any item, action, or procedure that:

  • Limits a child’s movement.
  • Limits their access to other people.
  • Limits their access to other locations or activities.
  • Restricts their rights.

CLTS Program requirements

In the very rare case that a restrictive measure is necessary for safety, it should be the last method used. Restrictive measures should only be used after all other strategies have been tried and are found to not stop dangerous behavior.

To protect children’s health and safety, the CLTS Program has rules and processes about restrictive measures. Restrictive measures rules apply to any items, supports, and services the program pays for, no matter who uses the restrictive measure. This includes not only CLTS Program providers, but also unpaid caregivers using items, services, or supports with a restrictive component that they have asked the CLTS Program to pay for.

CLTS Program providers are obligated to follow CLTS policy when the services they are delivering are CLTS funded. These requirements may differ from DPI regulations and other funding sources such as private insurance. When services are CLTS funded, the provider must understand and follow CLTS Policy.

Types of restrictive measures

There are five types of restrictive measures, but only two can be approved for planned use in the CLTS Program:

Prohibited in all instances

 Isolation
 Seclusion

Prohibited except in strictly defined emergencies

 Manual restraints

Eligible for approval for planned use 

 Mechanical restraints
 Protective equipment

Isolation and seclusion are prohibited in all instances

Seclusion and isolation in which the child or youth is involuntarily separated from others by the actions or direction of staff contingent upon behavior with or without the use of locked doors are strictly prohibited.

The CLTS Program never allows seclusion and isolation, even in emergency situations.

Isolation and seclusion are not:
  • Separation to prevent the spread of contagious diseases.
  • Cool-down if:
    • It is in an unlocked room.
    • If it is voluntary.
    • There are no bad consequences if the child refuses to go into the room or chooses to leave the room.

Other prohibited practices

The following maneuvers, techniques, and procedures may not be used in any circumstances:

  • Any maneuver or technique that does not give adequate attention and care to protection of the head
  • Any maneuver or technique that places pressure or weight on the chest, lungs, sternum, diaphragm, back, or abdomen
  • Any maneuver or technique that places pressure, weight, or leverage on the neck or throat, on any artery, or on the back of the head or neck, or that otherwise obstructs or restricts the circulation of blood or obstructs an airway, such as straddling or sitting on the torso, or any type of choke hold
  • Any maneuver or technique that involves pushing into a person’s mouth, nose, or eyes
  • Any maneuver or technique that utilizes pain to obtain compliance or control, including punching, hitting, hyperextension of joints, or extended use of pressure point
  • Any maneuver or technique that forces a person to remain in a prone (face down) position
  • Any maneuver or technique that forcibly takes a person from a standing position to the floor or ground. This includes taking a person from a standing position to a horizontal (prone or supine) position or to a seated position on the floor
  • Any maneuver or technique that creates a motion causing forcible impact on the person’s head or body, or forcibly pushes an individual against a hard surface
  • Any use of seclusion in which the child or youth is physically set apart by staff from others through the use of locked doors or the door to the room would remain locked without someone having to remain present to apply constant pressure or control to the locking mechanism
  • Any use of isolation in which the child or youth is involuntarily physically or socially separated from others by the actions or direction of staff, contingent upon behavior

Manual restraint is prohibited except in strictly defined emergencies

Manual restraints involve one or more people holding the limbs or other parts of the body of the child to restrict or prevent their movement or to make them move.

This includes:

  • Physical holds
  • Escorts—someone physically moving the child

Actions that are not restrictive measures:

  • Holding limbs to provide support or prevent falls
  • Blocking aggressive behaviors for self-protection
  • Guidance to assist movement if it does not restrict movement and is approved as a support or teaching approach

Manual restraints are never approved for planned use but can be used in emergency situations.

Manual restraint is prohibited except in emergencies that meet all three criteria:

  • The participant’s behavior places the participant or any other person at imminent, significant risk of physical injury.
  • The measure used is the least restrictive approach possible.
  • The manual restraint is used for the shortest time possible.
Emergency use of manual restraint

Providers must meet certain requirements to use emergency manual restraint:

  • Written policy: Each provider must have a written policy describing the process used if emergency manual restraint is needed. The policy must:
    • Identify the specific person or type of staff position authorized to initiate and use manual restraint in an emergency.
    • Identify how the participant’s response to the manual restraint will be monitored.
    • Outline the process for documenting the details of an incident.
  • Continuous monitoring:
    • The participant’s health and well-being must be continuously monitored during the emergency use of manual restraint.
    • The restraint must be immediately terminated if the participant displays any signs of adverse physical reaction.
  • Time limits: The use of a manual restraint in an emergency may not exceed 15 minutes. After 15 minutes:
    • The provider must assess the degree that the emergency is still present.
    • If an emergency is still present, a continuation of the manual restraint may not exceed 15 minutes.
  • Release criteria: The provider has established release criteria for an emergency. Release criteria must include:
    • Termination of the manual restraint when:
    • The imminent risk of physical harm is diminished.
    • 15 minutes has been reached.
    • The participant displays any signs of adverse physical reaction to the manual restraint.

Any threats to a participant’s health or well-being caused by the measure during its application require the immediate release from the manual restraint and notification of medical personnel (if the participant requires immediate medical care), supervisory personnel, and the CWA.

Requirements following emergency use of manual restraint

If a provider uses a manual restraint in an emergency, it must be reported to the SSC as an incident to be reported to DHS.

Following an emergency use of manual restraint, the SSC will discuss the incident with both the provider and the participant. The SSC will ask the participant for their perspective on the incident, including why it happened and how they would like to be supported in the future. The SSC will discuss with members of the child’s team, including the provider, their perspectives on the factors that may have contributed to the escalation of behaviors. The SSC will identify the concrete steps or prevention strategies the team will use to prevent a similar incident from occurring in the future.

If there has been more than one incident involving the use of unapproved restrictive measures in less than six months, the SSC will also meet with the team to evaluate the support plan to identify changes to the support plan, ISP, and/or the manner in which the participant’s services are being delivered to prevent future incidents from occurring. After each subsequent incident within six months, the team must evaluate the support plan again. For example, the team must meet after a second, third, and any additional incidents occurring within six months of one another. The outcomes of this evaluation will be reported to DHS in the final incident report.

For more detailed information, see Children's Incident Reporting for Providers, P-02613 (PDF).

Protective equipment and mechanical restraint are eligible for approval for planned use

Mechanical restraints and protective equipment are the only types of restrictive measures that can be approved in the CLTS Program.

Mechanical restraints

Mechanical restraints may help prevent injuries by limiting the movement of a specific part of the child’s body. They can be approved for certain uses. Mechanical restraints are devices that:

  • Restrict or prevent voluntary movement.
  • Cannot be easily removed by the child.
  • Are above and beyond typical safety measures used for children the same age. Mechanical restraints include devices that are applied to any part of the child’s body. An example of mechanical restraints are arm or elbow immobilizers.

Protective equipment

Protective equipment may help prevent injuries by limiting access to a specific part of the child’s body. They can be approved for certain uses and are devices that:

  • Do not restrict movement.
  • Limit access to one’s body.
  • Are applied to any part of a child’s body.
  • Help prevent physical harm that may result from their behavior.

Examples of protective equipment:

  • Specialized clothing
  • Soft- or hard-sided helmets
  • Mitts or gloves
County and DHS approval is required for use of protective equipment or mechanical restraint

The SSC works with the child’s team to develop a request for approval for the use of mechanical restrains or protective equipment. The provider is included in developing the support plan for the child. Once the CWA approves the application, it is submitted to the Wisconsin Department of Health Services (DHS). DHS must approve the use of mechanical restraints and protective equipment before they may be used.

With approval, any use of mechanical restraints or protective equipment is monitored to make sure:

  • The child is protected from harm.
  • It is not used when less restrictive supports are working.
  • It is not used in place of adequate staffing levels.
Provider requirements for the use of approved restricted measures

When mechanical restraint or protective equipment are approved for planned use, the provider is responsible for:

  • Using the restrictive measure only when the participant’s behavior poses an imminent risk of serious harm to self or others and when less restrictive strategies have not been effective.
  • Using the restrictive measure for the shortest time possible but for no longer than the maximum time approved by DHS.
  • Ensuring that approved restrictive measures are only used by staff who have received appropriate, required training specific to the measures being used.
  • Reporting to the SSC any instance in which:
    • Any other restrictive measure is used.
    • The restrictive measure is used in a way that is different from what is approved by DHS, including any instance exceeding the maximum approved duration.
    • The use of the approved restrictive measure results in injury to the participant.
  • Collecting data on the use of approved restrictive measures during the provision of services.
  • Supporting or implementing the reduction and elimination plan developed by the team.

Approval for planned use of a restrictive measure may be revoked at any time upon a determination by DHS that there has been a negative impact on the participant.

For more information on CLTS Program instructions and requirements around restrictive measures, see Instructions and Requirements for the Use of Restrictive Measures in Long Term Support Programs for Children, P-02616 (PDF).

Glossary