Physical intervention for children with medical conditions and physical disabilities in children's homes

A fourteen-year-old with brittle bones becomes distressed in the kitchen and starts throwing plates. A new member of staff, trained in the same holds as everyone else, moves towards him. Nobody on shift has read the line in his health plan that says any physical intervention carries a real risk of fracture. In that moment, a technique that is "approved" for most children could cause him serious harm.

At ProActive Approaches, our position is #AimingForZero, a stance our founder Simon Gower has held since 2016. A reduction target implies there is a number of restraints that is acceptable. Zero removes that permission, and it changes what a team asks after an incident. For a child with a medical condition or physical disability, that question carries extra weight, because the margin for harm is narrower and the consequences of getting it wrong are greater. This guide sets out how residential teams can plan for these children so that physical intervention becomes even less likely, and so that if it ever happens, it is shaped around the child's body rather than around a standard syllabus.

Regulation 20 of the Children's Homes (England) Regulations 2015 already requires that any restraint is necessary and proportionate, and only used to prevent injury or serious damage to property. For a child whose condition makes restraint more dangerous, what counts as proportionate shrinks. That legal test is the floor. The aim is that these children are never held at all. For the wider picture of how training fits into that aim, see our guide to physical intervention training for children's homes.

Why these children face higher risk

Every physical intervention carries risk. For some children, the risk is significantly higher because of how their body works. Examples residential teams commonly meet include:

• Bone and joint conditions, such as brittle bone conditions or hypermobility, where pressure on limbs or joints can cause fractures or dislocations.
• Respiratory conditions, such as severe asthma, where any position that restricts breathing becomes dangerous much more quickly.
• Heart conditions, where the physical stress of a struggle can place a dangerous load on the body.
• Epilepsy, where staff may mistake seizure activity or post-seizure confusion for deliberate aggression.
• Diabetes, where low blood sugar can cause agitation and confusion that looks like distressed behaviour.
• Recent surgery, medical devices or feeding tubes, where pressure on particular parts of the body must be avoided.
• Physical disabilities and wheelchair use, where a child cannot move away from a situation and may experience being approached very differently.
• Sensory impairments, where a deaf or visually impaired child may not hear or see what staff are asking, and may respond to sudden contact with fear.

Weight, medication and general health also matter. Some medications affect heart rhythm, breathing or bone density. A child who is unwell, dehydrated or in pain is less able to cope with stress and more vulnerable if held.

The risks discussed in our guide to physical intervention risk assessment apply to every child. For these children, they apply with greater force.

Distress often starts in the body

Before any plan for responding to distress, the team should ask what is causing it. For children with health needs or disabilities, the answer is often physical.

A child who cannot easily tell adults they are in pain may show it through shouting, hitting or refusing to move. Constipation, toothache, a pressure sore, an ill-fitting splint or a missed dose of medication can all present as a change in behaviour. A child with limited mobility who has been in the same position for hours may be uncomfortable in ways staff have not noticed.

The health and well-being standard in regulation 10 requires the registered person to ensure each child's health and well-being needs are met, and that each child has access to the medical, nursing, psychiatric and psychological services they need. In practice, this means a pattern of incidents should prompt a health review as well as a behaviour review. Many restraints in disabled children could be prevented by treating pain earlier.

Restrictive practice is wider than holding

For disabled children, the most common restrictive practices are often not holds at all. Teams should look closely at:

• Applying wheelchair brakes to stop a child moving away, or moving a child in their chair against their wishes.
• Removing a walking frame, crutches or other mobility aids.
• Taking away a communication device or switching it off.
• Using lap straps, harnesses or splints beyond their prescribed medical purpose.
• Placing a child somewhere they cannot leave because of their physical needs.

Each of these can restrict a child's movement or voice as much as a hold. They should be named in the child's plan, justified, recorded and reviewed with the same seriousness. A child who cannot walk and has had their chair moved against their will has been restrained, even if nobody touched their arms.

Planning around the individual child

Bring health professionals in early

The home should not write the physical intervention section of a disabled child's plan alone. Ask the child's GP, consultant, physiotherapist, occupational therapist or specialist nurse what positions, pressures and movements must be avoided, and what signs of medical distress staff should watch for. Record their advice, and the date it was given, in the child's behaviour support plan.

Write a clear "never" list

For many children, the most important part of the plan is what staff must never do. Examples might include never applying pressure to the chest, never holding a particular limb, never moving the child from their chair, or never using a standing hold. A short "never" list that every member of staff knows by heart is worth more than pages of general guidance.

Plan for medical emergencies

If a child might have a seizure, an asthma attack or a hypoglycaemic episode, staff need to know how to tell this apart from distressed behaviour, and what to do instead of intervening physically. The plan should say where medication is kept, who is trained to give it and when to call for emergency help.

Make information usable

Health information often sits in files that frontline staff rarely open. Summarise the key points on a single page: the child's condition, the "never" list, early signs of pain or illness, and what helps them feel calm. Make sure it is read at every handover and by every agency worker before they start a shift.

What good prevention looks like

Physical intervention is the smallest part of what a setting does about distressed behaviour, and the only part most training covers well. For disabled children and those with medical conditions, the work that matters most happens long before any incident.

• Know how the child communicates. Learn their signs, sounds, signs of pain and preferred communication methods, and make sure everyone uses them.
• Design the environment for them. Space to move a wheelchair, quiet areas, accessible exits and reduced sensory load all reduce stress.
• Keep routines predictable. Many children with complex health needs experience frequent appointments and disruption. Consistency at home matters.
• Offer control. Children whose bodies limit their independence often feel powerless. Choices about small things reduce the need to take control in other ways.
• Treat pain and discomfort quickly. Make physical comfort a routine check, not something staff only think about after an incident.

The equality dimension

Disabled children have a right to be treated fairly. Under section 20 of the Equality Act 2010, service providers must take reasonable steps where a practice puts a disabled person at a substantial disadvantage. Applying the same restraint approach to every child, regardless of their condition, can place disabled children at exactly that kind of disadvantage. Adjusting the approach is not optional good practice. It is part of meeting the child's rights.

It also matters which children are being held. If disabled children in your home are restrained more often than their peers, that is a pattern worth examining. It may point to gaps in communication support, health care or staff understanding rather than anything about the children themselves.

Training that reflects the children you support

Generic physical intervention training rarely covers medical conditions or physical disabilities in depth. The RRN Training Standards require training to be based on the needs of the people being supported, which means a home that cares for disabled children needs training that reflects those children.

That training should include recognising pain and medical distress, communicating with children who do not use speech, safe responses for wheelchair users, and how to adapt or abandon physical skills when a child's health makes them unsafe. Our physical intervention training is built around the population each setting actually supports, with a documented track record of reductions of up to 80 per cent in restraint use. Find out more about how we work with residential providers on our children's services page.

If a hold does happen

If physical intervention is used with a child who has a medical condition or physical disability, the response afterwards must include a health check. Staff should look for injury, breathing difficulties, pain or changes in the child's condition, and seek medical advice if there is any doubt. The record should note what health precautions were followed, and the review should ask whether the plan was known, followed and adequate.

The conversation with the child afterwards should use their own communication method. A child who uses symbols, signing or a device must be given the same chance to say how they felt as any other child. Their account belongs in the record.

Finally, ask the #AimingForZero question honestly: what did we miss, and what will we change so that this child is never held again?

Frequently asked questions

Should a child with a serious medical condition ever be restrained?

Only in the most extreme circumstances, where there is an immediate risk of serious injury and nothing else will prevent it. For some children, health professionals may advise that certain or all forms of physical intervention are unsafe. In that case the plan should set out alternative ways to keep everyone safe, such as moving other children away, removing hazards and calling for help.

Is applying a wheelchair brake a form of restraint?

It can be. If brakes are applied, or a chair is moved, to stop a child going where they want to go, that restricts their movement and should be treated as a restrictive practice. It needs to be planned, justified, recorded and reviewed, and it should never be used for convenience.

Who should write the physical intervention section of a disabled child's plan?

The home should lead, but with direct input from the child's health professionals, the child and, where appropriate, their family. The plan should record what advice was given, by whom and when, and it should be reviewed whenever the child's health changes.

How can staff tell a seizure or hypoglycaemia from distressed behaviour?

Through training and a clear individual plan. The plan should describe how the child's medical episodes usually present, what staff should do and when to call for help. If staff are unsure, they should treat the situation as a possible medical emergency rather than intervene physically.

Children with medical conditions and physical disabilities are among the most vulnerable in residential care, and the most at risk if physical intervention goes wrong. Planning around their bodies, their health and their voices is how a home moves from managing that risk to removing it.