NATSAP Principles of Good Practice

These guidelines refer to therapeutic programs and emotional growth schools as “programs/schools” and refer to client/students as “program participants“.

Guidelines which refer to “programs/schools” are relevant to all programs/schools.

Guidelines which refer to “small residential programs” are relevant to programs/schools that meet the definition of a small residential program (see Definitions).

Guidelines which refer to “therapeutic boarding schools” are relevant to programs/schools that meet the definition of a therapeutic boarding school (see Definitions).

Program Types


Boarding Schools (Emotional Growth, Therapeutic) – These schools generally provide an integrated educational milieu with an appropriate level of structure and supervision for physical, emotional, behavioral, familial, social, intellectual and academic development. These schools grant high school diplomas or award credits that lead to admission to a diploma granting secondary school. Each school will vary in their approach to the emotional and behavioral needs of the child and we urge parents to review this approach with the professional that has been working with their child to ensure appropriate placement. Often individual, group and family therapy are a part of the milieu. Placement at these boarding schools can range from 12 months to 2 years depending on the program’s therapeutic components.

Outdoor Behavioral Health (Wilderness Programs and Outdoor Therapeutic Programs) - Most outdoor behavioral health programs subscribe to a variety of treatment models that incorporates a blend of therapeutic modalities, but do so in the context of wilderness environments and backcountry travel. The approach has evolved to include client assessment, development of an individual treatment plan, the use of established psychotherapeutic practice, and the development of aftercare plans. Outdoor behavioral health programs apply wilderness therapy in the field, which contains the following key elements that distinguish it from other approaches found to be effective in working with adolescents: 1) the promotion of self-efficacy and personal autonomy through task accomplishment, 2) a restructuring of the therapist-client relationship through group and communal living facilitated by natural consequences, and 3) the promotion of a therapeutic social group that is inherent in outdoor living arrangements.

Residential Treatment Centers – The focus of these programs is clinical treatment with both academic and behavioral support included. Medication management and medial monitoring is generally available on-site. These facilities treat adolescents with serious psychological and behavior issues. Most are Joint Commission accredited. These facilities provide individual, group and family therapy sessions. They are highly structured and offer recreational activities and academics. Specialty residential treatment centers will include psychiatric and behavioral hospitals that will provide a description of their special services.

Small Residential Programs are designed to serve fewer than 30 participants in nurturing, often family-like settings. Small residential programs offer a holistic therapeutic milieu, which is based upon, the relationships formed and the social dynamics created in small, intimate environments. These programs offer appropriate levels of structure and supervision for the emotional, social and academic development of their participants. These programs often incorporate life skills training, academic instruction, outdoor adventure, recreation, and family involvement into an experiential living environment. Small residential programs often maintain an area of specialty for the participants they serve.

Transitional Independent Living / Young Adult Programs are designed for young people over 18 needing a safe, supportive environment and life skills training as they transition into adulthood. Many offer access to 12-step programs and may have a psychiatric component. Generally they will offer educational programs that are linked to community colleges or universities or provide schooling at their location. Volunteering, employment arrangements, community service and re-integration into the community at large are general components of the programs. Many operate on a small residential model and transition to a community based, independent living apartment model.


The program/school shall adhere to all applicable state and federal laws in conducting the operation, including administration, hiring and employee practices, observance of safety regulations, and the care of program participants.


The program/school has a responsibility and duty to strive to provide its program participants with appropriate ethical and professional service in all areas of operations.

2.1 The program/school will have a written plan for governance, program administration, and professional services. The Plan includes the following elements:

2.1.1 Introduction and history of the program/school.

2.1.2 A delineation of the responsibility of the governing body including, policy development, responsibility for implementation, compliance, amendment, and oversight of the policies. The program/school has a governing body of appropriate size, structure, and composition to make policy, structure, and composition to make policy, to hold the program/school mission in trust, and to monitor the school activity and programs. The program/school governing body provides fiduciary oversight and resources adequate to support the realization of the program/school mission and program. The governing body has an approved strategic plan that is supported by a financial plan. The governing body regularly evaluates its effectiveness. NATSAP Member Programs will have a written policy describing their process for awarding scholarships or discounts. A copy of that policy will be made available upon request.

2.1.3 Mission Statement. Programs/Schools will have a clear mission statement, philosophy, and goals.

  • The program/school owners, management personnel, and staff will understand and support the program’s mission, philosophy, and goals.
  • The program/school will effectively communicate the program/school mission statement, philosophy and goals.
  • The program/school operations will reflect the mission statement, philosophy and goals. Programs/Schools will have policies, procedures, and plans that describe the integration of its several school components within the context of its mission and philosophy Programs/Schools will have policies, procedures, and plans that describe the integration of its several components within the context of its mission and philosophy. This plan will include:

  • Direct references to the program/school mission and philosophy.
  • Policies providing for effective sharing of all information concerning the participant.
  • An explanation of how all aspects of a participant’s’ life are integrated by the program in such areas as academics, daily living, recreation, and counseling/therapy.
  • A description of the structure and process by which the program shares information both internally and to outside sources, such as public schools. (e.g. meetings, regular reports, etc.) The mission statement of a Therapeutic Boarding School will include:

  • The school will provide an intellectual environment that promotes participant freedom of inquiry and in which participants are encouraged to express individual points of view, develop independent critical thinking and to examine and debate all sides of a subject in a rational mature manner.

2.1.4 Philosophy of the program/school. Programs/schools will have a clear mission statement, philosophy, and goals.

  • The program/school philosophy, principles, and practices will be consistent with a humane and diverse society.
  • The program/school will provide a nurturing, safe, and structured environment in which program participants are encouraged to develop healthy relationships, to express individual points of view, to accept diversity and to examine their own perspective of the world while respectfully engaging in critical discussion about the perspectives of others.

2.1.5 Description of the population the program/school serves, including admission, non-admission and discharge criteria.

2.1.6 Description of services provided. Programs/Schools will have an integrated, individualized plan for each participant and the participant’s family relevant to the participant’s needs and program/school mission that includes:

  • An admission procedure to ensure the successful integration of the participant into all aspects of program components.
  • An on-going planning and review process with:
    • Appropriate and available program services designed to support the educational, emotional, spiritual, physical, social, behavioral and intellectual needs of each individual participant.
    • Appropriate family interaction and participation throughout all program components.
    • Systematized evaluation of the participant’s growth in the program to determine if the goals of the planning process are met.
      • A process to assess the ongoing suitability of the participant to the program.
    • A completion strategy that assists the participant in planning for a successful transition from the program to their next step which includes:
      • Appropriate and timely support at the time of discharge or participant exit from the program designed to support the educational, emotional, physical, social, behavioral, and familial needs of the participant and the participant’s family.
      • Appropriate and ongoing support for the participant and the participant’s family following discharge from the program. Credit, grades, and Graduation Requirements

  • Programs/Schoolsthat award academic credits must have:
    • Clearly defined grading rubrics and requirements
    • Clearly defined criteria for awarding course credit
  • Programs/Schoolsthat issue academic diplomas must have:
    • Clearly defined graduation requirements that are consistent with the program/school mission and goals, integrated with the program/school program components and designed to meet the needs of the participants.
    • School accreditation by a state, regional, or national accrediting body.
  • Small Residential Programwill have developed and articulated and/or made available to participants, parents, and others the following:
    • State and/or national accreditation of any local public or private school in which participants are enrolled to complete academic requirements.
    • State and/or national accreditation of any independent study coursework utilized.
    • Clearly defined plan for independent study coursework credit earned to be indicated on participant’s master transcript.
    • Clearly defined graduation requirements as indicated by the local public and/or private school in which participants are enrolled per state standards. A Therapeutic Boarding School will have a school curriculum designed to foster the intellectual, aesthetic, personal, physical, social, and career development of the student population and engage participants in rigorous and challenging educational pursuits commensurate with their level of development.

  • The Therapeutic Boarding School will have a collaboratively developed program of studies that includes a balance of disciplines that reflect the needs and interests of the participants and is consistent with the program/school mission and beliefs.
  • The curriculum will include a set of essential knowledge and skills in each content area with written course descriptions that reflect attention to scope, sequence, continuity, integration, materials, and performance assessments as appropriate to the program/school mission and goals.
  • The curriculum will address the development of content standards and an appropriate balance of the following components of learning: factual mastery, skill development, creativity, comprehension, application, analysis, synthesis, and evaluation as appropriate to its mission and goals.
  • The Therapeutic Boarding School will have a process for a timely review and revision of curriculum.
  • The participant’s academic progress will be monitored, documented, and communicated to parents in an appropriate manner.
  • Assessments of participant learning will be based on clearly articulated and appropriate expectations for participant academic achievement. A Small Residential Program will have access to and implement an accredited curriculum or curriculums individually chosen and implemented to foster the intellectual, personal, physical, social, and career development of the participants. The curriculum options will engage participants in rigorous and challenging educational pursuits commensurate with their level of development.

  • The program will implement accredited curriculum options that encompass a collaboratively developed program of studies, based upon the individual needs of each participant. The individual curriculum developed and implemented for each participant will include a balance of disciplines that reflect the needs and interests of the participant and is consistent with the program/school mission and beliefs.
  • The program will have a policy delineating how participant’s earned credits will be shown on participant’s master transcript, whether or not the program/school awards credits or utilizes other credit-granting institutions.

2.1.7 Organizational Structure including an organizational chart.

2.1.8 Tuition / Fee statement including all ancillary cost, and refund policy.

2.1.9 A plan for self-evaluation and program/school improvement. Programs/Schools will develop and implement an ongoing improvement plan that emphasizes learning for all participants and is consistent with the program/school mission and goals.

  • The program/school will have a regular review of its mission and goals.
  • The program/school will have a process for initiating, planning, and coordinating theprogram/schoolimprovement efforts. The planning process may include the following components:
    • Evaluation to select focus for areas of improvement
    • Development of strategies for improvement
    • Implementation of strategies
    • Monitoring and evaluation of results.
    • The program/school will engage in a periodic self-study or evaluation process that provides for broad participation of its stakeholders and full disclosure of the strength and weaknesses of theprogram/school.

2.2 The program/school shall have proof of general liability, professional liability, fire, and vehicle insurance coverage as appropriate.

2.3. The program/school will be financially responsible.

2.3.1 A program/school will have accepted accounting practices

2.3.2 A program/school will have sufficient financial resources available to provide space, people, time, and materials to support the balanced integration of programs and services to maximize the potential for all program participants as appropriate to its mission.

2.4 The program/school will adhere to Ethical Principle #5 regarding dual relationships

2.4.1 Not offer or accept payment for referrals Payment or compensation includes, but is not limited to, any form of payment, in money or in kind, and any sort of favor or special treatment to reward or encourage placements. This includes any payment or reduction of tuition to current clients or alumni as well as referring professionals; To meet the needs of children and families, programs will at times make professional referrals to educational consultants and other professionals

  • These referrals are to be made without obligation or expectation of any future financial considerations or return;
  • An informed professional referral includes, but is not limited to an assessment of the qualifications, expertise, and location of the referral. Whenever possible multiple referrals will be made. Quid pro quo relationships are expressly forbidden. A quid pro quo relationship exists when:

  • Clients are referred with the expectation that a future referral with be forthcoming
  • The relationship promises the exclusive use of a member’s program/school;
  • Transactions establish debt or a perception of debt. The primary purpose of marketing to referring professionals will be to educate about theprogram/school and the services provided. No marketing event should be so extravagant as to create a debt or an impression of a debt.

  • program/school may, at the discretion of the program/school, reimburse some or all of reasonable travel, lodging and meal expenses for program/school visits.
  • The scope and the focus of an event must be primarily educational to the program/school services.
  • program/school will adhere to a $75 limit on gifts in a calendar year. Gifts are intended to express appreciation as opposed to comprising the referring relationship. The program/school remains obligated to make an informed, appropriate and professional referral when services are terminated as stated in Ethical Principle 12.

2.4.2 Represent fact truthfully to program participants and third-party payers.

2.4.3 Disclose fully all costs and fees for service.

2.4.4 Respect copyrights, trade authorship, and proprietary information, and will not plagiarize or use materials, documents, or resources from other sources or programs without permission.

2.4.5 Not use a name or marketing strategy that misleads the public or make guarantees of outcome to consumers.

Disclose fully all ownership and financial relationships between associated programs, services, and professionals where there is a potential for a conflict of interest.

Disclose fully in the membership application process any past sanctions, licensure/accreditation revocation, and criminal conviction against any school, program/owner, and board of directors or executive officer.

2.5 Programs/Schools will have an independently state licensed mental health professional that has direct oversight responsibility for individual treatment/service plans and is openly accessible to the participants.

2.6. At NATSAP Conferences and Events, Programs/Schools may not host an open bar.


The program/school will only provide services (including assessment services), that lie within the scope of the service and the training and qualifications of its staff. The program/school will accurately and factually represent the competence, education, training, certification and experience of its employees. NATSAP members will not discriminate on the basis of race, religion, sex or sexual orientation.

3.1 Hiring Practices

3.1.1 Applicants are required to complete an Application for Employment. The application form must include the following:

  • Previous place(s) of employment.
  • Relevant education and experiences
  • Signature, verifying that all information is correct and factual.

3.1.2 Upon extending an offer for employment, the program/school will obtain:

  • A criminal background check including driving history.
  • A minimum of two professional references (written or verbal).
    • Proof of professional credentials.
  • A medical examination or statement signed by the employee assuring fitness to execute the physical and mental requirements delineated in the job description.
  • If the employee is required to drive a company vehicle, or is asked to transport program participants in his/her own car, the Department of Motor Vehicle will be contacted to determine that the respective employee has a valid driver’s license.

3.1.3 The program/school will have a process to describe the qualifications for all program/school staff, employees and faculty as appropriate to its mission and goals. A Therapeutic Boarding School will

  • The therapeutic boarding school will establish demonstratable levels of professional competency for faculty by education, experience, and/or certification as appropriate to its mission.

3.2 On-Going Employee Practices

3.2.1 Each employee will have a written job description. The job description will include the following:

  • Job title.
  • Duties and responsibilities.
  • Minimum level of education, training and work experience required for the position.
  • Physical demands of the position.
  • Lines of authority. (Delineation of supervisory responsibility).
  • Small Residential Programwill further delineate lines of authority and supervisory responsibility, as follows:
    • In cases where multiple job descriptions are held by one person, the interrelatedness of the positions will be delineated.
    • In cases where multiple/dual supervisors oversee one position, the lines of authority will be explained for the employee.

3.2.2 The program/school shall have written Employee Policies and Procedures that will include policies on: New Employee orientation procedures include:

  • Orientation in philosophy, objectives and services.
  • Emergency procedures (Fire, Disaster, etc.).
    • Small Residential Programs will provide training for all employees regarding contingency plans in case of accidental death or disability of the owner/s if appropriate.
  • Current program/school policy and procedures including behavior management.
  • First aid and CPR training.
  • Statutory responsibilities, including those covered by state and federal laws.
  • Programs/Schools will comply with the Fair Labor Standards Act in regard to minimum wage, overtime, and record keeping as well as any applicable state laws.
  • Small Residential Programs will have written policies designed to ensure that the program is adequately and appropriately staffed during all hours of operation. During such hours, there shall be a qualified staff member on site who is designated to be responsible for oversight of program operations. Continuing staff training and development.
• Programs/Schools will have an on-going staff development program that is responsive to the demands of its curriculum and the unique needs of its participants and is consistent with the mission and goals of the program/school. Performance appraisals. Methods for filing and addressing employee grievances. Disciplinary actions, termination, and discharge practices. Sexual and other forms of harassment or misconduct. Abuse reporting laws Vacations, holidays, illness, extended leave, military leave, and jury duty. Volunteers, interns, and contract personnel if applicable.

  • program/school will perform background checks for any individual who has unsupervised access to program participants. Confidentiality and information disclosure within the limits recognized by appropriate professional principles, including state and federal regulation.

  • Programs/Schools that make use of community agencies and schools will take measures to protect the confidentiality and privacy of program participants. Transporting program participants and their parents/guardians.
  • Programs/schools will include policies regarding transporting program participants by non-employees (i.e. bus drivers, teachers, etc).Prevention and investigation of allegations levied by program participants regarding employee misconduct.The program/school will describe employee benefits.Theprogram/school will obtain a criminal background check including a driving history for all employees, and a criminal background check including a driving history for all volunteers and contract employees who have unsupervised direct contact with the participants.
  • Programs/Schools shall require regular volunteers to come under the same requirements in personnel management and staff training as paid employees. Where volunteers have limited or very distinct responsibilities, policies and training will be implemented commensurate to the service they provide

3.3 Personnel File

3.3.1 The program/school will maintain a personnel file on each employee that includes:Application and/or resume

  • Background clearance.
  • Proof of credentials including education, licensure, certifications, etc. as applicable.
  • Proof of medical examination or statement of ability to perform duties.
  • Signed job description.
  • Documentation of new employee orientation and ongoing staff development training.
  • Performance evaluation(s).
  • Emergency contact information.
  • Documentation of disciplinary actions termination or discharge
  • Signed confidential agreement regarding the exchange of information concerning program participants, their families, and fellow workers.
  • Copy of driver’s license (if employee is required to drive a company vehicle as part of the job).
  • Documentation of employment status e.g. hourly, salary, part-time, full time, exempt, non-exempt, etc.

3.3.2 Programs/Schools that utilize volunteers will maintain a personnel file as required for paid employees. Where volunteers have limited or very distinct responsibilities, employee records should be maintained appropriate to the service they provide.


The program/school will have a written Admission Policy, which defines the enrollment criteria and delineates inclusion and exclusion criteria. Such criteria will be consistent with the mission of the program/school. Admission forms will provide pertinent history including family, medical, psychiatric, developmental, and educational background information.

4.1 The Admissions screening process will examine the physical, emotional, behavioral, and academic history, in order to determine whether the program is appropriate in light of the respective participant’s needs and limitations.

4.2 The program/school will provide program participants, parents, legal guardians, or other pertinent parties with a clear and informed statement of the nature of the services that will be provided including, risks associated with these services.

4.3 Upon admission, a file will be created for each program participant, containing the following:
4.3.1 Demographic information including emergency contact information.
4.3.2 Basic medical, family, behavioral, legal, educational, information including past and current assessments.
4.3.3 A signed statement indicating receipt of a copy of the participant handbook or statement of Participants Rights and Responsibilities, or a witness attesting to the participant’s refusal to sign. (For details see principle 6.0).
4.3.4 Contract, release and consent forms.
4.3.5 Documentation of communication with parents, legal guardians, payer sources and other parties.
4.3.6 Photograph.
4.3.7 Copy of any grievance filings and action taken.
4.3.8 Documentation of services rendered
4.3.9 Therapeutic Boarding Schools will maintain cumulative records for academics that include at a minimum all records of standardized testing, grades, credits earned, and diplomas awarded.
4.3.10 If a Small Residential Program utilizes an outside source for its participants’ educational needs, (i.e. public school or home school curriculums, etc) the program will keep records of the participants’ academic work.

4.4 The program/school will conduct ongoing assessment to determine appropriateness of continued placement.

4.5 Upon termination or discharge of a program participant, the program/school will provide a written discharge/termination summary, including recommendations for continued care to the participant’s parents/guardians and be added to the participant file.


5.1 The program/school shall have a written Behavior Management Plan, which describes:
5.1.1 How human dignity and rights will be respected in the application of behavior management practices.
5.1.2 Special treatment/intervention processes including such techniques as: seclusion, restraint, therapeutic holding, passive holding.
5.1.3 Procedures for handling emergency situations such as suicidality, abuse, assault, and runaway.
5.1.4 Acceptable and non-acceptable consequences.
5.1.5 On going training procedures for employees.
5.1.6 Adhere to the practices and guidelines set forth in the NATSAP Behavior Support Management in Therapeutic SchoolsTherapeutic Programs and Outdoor Behavioral Health Programs and is an addendum to these Principles of Good Practice.


6.1 The program/school will have a written Participant Handbook or statement of Program Participant Rights and Responsibilities as appropriate to the setting, purpose, and pertinent state and federal law. Such manual or statement will include statements regarding the following rights:
6.1.1 To receive care or services within the program/school capability, mission, and applicable law and regulations.
6.1.2 Freedom from discrimination.
6.1.3 The expectation of a safe environment with respect of human dignity.
6.1.4 Respect for privacy of information and records of each individual and family served.
6.1.5 A description of any restrictions in communication or visitation.
6.1.6 A description of privileges and limitations for participants.
6.1.7 A description of access to religious services and practices.
6.1.8 A statement indicating that the program/school retains the right to maintain a contraband free environment and will make known any search or testing procedures used in this effort.
6.1.9 Procedures for participant/participant grievance and complaint will be clearly outlined along with a statement guaranteeing freedom from retaliation for making complaints.
6.1.10 A diet that is nutritionally sufficient for age and activity level.
7.1 The program/school will have a policy on health care that addresses the following issues:
7.1.1 Programs/schools will provide regular and appropriate access to necessary health care provider/s.
7.1.2 Participant access to first aid and CPR by currently certified on-site staff. A Small Residential Program will require current certified first aid and CPR for all staff with direct participant contact.
7.1.3 Delineation of whom is authorized to dispense medications.

7.1.4 A policy on dispensing, storing, accounting, and security of medication.


8.1 The program/school shall have Plant, Technology and Safety Policies and Procedures containing the following:
8.1.1 A fire and disaster plan which includes the following:

  • Delineating responsibility of all employees in the event of fire or other disasters.
  • A description of available emergency services, escape routes, relocation plans, and other contingency plans.
  • Documentation of all fire and emergency drills.

8.1.2 Policies concerning staff training for emergencies and access to emergency medical care
8.1.3 A safety committee who is responsible for risk management as well as training and implementation of emergent procedures
8.1.4 A policy or procedure for equipment maintenance and repair.
8.1.5 An infectious disease control policy.
8.1.6 A policy on the transportation of participants that addresses risk management,


9.1 The program/school will have an Incident Reporting policy and procedures, including a reporting mechanism to the governing body.


The program/school will have facilities of a sufficient size, space, configuration, and condition to support the balanced integration of its programs and services, and manage its physical plant to keep risk within acceptable parameters for the participants as appropriate to the program/school mission and goals.


Educational services will be consistent with the mission of the program/school and may include: fully developed college preparatory academic programs leading to a diploma, individual courses offered for credit, services such as academic packets or online courses offered for credit through materials developed or administered by third party providers, and academic support and skills development offered for no credit. Some programs may choose to outsource academic services to private contractors or public school districts.

The scope, extent, and instructional methodology of the educational services including, whether the services are provided in house or out sourced, will be fully disclosed by NATSAP members to any interested party, program participants, families, referring professionals, and school, college and university admission offices. All programs/schools that offer academic credit to program participants as a part of their in house services shall:

11.1 Maintain an academic transcript for each program participant in his or her permanent file that is current and up-to-date.

11.1.1 Required information at a minimum includes:

  • Program/school name, address, phone number, and date prepared
  • Participant name, address, and DOB
  • Admission date, emission date
  • Grading scale
  • List of individual classes, with grades and credit earned, and GPA

11.1.2 Programs/schools that grant diplomas and advertise as a school, or as providing academic or educational services comparable to a school will include the additional information on the transcript:

  • If applicable, diploma earned and graduation date.
  • Accrediting body and the program/school accreditation status

11.1.3 Programs/schools that provide academic or educational services may include the following additional information on the transcript:

  • Standardized test scores (PSAT, SAT, ACT, ITBS, etc.)
  • Immunization records
  • Class rank

11.2 Provide a written description of educational services that includes:
11.2.1 A profile of educational services with descriptions of:

  • Ages and grades taught
  • Educational philosophy
  • Graduation requirements leading to a diploma
  • Policy delineating how credit is earned and assigned
  • School calendar
  • Policy describing curriculum oversight and quality assurance
  • Official school contact for questions about the educational program

11.2.2 A curriculum catalog with:

  • Course descriptions
  • Scope and sequence
  • Goals and objectives
  • Method of instruction
  • Evaluation and assessment

11.2.3 A participant profile
11.2.4 Teacher qualifications including education, experience, and/or certification.


Addendum to the NATSAP Principles of Good Practice

The following Guidelines and Practice of Behavioral Management have been unanimously adopted by the Board of Directors of the National Association of Therapeutic Schools and Programs as basic practice standards.

Guidelines and Practice of Behavioral Management

1.0 Introduction

When dealing with at-risk, troubled, oppositional, acting out, maladaptive and/or defiant youth, the program staff might be required to employ behavior support management techniques to foster adaptive, appropriate and pro-social behavior and assure the safety of the individual youth, other program participants and/or the staff. Such techniques start with the establishment of written guidelines, rules and expectations of appropriate and pro-social behavior. When a program participant’s behavior is in opposition the written rules and guidelines and places him/herself and/or others in harms way, additional behavior management techniques may be utilized. Those behavior support management techniques range from verbal persuasion to physical interventions.

Hence, a school or program concerned with the safety of its program participants must advocate and practice a policy of behavioral support management that should:

  • 1.1 practice behavior support management techniques designed to foster pro-social behavior. Such techniques are utilized not exclusively for the purpose of behavioral control. Behavioral support techniques include respondent and operant conditioning, shaping, extinction, redirection and social modeling with both primary and secondary reinforcement integrated within the programming. Such techniques can be used appropriately to reduce excessive negative behavior and promote pro-social behavior and development;
  • 1.2 employ the least intrusive method possible to assure the safety of all parties concerned (i.e. the individual child, other program participants and staff);
  • 1.3 when possible, assure that less intrusive interventions have been offered to the child before more restrictive methods are applied;
  • 1.4 when faced with the necessity of applying such interventions, protect as much as possible, the dignity and privacy of the program participant.

2.0 The Continuum of Behavior Management Techniques

Fundamentally, the continuum of behavioral support management techniques and interventions can be divided into three general categories: 1) behavioral management interventions that foster adaptive and pro-social behavior; 2) de-escalation procedures when the child becomes agitated (see 4.0); and 3) special treatment procedures when the program participant’s intensity and duration is such that de-escalation techniques, including brief physical holdings, are no longer effective to bring the behavior under control (see 5.0).

3.0 Behavior Support Management Techniques Designed to Foster Pro-Social Behavior

Behavior support management techniques are therapeutic interventions utilized to foster pro-social and discourage maladaptive behavior within the program participants.

A school or program employing behavior support techniques should:

  • 3.1 develop and implement written policies that govern the use of behavior support techniques;
  • 3.2 fully inform program participants and his/her family regarding the behavior support system at the time of admission. (i.e. level system, pre-determined consequences for certain adaptive and maladaptive behaviors);
  • 3.3 group consequences must be approached with great care and an effort not to infringe on individual’s appropriate care. A written policy should describe the appropriate use of group consequences and describe limits on such consequence;
  • 3.4 specify procedures and interventions that are prohibited. At a minimum, the following are prohibited:
  • 3.4.1 procedures that deny a nutritionally adequate diet.
  • 3.4.2 physically abusive punishment.
  • 3.4.3 any behavior support intervention that is implemented by another program participant without the expressed consent of a staff member
  • 3.4.4 any behavior support management intervention that is contrary to local, state and/or national licensing or accrediting bodies, should school or program be so licensed and/or accredited.
  • 3.4.5 application of consequences that are not in accordance with the program participant’s rights.

4.0 De-Escalation Interventions

De-escalation techniques are a part of the organization’s overall behavior support policy and procedures, but are specifically delineated as those interventions that are designed to de-escalate agitated behavior that, if unchecked by the staff and/or the program participant, may rise to the level of being a danger to self, others, destruction of property or serious disruption of the therapeutic environment. Hence, the purpose of de-escalation interventions is to reduce maladaptive and agitated behavior and replace it with pro-social behavior. The skilled practice and application of de-escalation techniques are the most effective way to prevent the use of special treatment procedure.

De-escalation Technique should include Verbal Interventions (Example: Extensive training on the following topics should be in place.

  1. Staff members need to mentally prepare. Remain calm, become aware of what the person is saying and doing, feel respect for person not the behavior.
  2. Share your observations and listen to what is being processed.
  3. Identify what is causing the issue and/or feeling.
  4. Assist the person with developing more productive avenues to express feeling.

A school or program, employing de-escalation interventions, should incorporate the following elements into their behavioral support plan:

4.1 Whenever appropriate, least restrictive behavioral de-escalation interventions should be used.

4.2 Policy and procedure protocols delineate the a) type of behavior interventions utilized, b) what contextual circumstances call for what type of behavioral interventions and c) the duration and methods employed in the de-escalation process.

Examples for the use of least restrictive to most restrictive intervention could be:

  • Category I interventions might include teaching interventions, benign response reduction techniques such as verbal directives, prompts, redirection, contingent observation.
  • Category II interventions might include over-correction, quiet time, time-out, and positive practice. Category III interventions might include novel, non-standard or experimental interventions.

4.3 Policies and procedure govern the use of time-out.

4.3.1 The time-out protocols should distinguish between a self-directed time-out and a staff-directed time-out. Timeout should also be included in a tiered approach.

Examples of Time-Out Procedures:

  1. A program participant, returning from a group therapy session, is visibly agitated and is requesting a time-out. The individual is placed in an open-door time-out room and instructed that he may return to the regular, scheduled activity when he feels that he has regained adequate behavior and emotional control. After the program participant is requesting to re-join the regular activity, the staff assesses the program participant whether or not the program participant has sufficiently de-escalated to return to the regular group activity. Should the program participant not be ready, the staff directs the program participant to take additional time to regain control and composure.
  2. Prior to a group therapy session, a program participant is requesting a self-directed time-out. The program participant has a pattern of avoiding group therapy because she does not want to be exposed to her peers’ feedback about her behavior. The staff denied the program participant request for a self-directed time-out because it is clinically contraindicated and encouraged the program participant to attend the group.
  3. A program participant is demonstrating agitated behavior, but is not requesting a self-directed time-out. As part of a progressive de-escalation protocol, the staff is directing the program participant to take a time-out in the open-door time out room. The staff member stands in the open door to prevent the individual from leaving the time-out room. Periodically, the staff will assess the individual as to whether or not he has gained sufficient behavioral control to return to the regularly scheduled activity. If the staff decides, following an assessment of the program participant, that he should not rejoin the regular scheduled activity and prevents him from leaving the time-out room by physically blocking the exit for more than 30 minutes, the time-out procedure has risen to the level of a special treatment procedure.

4.4 Policies and procedure should govern the use of brief physical holding interventions.

4.4.1 Brief physical holdings may only be utilized under the following conditions: Danger to self (i.e. attempting to or in the process of head banging, punching the wall, attempting to swallow a “sharp,” scratching or carving in an attempt to cause damage, etc.). Danger to others (i.e. attempting to or endangering others by slapping, kicking, biting, etc.). Substantial destruction of facility/staff/others property (i.e. damaging furniture, computer equipment, etc.).

NOTE: Programs should check with their individual licensing agency when considering the above examples.

4.4.2 Therapeutic holds should not exceed 30 minutes. If a program participant, placed in a therapeutic hold, is unable to regain control within 30 minutes and the procedure needs to be extended beyond the 30 minutes, the therapeutic hold then rises to the level of a special treatment procedure.


  1. An individual is shouting obscenities at his peers. The peers are visibly agitated. The individual is not responding to verbal request from the staff. The individual is offered a staff directed time-out. The individual refuses to walk to the time-out area but escalates with obscenity and threats of violence. The Staff attempt to physically escort the individual to the time out area. In the process, the individual is punching a staff member. As a result, the individual is placed in a therapeutic hold. Within 10 minutes, the individual is calm and released from the therapeutic hold – this is not a special treatment procedure.
  2. Should the child require a therapeutic hold for more than 30 minutes in order to regain control, the therapeutic hold will rise to the level of a special treatment procedure.

4.5 Brief physical holds are never used as punishment.

4.6 Therapeutic holds are documented in the program participant’s treatment record.

5.0 Special Treatment Procedures (STP)

Special Treatment Procedures refer to a specific class of behavioral interventions that restrict the free movement of a child by mechanical or physical means for a prolonged period of time when the child becomes a danger to self and/or others, is destructive of property, or is a serious disruption to the therapeutic environment. Specifically, those interventions are referred to as seclusion, restraint, or more than 30 minutes of a physical hold.

Seclusion is a procedure where the individual is restricted to a small space, such as a time-out room, without the ability to leave the room, i.e. the individual is blocked from exiting either by a locked-door or by a staff standing in the door and preventing the program participant from leaving the room for more than 30 minutes.
A Restraint procedure occurs when a mechanical device such as leather belts, posy belts, strait jackets, hand cuffs, or other devices are used to restrict the free movement of an individual or whenever a program participant is placed in a physical hold exceeding 30 minutes.

Those NATSAP members, who employ special treatment procedures, must be licensed or accredited by state and/or national regulatory organizations that specifically address the use of said procedures.

However, any NATSAP member program may resort to physical restraint in order to remove a participant to a more restrictive level of care in the event of imminent threat of serious injury to the program participant or others. All NATSAP programs must have specific policy, procedures, and training to respond to such emergent situations.

6.0 Risk Management and Performance Improvement

6.1 Physical holdings, restraint and seclusion can be high risk and problem prone. The organization should collect data on the use of brief physical holding interventions and special treatment procedures in order to monitor and improve performance of processes that involve risk or may result in sentinel events.

7.0 Informed Consent

7.1 Parents/guardians and students/residents are informed, at the time of admission regarding behavior management interventions including physical holding and special treatment procedures.

Elements of Guideline:

  • Upon admission, the family and program participant are informed about the general conditions under which behavior management techniques are utilized, including physical holdings, seclusion and/or restraint. A written consent is obtained for the parent/guardian, and if applicable, by the program participant for the use of these interventions.
  • As part of the admission process, the staff presents the parent/guardian with a written, general explanation of behavior management policies and procedures, including the use of physical holdings, seclusion and/or restraint.
  • Parent/Guardian signature(s) are obtained for the use of those interventions. Students/residents are equally informed about these interventions and are encouraged to sign the consent form. They may refuse to sign the form but parental/guardian written consent will permit the application of those interventions.

8.0 Staff Training and Competence

8.1 Staff is trained and competent in the use of the behavior support policy and procedures.

8.2 Staff is trained and competent to minimize the use of intrusive behavior intervention such as physical holdings, seclusion and/or restraint.

Elements of Guideline:

  1. The organization educates, assesses and documents the competence of staff in minimizing the appropriate use of physical holdings, seclusion and/or restraint and, before they participate in any use of said interventions, are also educated and trained in their safe use.
  2. In order to minimize the use of these procedures, all direct care staff as well as any other staff involved in the use of said interventions receive ongoing training in and demonstrate an understanding:
  • of the underlying causes of threatening behaviors exhibited by the program participants;
  • of the possibility that a program participant may exhibit an aggressive behavior that is related to a medical condition and not related to his or her emotional condition, for example, threatening behavior that may result from delirium in fever and hypoglycemia;
  • of how a staff’s own behaviors can affect the behaviors of the program participant;
  • of the use of de-escalation, mediation, self-protection and other techniques, such as time-out,
  • recognizing signs of physical distress in individuals who are being held, restrained, or secluded.

3. Staff charged with monitoring or initiating the holdings, seclusion and/or restraint procedure receive the training and demonstrate the competence to assess the program participant throughout these procedures

Glossary of Terms

Brief Physical Holding: A non-violent physical intervention restricting the movement of a youth, or restricting the movement of normal function of a portion of the youth’s body as described in agency-approved training methods, by forcefully and involuntarily depriving the youth of free liberty to move about. Simple physical redirection which does not cause pain, such as hand on the back or briefly holding the upper arm or clasping of the hand, should not be considered a physical restraint. Brief Physical Holdings may not exceed 30 minutes in duration. If a program participant requires holding for more than 30 minutes, said procedure has risen to the level of a Special Treatment Procedure.

Special Treatment Procedure: A specific class of behavior interventions restrict the free movement of a child by mechanical or physical means for a prolonged period of time, and/or a physical holding that exceeds 30 minutes in duration in response to threats or actions of self harm, harm towards others, destruction of property, and serious disruption of the therapeutic environment. Specifically, those interventions are referred to as seclusion and mechanical restraint and/or physical holdings for more than 30 minutes in duration.

Seclusion: A procedure where the individual is restricted to a small space, such as a time-out room, without the ability to leave the room, i.e. the individual is blocked from exiting either by a lock-door or by a staff-restricting exit for more than 30 minutes. That is to say, that a procedure where the individual is prevented from exiting a confined space for 29 or less minutes, is not a seclusion procedure.

Mechanical restraint: A procedure where a mechanical device such as leather belts, posy belts, strait jacket, hand cuffs, and other devices are used to restrict the free movement of an individual. Therapeutic holds (see 4.4) that are longer then 30 minutes in duration, are also considered restraint procedures.

Time-Out: Time-out procedures are those classes of interventions in which the program participant is offered a time away from the regular scheduled activity in order to gather himself and/or re-establishing the locus of control within him/her, in an attempt to de-escalate agitated behavior and/or to prevent a serious disruption of the therapeutic environment. When possible, time-out interventions are conducted away from stimuli that may contribute to the escalation of maladaptive behavior and/or reduce the probability for serious disruption to the therapeutic environment. Time outs in excess of 30 minutes should be classified as seclusion.

Self Directed Time-Out: A procedure where the program participant is requesting a time-out in effort of regain control and/or composure, sensing or knowing that he/she is agitated and desiring some time to de-escalate. The program participant should be given adequate time to do so. At any time during a self-directed time-out, when it becomes evident that the continuation of the self-directed time-out becomes clinically contraindicated, the procedure is terminated by the staff.

Staff Directed Time-Out: A time-out procedure where the program participant is restricted, for 30 minutes or less, from leaving an unlocked room or area. A procedure where the individual is restricted for 30 minutes or more in the time-out area is a special treatment procedure (see definition). A staff directed time-out procedure may not deny the program participant from daily, adequate nutritional intake and deprive him/her from regular eliminating.


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Core Standards of the Office of Licensure of the Utah Department of Human Services.

Corded, S., and Gair, D.S.: Freedom Within Limits. Proceedings of the Fourth Annual Children’s Advocacy Conference. Boston, New England Children’s Mental Health Task Force. (A U.S. Public Health Service Document, 1978.

Dorr, D.: The Need to Understand Discipline. In The Psychology of Discipline. Edited by Dorr, F., Zax, M., Bonner, J. New York, International Universities Press, 1983.

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Guthrell, T.: Observations and the Theoretical Basis for Seclusion of the Psychiatric Resident. Am I Psychiatry 135:325-328, 1978.

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