Restrictive Housing in Juvenile Settings (2021)

1. The practice of restrictive housing should not be used in juvenile corrections.

a. Restrictive housing should never be used as a disciplinary or punitive measure under any circumstances.
b. Restrictive housing should never be used as a response to minor infractions.
c. Restrictive housing should never be instituted because of staffing shortages, for administrative convenience, or for retaliation.

2. The following measures should be considered as alternatives to restrictive housing:

a. Facilities that house juveniles should maintain clear policies and procedures around safe, trauma-informed, and developmentally sensitive behavioral management.
b. Staff must have the training and resources to utilize therapeutic strategies such as:

i. Trauma-informed de-escalation techniques
ii. One-on-one time with a staff member engaging in an activity separate from the general population (e.g., outside recreation, journaling, calling family or loved ones)
iii. Carefully described consequences such as the use of verbal reprimands, loss of privileges, and work duty
iv. Option for youth to voluntarily lock themselves in their cells to avoid situations of conflict (with appropriate monitoring and precautions to minimize risk for self-harm)
v. Access to mental health professionals and others trained in conflict resolution
vi. Evidence-based interventions based on such principles as motivational interviewing and cognitive-behavioral or dialectical-behavioral therapy

c. Facilities should repurpose unused cells and other spaces as soothing de-escalation rooms that youth may use when needed.
d. Facility programming should be robust in order to reduce idleness that may lead to conflict between youths by increasing access to groups, recreation, and other activities.

3. In the rare event that restrictive housing is deemed necessary to maintain safety after all alternative therapeutic strategies and de-escalation techniques have been exhausted, these minimum steps must be taken to ensure the health and well-being of juveniles:

a. Policies must outline clear and effective behavior management protocols that prevent or limit the use of restrictive housing, and must align with relevant laws, regulations, and ethical standards. Any use of restrictive housing must occur in accordance with those policies.
b. Restrictive housing should never be assigned for a fixed period of time. As soon as the youth is determined to no longer be of risk to self or others, isolation should be terminated.
c. Clear communication that is developmentally and linguistically appropriate must be provided to the youth as to why restrictive housing is being used, what specifically is involved in the restriction, and what criteria will be used to determine an endpoint to the restrictive housing.
d. Custody or administrative staff must communicate the same to members of the youth’s medical and mental health treatment team upon initiation of restrictive housing.
e. Medical clearance for restrictive housing must be obtained prior to a youth being placed whenever possible, otherwise within one hour of placement, to ensure that any underlying medical or psychiatric conditions are safely managed without acute risk of harm to the youth. This clearance will include an in-person assessment by a qualified health care professional or a designated “health-trained child care staff” per the NCCHC standards with phone back-up from the on-call qualified health care professional. If an in-person assessment cannot occur within one an hour, an on-site or on-call qualified health care professional should review the youth’s available medical records. If a comprehensive mental health assessment has not yet been conducted for the youth, this must be done within the first 24 hours in restrictive housing.
f. The medical clearance should include specific consideration of risks for suicide, trauma, and other underlying medical or mental health conditions, and consultation with appropriate medical and mental health professionals must occur when indicated to minimize risk of harm to the youth.
g. Ongoing routine monitoring for medical and psychiatric status must occur by a qualified health care professional or a designated “health-trained child care staff” with phone back-up from the on-call qualified health care professional, at minimum twice daily in person and as needed for condition change.
h. If a qualified health care professional deems further medical or psychiatric attention is needed, transfer to a medical or mental health unit should occur immediately.
i. Custody staff should conduct frequent checks, at least every 15 minutes, for any youth in restrictive housing.
j. The youth must maintainaccess to all standard rights, including but not limited to adequate nutrition, communication with attorneys and family, educational programming, daily exercise of large muscles and outdoor time, access to reading and legal materials, and access to medical and behavioral health care.
k. A clear exit strategy from restrictive housing must be included in the protocol and communicated with the youth and with staff members.
l. An individualized behavioral management plan should be developed for any youth for whom restrictive housing interventions are used more than once in 6 months.

4. Documentation and Monitoring

a. Any restrictive housing placement of 4 hours or longer should be considered a reportable event and thoroughly documented. Facilities may choose to use a lower threshold.
b. For youth placed in restrictive housing for more than 1 day, administration should convene a multidisciplinary team meeting to review the case and develop a safety/treatment plan.
c. Restrictive housing events should be documented in a daily list that includes the youth’s age, gender, and race; the start date; and the number of hours or days in restrictive housing. The list should be provided daily to the medical department and the facility administration. At least monthly, facility administrators should review the list to ascertain when practices are inappropriate, are ineffective, or have negative consequences.
d. Use of restrictive housing should be tracked to include monitoring for racial disparities. Staff training around use of restrictive housing must include steps to mitigate disproportionate use for racial minorities.

5. If medical isolation is necessary for infection control purposes, steps to take include continual reevaluation for safe management in the least restrictive alternative setting as soon as possible, close monitoring for medical and psychological concerns during isolation, and access to as much programming and contact with family and providers as possible given the specific situation, as well as meeting standard Y-B-01 Infection Prevention and Control Program from the NCCHC standards.

Adopted by the National Commission on Correctional Health Care Board of Directors
February 3, 2021

Endorsed by:
The American Academy of Pediatrics
The Society for Adolescent Health and Medicine