Most crises on a unit have a runway. This article is about what you do with it. It is a practical framework for supporting autistic residents in long-term care: reading escalation earlier, adjusting the environment before the behavior escalates, and documenting what you tried—so that restrictive measures are a last resort rather than a default. It is written for CNAs, nurses, and direct-care staff, and it is not a substitute for your facility’s policy, your training, or clinical judgment.
The Case for Prevention Is Not Soft—It Is Evidence-Based
The argument against restraint is often framed as ethical. It is also practical, and the evidence is stronger than most staff are told.
A Cochrane systematic review of interventions to reduce physical restraints in long-term care found that restraint use can be reduced without evidence of increased falls or fall-related injuries when frontline staff are empowered by supportive managers (Möhler et al., 2023). The review included 11 studies and 19,003 residents. In the four trials of organizational interventions—packages combining training, managerial support, and individualized strategies—the number of residents with at least one restraint fell by about 14%, from an estimated 274 to 236 per 1,000 residents (Möhler et al., 2023). The evidence on falls was low-certainty, and the interventions probably made little or no difference to psychotropic medication prescribing (Möhler et al., 2023). The review was uncertain whether simple educational interventions reduce restraint use, which fits the finding that organizational support matters. The lesson for a frontline worker is not “try harder.” It is that the environment you work in determines whether prevention is possible.
One limit matters for this article: the studies in the review took place in long-term care settings and largely involved older residents, many of whom had dementia. The review does not report results for autistic residents, so its numbers should not be quoted as autism-specific findings. We borrow its logic—prevention works when staff are supported to use alternatives—and pair it with approaches developed for autistic people, described below.
Restraint itself carries real harms: reduced mobility, pressure injuries, increased fall risk, and psychological effects including confusion, agitation, and depression (Ontario Health, 2026). For many residents, restraint use negatively affects dignity and quality of life (Ontario Health, 2026). The goal is not zero risk—that is not achievable in any care setting. The goal is to reduce the risks you create in the name of safety, and to make sure the alternatives have actually been tried and documented before a restrictive measure is used.
What “Without Restraint” Actually Means on a Shift
It does not mean you never use a restrictive measure. Policy and safety sometimes require it, and pretending otherwise would make this article useless to anyone who has actually worked a unit. It means three things:
- You know what to try first, and you try it.
- You document what you tried, so the record reflects the alternatives before the restraint.
- You treat restraint as a last resort, not a first response, and you know the difference between a situation that requires it and a situation that requires a quieter room.
This framing matches RNAO’s best practice guideline, which calls for alternative approaches and de-escalation as first- and second-line strategies, with restraint as a safety measure of last resort (RNAO, 2012). The rest of this article is about the first two points. The third is a judgment call that belongs to you, your charge nurse, and your facility’s policy—but the quality of that judgment depends on how well you can read escalation and how many alternatives you have already practiced.
Read the Runway: What Escalation Looks Like Before the Behavior
Behavior is communication, and escalation usually announces itself before it becomes a crisis. The earlier you see it, the more options you have.
The most important tool is knowing the person’s baseline. Many autistic people use repetitive movement, limited eye contact, or particular speech patterns as part of how they regulate and communicate every day. Those are not warning signs on their own. The signal is a change from what is usual for that person. Ask the resident, their family, and the care plan what “normal” looks like, and write it down where every shift can see it.
Early signs (the runway is long; you have the most options):
- Changes in breathing—faster, shallower, or held
- Posture shifts—stiffening, pulling away, turning the body toward an exit
- Facial changes—jaw tightening, brow lowering, eyes widening or narrowing
- Vocal changes—pitch rising, speech speeding up, or going silent
- A change in the person’s usual repetitive movement—faster, more intense, or different from their baseline—or new pacing, rocking, or repeatedly touching a specific object
- Refusing a specific task, room, or person without a clear reason
Mid escalation (the runway is shorter; options are narrowing):
- Verbal escalation—repetition, raised voice, threats, or protest language
- Physical agitation—pushing items away, standing up abruptly, removing clothing or equipment
- Attempts to leave the area
- Pulling away from contact or responding less than usual, compared with the person’s baseline
Crisis (the runway is gone; the priority is safety):
- Striking out, grabbing, biting, or throwing
- Self-injury
- Attempting to leave the building or enter a restricted area
- A level of distress that is dangerous to the person or to others
Most de-escalation training focuses on the crisis stage. The leverage is in the early and mid stages, where a change in the environment, a reduction in demand, or a shift in your own approach can still change the outcome. The earlier you intervene, the less restrictive the intervention has to be.
The Low Arousal Approach: Less Is Usually More
The Low Arousal Approach, developed by McDonnell and colleagues, is a prevention and de-escalation framework built on a counterintuitive premise: in a moment of escalation, the most useful thing a supporter can often do is reduce—reduce demands, reduce language, reduce stimulation, reduce the number of people in the space (McDonnell, 2019; Woodcock & Page, 2010). It was developed in the 1990s as an approach to supporting people with behaviors of concern and is widely used in autism and learning disability services (McDonnell, 2010; McDonnell et al., 2024).
The approach rests on a finding that is uncomfortable for staff to hear: many challenging situations are inadvertently triggered by supporters (McDonnell, 2010). Not because staff are cruel or incompetent, but because the default response to escalation—talking more, moving closer, asking questions, issuing directives—adds load to a nervous system that is already overloaded. Low Arousal asks staff to do the opposite: step back, lower the voice, stop talking, and wait.
The practical moves of Low Arousal are simple to state and hard to do under pressure:
- Reduce demands. Stop the task. Pause the care. Let the moment pass.
- Reduce language. Fewer words, shorter sentences, or no words at all.
- Reduce proximity. Give space. Do not crowd.
- Reduce audience. Move other residents or staff away if you can.
- Reduce stimulation. Lower the lights, turn off the TV or radio, close the door.
- Regulate yourself. Your nervous system is the intervention. If you are escalating, the resident will too.
Scottish Autism adopted Studio III’s Low Arousal training in 2020, describing it as consistent with its ethical approach and its commitment to eradicating restrictive practices, with wellbeing and human rights as fundamental principles (Scottish Autism, 2026). The evidence base for Low Arousal is still developing. Peer-reviewed outcome research is limited, and the published evidence includes a 2024 qualitative study in which 17 trained parents described feeling more confident and better able to advocate for their family member (McDonnell et al., 2024). The approach has not, to our knowledge, been tested in randomized trials in long-term care. Its core logic is, however, consistent with what the restraint-reduction literature recommends: prevention, environmental adjustment, and less restrictive alternatives before physical intervention (Möhler et al., 2023; RNAO, 2012).
Environmental and Sensory Adjustments That Reduce Escalation
A meaningful share of what looks like “behavior” on a unit is a response to an environment that is too loud, too bright, too crowded, or too unpredictable. Ontario Health’s change ideas for reducing restraint include adjusting lighting, noise levels, and room layouts to prevent confusion and agitation (Ontario Health, 2026). The RNAO’s Promoting Safety: Alternative Approaches to the Use of Restraints (Appendix J) provides a practical list of alternatives organized by presenting behavior—and the list is largely environmental and sensory (RNAO, 2012).
For agitation, the RNAO suggests mobility and exercise routines, routine repositioning, medication review, pain relief, regular toileting, a normal schedule and individual routine, assessing for hunger, pain, heat, and cold, increasing social interactions, redirecting with simple commands, relaxation techniques, gentle touch, assessing past coping strategies, involving family, diversional activities (pets, music, puzzles, crafts, cards, snacks), and scheduling daily naps (RNAO, 2012).
That list was not written specifically for autistic residents, so apply it with the individual in mind. Some items may add load rather than reduce it for a given person—increased social interaction and gentle touch are the obvious examples—so check the resident’s profile and preferences before using them. Items that support predictability and sensory comfort, such as a consistent routine, a quiet space, and preferred activities, tend to fit the Low Arousal logic. The RNAO also publishes separate lists for cognitive impairment and dementia and for acute confusion and delirium; if a resident has one of those in addition to being autistic, those lists are worth consulting too.
The pattern is the same: check the body first, then the environment, then the interaction. Pain, toileting, hunger, thirst, temperature, and sensory overload are common contributors, and they are the most commonly missed because they are not behavioral. Many autistic people have difficulty identifying or communicating physical discomfort—a well-documented feature of interoceptive differences in autism (DuBois et al., 2016)—so a change in behavior may be the only signal.
Communication During Escalation
What you say—and how much you say—matters as much as what you do.
Lower your voice and slow down. A raised voice meets a raised nervous system and escalates it. A lower, slower voice gives the person something to regulate against.
Use fewer words. A person in escalation cannot process a paragraph. “You’re safe. I’m going to step back” is more useful than an explanation of why the task needs to be done.
Give processing time. After you speak, wait. Repeating yourself or rephrasing right away adds more to process. If the resident uses a communication system, a picture schedule, or written cues, use their preferred method rather than more speech.
Do not argue with the content. If the person is saying something that is not true—that someone is trying to hurt them, or that they need to leave right now—correcting the fact is rarely the first move. Validate the emotion, not the fact: “That sounds frightening. I’m here.”
Offer choices, not instructions. “Do you want to sit here or by the window?” is easier to process than “You need to sit down.” Choice preserves autonomy, and autonomy reduces escalation.
Narrate what you are doing before you do it. “I’m going to check your blood pressure now. It will feel tight on your arm.” Predictability lowers arousal.
Give space. Do not block the exit unless safety requires it. A person who feels trapped will escalate to get out. A person who believes they can leave is often calmer.
Regulate yourself first. If you are frustrated, scared, or rushed, the person will read it. Take a breath before you speak. Your calm is not a luxury—it is the intervention.
These principles are consistent with trauma-informed care, which emphasizes safety, trustworthiness, choice, collaboration, and empowerment. For residents with trauma histories, a raised voice, a sudden touch, or a crowded room can be a trigger rather than a neutral event. The same de-escalation skills work, but the threshold for using them is lower.
What to Document (and Why It Protects You)
Documentation is where de-escalation becomes visible to the clinical team, to surveyors, and to the next shift. A note that says “resident was agitated, restraint applied” is likely to be read as a failure to try alternatives. A note that says what you observed, what you tried, and what happened shows least-restraint practice.
Document these four things every time:
- The early signs you observed, in behavioral terms—what the person did, not what you inferred they felt, and how it differed from their baseline. “Began pacing and pulling at her shirt when the dining room filled” is observable. “Was anxious” is not.
- The alternatives you tried, in order, and the response to each. “Reduced noise, offered a quiet room, provided a preferred snack; settled within fifteen minutes” is the sentence that shows least-restraint practice.
- What preceded the escalation—time of day, noise, a change in routine, a new staff member, a care task, a visit, a medical change.
- What happened afterward—whether the person returned to baseline, how long it took, and what the next shift should know. A handoff note that says “calm with the door open and lights low” is worth more than three paragraphs describing the incident.
Ontario Health’s guidance on enforcing a least-restraint policy asks for documentation of the rationale for any restraint use, including all attempted alternatives and reassessment plans (Ontario Health, 2026). If you are ever asked why a restraint was used, the record of what you tried first is your evidence that it was a last resort.
When Restraint Is Required
Sometimes it is. A resident is striking a peer, attempting to leave the building into traffic, or is at imminent risk of serious injury. In those moments, safety comes first, and the decision belongs to your clinical lead and your policy—not to this article.
What this article asks is that the moments before that point were not empty. That you read the runway. That you reduced demands, adjusted the environment, changed your communication, and gave the person space and time. That you documented what you tried. And that afterward, you and your team reviewed what happened—not to assign blame, but to ask what could have been different earlier. Ontario Health also recommends reassessing after any significant health, cognitive, or behavioral change (Ontario Health, 2026).
Restraint reduction is not a single decision. It is a pattern of decisions, made on every shift, by staff who are supported enough to make them.
References
DuBois, D., Ameis, S. H., Lai, M.-C., Casanova, M. F., & Desarkar, P. (2016). Interoception in autism spectrum disorder: A review. International Journal of Developmental Neuroscience, 52, 104–111. https://doi.org/10.1016/j.ijdevneu.2016.05.001
McDonnell, A. (2010). Managing aggressive behaviour in care settings: Understanding and applying low arousal approaches. Wiley.
McDonnell, A. (2019). The low arousal approach. Studio III Training Systems.
McDonnell, A. A., Page, A., Bews-Pugh, S., Morgalla, K. A., Kaur-Johal, T., & Maher, M. (2024). Families’ experiences of the Low Arousal Approach: A qualitative study. Frontiers in Psychology, 15, 1328825. https://doi.org/10.3389/fpsyg.2024.1328825
Möhler, R., Richter, T., Köpke, S., & Meyer, G. (2023). Interventions for preventing and reducing the use of physical restraints for older people in all long-term care settings. Cochrane Database of Systematic Reviews, 2023(7), CD007546. https://doi.org/10.1002/14651858.CD007546.pub3
Ontario Health. (2026, August 26). Percentage of long-term care residents in daily physical restraints. https://ontariohealth.ca/quality/quality-improvement-indicators/details?cf=percentage-of-long-term-care-residents-in-daily-physical-restraints
Registered Nurses’ Association of Ontario. (2012). Promoting safety: Alternative approaches to the use of restraints (Appendix J: Example: Alternative approaches list). https://ltctoolkit.rnao.ca/sites/default/files/resources/RNAO_Safety_Alternative_App_to_Use_Restraints_AppJ_pg104_107.pdf
Scottish Autism. (2026, April 15). Scottish Autism’s position on Positive Behaviour Support. https://www.scottishautism.org/practice-policy-and-research/our-approach-to-practice/position-on-positive-behaviour-support/
Woodcock, L., & Page, A. (2010). Managing family meltdown: The low arousal approach and autism. Jessica Kingsley Pubishers.
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