ORIGINAL PAPER The Reduction of Mechanical Restraints and PRN Medication in 400 Persons with Neurodevelopmental Disorders: an Analysis of 11 Years Process in 23 Italian Residential Settings Mauro Leoni 1 & Roberto Cavagnola 1 & Giuseppe Chiodelli 1 & Serafino Corti 1 & Francesco Fioriti 1 & Maria Laura Galli 1 & Giovanni Michelini 1 & Giovanni Miselli 1 & Michela Uberti 1 # Springer Nature Switzerland AG 2018 Abstract Contrary to public policy and research expectations, restrictive behavior practices continue to be used with individuals with intellectual disabilities. This paper reports the effects of a multi-component service package for a residential service for over 400 adults with intellectual disabilities and challenging behavior. Over an 11-year period, there was a large and near elimination of mechanical restraints and pro re nata medications and a decrease in staff working days missed because of resident aggression, despite an increase in the complexity of resident needs. This study demonstrates that large-scale, long-term reduction of restric- tive behavior management practices is possible using a multi-component organizational reform package. Keywords Mechanical restraint . Pro re natas . Intellectual disability . Autism . Medication management . Staff training The restriction of personal freedom is common among persons with neurodevelopmental disorders and intellectual disability. The use of proactive and reactive interventions has been well documented in the literature. Due to the severity of challenging behavior and risk of harm to self and others, restrictive behav- ioral practices may be necessary (Harris 1996; Luiselli 2009). Restrictive behavioral practices refer to all interventions which limit a person’ s movement or liberties (Sturmey 2009). The forms of restrictive behavioral practices may be classified across several dimensions. For example, the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (2017) defined the differ- ent forms of restraints and seclusion as: (a) physical restraint; (b) mechanical restraint; (c) chemical restraint; and (d) seclu- sion. Williams (2010) included the following useful features: (1) planned (i.e., within a written protocol) or unplanned (i.e., emergency); (2) used on a continuous basis; or (3) used on a contingent basis. Some forms of restraint, such as self-restraint, are learned, and humans naturally restrain their behaviors as a response to prevent from harm; therefore, restraint is not necessarily prob- lematic but must be evaluated by its function and conse- quences (Skinner 1953; Sturmey 2009). Physical restraint can be highly effective in reducing challenging in individuals with intellectual disabilities, but the effects vary significantly across individuals (Heyvaert et al. 2015; Luiselli et al. 2000). Additionally, there are several limitations associated with the use of restrictive behavioral practices (Luiselli et al. 2000) including: (1) physical contact can result in injury both to the person with disability and staff members; (2) restraint may be subject to abuse and misapplication; (3) it can worsen challenging behavior when restraints function as reinforcers or provoke challenging behavior during their application; (4) re- straint is often inappropriate for community-based programs; and (5) the long-term effects are unknown. Professionals’ perspectives on the use of restraints vary great- ly stemming from debates surrounding an individual ’ s needs, rights, and the aforementioned limitations surrounding use of restraints. This is of significant concern as Emerson (2002) found that 50–60% of children and adults with intellectual disabilities Electronic supplementary material The online version of this article (https://doi.org/10.1007/s41252-018-0087-z) contains supplementary material, which is available to authorized users. * Mauro Leoni mauro.leoni@fondazionesospiro.it 1 Disability Department, Fondazione Sospiro Onlus, P.zza Libertà, 2, 26048 Sospiro, CR, Italy Advances in Neurodevelopmental Disorders https://doi.org/10.1007/s41252-018-0087-z