In Harm's Way: Use of physical force on troublesome kids
unchecked
Third in a series
Tuesday, September 20, 2005
By Barbara White Stack, Pittsburgh Post-Gazette
Kidspeace
Larrel Dallas' arms already were broken when the breath began to be
pressed out of him.
Two workers from the Pressley Ridge Ohiopyle
Therapeutic Wilderness Camp were holding him face down in
the dirt, one on his legs, the other pinning the
14-year-old's arms behind his back.
Dallas heard the bones snap as one worker yanked his
hands toward his head. His arms went numb. He feared for his
life.
"Can't breathe, can't breathe," he choked out. An asthma
sufferer, he knew the panic of breathlessness.
Unmoved by his pleas, the workers remained on top of him
for 20 minutes. "I just closed my eyes," Dallas recounted.
"I thought I was going to die."
Dallas, a 5-foot, 10-inch, 176-pound youth, survived the
incident last Feburary. Other children, particularly younger
and smaller ones, haven't been so lucky.
In March, a 13-year-old boy was killed in a restraint at
a Georgia wilderness camp. As workers held him down, Travis
Parker said he couldn't breathe and asked for his asthma
inhaler. The workers refused and remained on top of him for
more than an hour. Travis suffocated.
Despite a decade of hand-wringing nationally over the
dangers of restraint, the Pennsylvania Department of Public
Welfare has done nothing substantial to limit its use in
institutions caring for abused, neglected and delinquent
children.
Clarification to be issued
The closest DPW has gotten to actually doing something is
planning to clarify current policy. Early next month, the
agency says it will reiterate that under state law, a child
is to be restrained only when someone is in imminent,
serious danger and alternative efforts to intervene have
failed.
This is despite the fact that Welfare Secretary Estelle
Richman wants restraints stopped altogether. "There has to
be zero tolerance," she said in a telephone interview last
month. "I can't say one or two restraints is OK [if] you
just do not have enough staff."
But when she discusses a no-restraint policy, agency
directors scream, she said.
And much as she may covet zero tolerance, enforcement
would be virtually impossible under DPW's current licensing
system.
That's because DPW doesn't require reporting on how often
restraints are used and doesn't track even the most basic
information, such as how many children are injured or killed
in takedowns.
By gathering stories and reviewing DPW's
incident reports for Allegheny County, the Post-Gazette
collected examples of serious injuries and deaths from
restraints in DPW-licensed facilities for children over the
past seven years.
In just six of Pennsylvania's 67 counties, restraints
have resulted in three deaths, seven broken arms, one broken
leg, one broken thumb, one broken nose and two serious
lacerations.
When Larrel Dallas' arms were broken at Pressley Ridge in
February, he said it happened like this:
A worker at Pressley Ridge told him to take out the
trash. He didn't.
The worker confronted him, and Dallas told the man that
he hadn't heard the order. As a result, the troop of boys to
which he was assigned was punished as a group with a forced
march in the woods. Workers confronted Dallas again, and he
repeated the defense that he didn't hear someone tell him to
take out the trash.
Workers ordered the boys to march again. They were angry
with Dallas. Questioned once more, he stuck with his story.
The workers demanded the boys march again. That's when
another youth, whom Dallas knew only as Lionel, knocked him
down.
Chaos ensued. First, the workers restrained Lionel. Some
of the other boys attacked Dallas. He got to his feet and
threatened Lionel. The workers released Lionel and
restrained Dallas.
After Dallas' arms were broken in the restraint, doctors
placed matching casts on him from armpits to fingertips,
immobilizing his arms and rendering him helpless.
Janet Emery, vice president and chief development officer
for Pressley Ridge, a $60-million corporation with
operations in six states and Washington, D.C., later
insisted that only one of Dallas' arms had been broken.
In addition, she said, workers were forced to restrain
Dallas to protect the "defenseless" Lionel: "This occurred
as the staff conducted a passive restraint to prevent the
young man from committing a violent act toward a defenseless
child."
How
passive is 'passive'?
"Passive physical restraint" is the jargon institution
officials use in explaining use of a dangerous procedure.
"A restraint is passive. It is not a fight. It is used
when a child is out of control," said John Patrick Lydon,
chief executive officer of Auberle, which operates a day
school and group homes.
Similarly, Kevin Jenkins, executive director of Holy
Family Institute in Emsworth, which also operates a school
and group home, said, "The youngsters we care for at times
are extremely combative. For their safety, a passive
physical restraint is employed."
But those who have been involved in these struggles
rarely recall them as passive.
"Anytime you have to put your hands on a child to stop
motion, that's aggressive," said Daniel P. Hunt, chief
executive officer at Bradley, which operates three
residential treatment facilities for children.
Dallas recalls kicking at the workers as they initiated
his restraint. That's common. Children frequently punch,
scream, bite and scratch during a takedown.
And that means workers get hurt too.
"Frontline mental health workers are some of the most
injured in employment," said Ronald W. Costen, a
Philadelphia attorney who represents families of children
and elderly people injured in homes, but who has an
insider's perspective from working early in his career in a
Pittsburgh mental institution.
There, he was with a patient who tried to stab herself
with a shard of mirror. He grabbed her hand to stop her. She
stabbed him instead.
Costen said "these are not the most desirable jobs. These
are very difficult positions to be in," referring to those
who work with combative adolescents.
"You need to control the adolescent and you need to
protect yourself as a staff member."
At the same time, he said, an institution "has an
obligation not to kill or injure the patient in the course
of delivering the care."
Emergency action only
Though Dallas was injured, Pressley Ridge's Emery
contended the restraint was unavoidable.
That, too, is a common refrain from
institution administrators -- mainly because institutions are
forbidden to hold children down except when it's unavoidable.
DPW put it this way in a 2002 bulletin to mental health
providers: "This procedure is justified only in situations of
emergency as a safety measure, when there is imminent danger of
bodily harm to the consumer or others and when less restrictive
interventions prove ineffective."
Richman believes a properly run facility should almost never
restrain.
She worked with patients and with successful programs to
limit restraints earlier in her career. "You really can reduce
restraints to practically zero," she said.
It takes training, adequate staffing and efforts to prevent
children from becoming so wound up that they're out of control.
"Our goal is to try to change the system so it is more
proactive," Richman said.
That's what Ellen Mancuso wants as well. She is director of
the Children's Project at Pennsylvania Protection and Advocacy,
a group assisting people with disabilities. She investigates the
circumstances of some restraints in which children are injured.
She has found numerous instances in which workers missed
opportunities to calm youngsters. In one case, for example, a
child had just been sent back to a treatment center because a
relative couldn't handle him.
Then he went to a court hearing and was ordered to remain in
treatment. "They knew the kid was in a situation that could
cause him to freak out, and they took no steps to prevent it,"
Mancuso said. "They allowed him to flip out, and, bam, they were
on top of him."
Imagine, Mancuso said, a case in which a teenage victim of
sexual assault is sent to a treatment center and restrained
there by four men holding her down on the ground. "What memories
would that bring up? Isn't that child going to fight back?"
Restraints show children that might makes right, said DPW's
Richman. "It teaches them to solve problems by hitting. That is
what adults did to them when they had a problem."
Restraint is antithetical to treatment, she said.
With that in mind, some institutions have reduced restraints.
Bradley conducted a study over nearly three years at two of its
facilities, during which it cut restraints by 62 percent. In a
study at an Illinois university hospital in 2002, restraints in
the adolescent unit were cut 48 percent the first quarter and 98
percent the second.
But DPW has no idea whether restraints overall are increasing
or decreasing, and many institutions will not divulge their
statistics.
Emery refused to give the number of restraints for the
Pressley Ridge school, saying state law exempts private schools
from the requirement that public schools make such figures
available. Lydon also refused to release the number of
restraints at either the Auberle school or its group homes.
The lack of data is deeply frustrating to Pennsylvania
Protection and Advocacy. The Department of Public Welfare
promised to forward incident reports on restraints to the
advocacy agency, but only one regional office, the Western one
covering Allegheny County, is routinely doing that. PPA
complained to Richman. Nothing changed.
The purpose of collecting the information is not to punish
facilities with frequent restraints but to help them get those
numbers down so children aren't hurt, Mancuso said.
DPW not only does not share statistics with outsiders like
PPA, but doesn't distribute the limited information it has among
its own licensing offices. That prevents officials from seeing
if one worker has injured children in more than one type of
facility, and makes it impossible to tell whether there are
trends in an agency providing various types of programs.
DPW didn't know, for example, that one Auberle worker injured
two children in restraints, one at a school licensed by DPW's
mental health office, and one at a home licensed by DPW's Office
of Children, Youth and Families.
The Post-Gazette created a spreadsheet of seven years of
violations the Department of Public Welfare found at Allegheny
County institutions. It clearly showed three large agencies --
Holy Family, Shuman and Auberle -- had more violations than
others, and most of those breaches were for restraint injuries.
Holy Family violated rules in restraints the most -- 11 times.
Auberle was second at 7.
Few
arrests
Three months after Dallas' arms were broken, state police
criminally charged one of the workers who held him down: Aaron
Paull, a 5-foot-11-inch, 220-pound Uniontown man with a Superman
logo tattoo on his left arm and a criminal record for disorderly
conduct. Paull now faces assault and child endangerment charges
for the restraint.
Three months after Travis Parker suffocated in the restraint
at the Appalachian Wilderness Camp in Georgia, six former
workers there were charged with murder.
But those are exceptions. Rarely is anyone held accountable
when a child is injured or killed in a restraint, not by the
police and not by DPW. In the three most recent restraint deaths
in Pennsylvania, no worker was charged.
In the vast majority of cases, blame is placed squarely on
the child. It was the child's behavior that prompted the
restraint, officials say.
Crystal McDonald, whose arm was broken at Shuman, said, for
example, "When my mom talked to people up there, they kept
saying it was all my fault."
Pressley Ridge blames Dallas entirely for what happened to
him. In its response to his lawsuit against the organization,
Pressley Ridge lawyers said, "At no time was Larrel Dallas
subjected to unreasonable or excessive force and if, in fact,
Larrel Dallas sustained any injuries as a result of the
incident, those injuries were caused by Larrel Dallas' own
violent conduct."
Workers are almost never accused of overreacting or creating
a situation in which the child behaved badly.
This conflicts with research that has shown a wide variation
in the use of restraint in psychiatric facilities treating
similar patients, suggesting the pivotal factors may be staff
training, experience, attitude and the alternatives to
restraint.
Barbara Jerome of Glassport, whose son was injured in a
restraint, works with volatile elderly people as a certified
nursing assistant and said staff in her field are required to
put up with a lot of nastiness and aggression from some very
large patients without resorting to restraint.
"They can't help what they do," she said of the patients. "We
do not take things personally. We walk away if we have to. I
have dodged fists, food. Some knock their meds across the room.
I get them to settle down. I have never been in a situation that
I could not settle by just talking to them."
'Talk
down' not 'takedown'
Dallas said there was no warning before his restraint.
Officials who've reduced or avoided restraints say that's not
a good idea.
J. Kaye Cupples, executive director of the program for
students with emotional and learning difficulties
in the Pittsburgh School District, said it's essential to talk
first. "Restraining kids has to be the last resort," he said,
"Most children can be talked down to a state where they can
respond to adults."
Hunt, from Bradley, where restraints were cut 62 percent,
said another factor is support from the top. "You have to have
the CEO behind these initiatives," he said.
Two other factors are important as well, he said -- training
for staff and incentives for children.
Each Bradley facility established a restraint reduction
committee, whose plans included pizza parties and other rewards
for children on units that had no restraints.
Workers asked each youngster what had enabled him to control
himself in the past and provided for that. It could be painting;
it could be pounding a punching bag.
Finally, Bradley got its restraint numbers down so low that
only a couple of children were ever being held down. The center
decided to put those youngsters on the restraint reduction
committees, which Hunt says was extremely effective in cutting
the number of times those children were held down.
Hunt said they found that limiting restraint made both
workers and children feel safer and happier.
He said he would support Richman in a no-restraint initiative
if programs like his get the money they need to do it. "I can
give you zero restraints if you give me the resources," he said.
Richman is all for that kind of response. She recounted one
director saying that if her program were prohibited from
restraining, it would just use more sedatives on children or
call police to arrest youngsters.
"I wanted that person to say give me more money," the
secretary said, because she could work on that.
"I didn't want to hear, 'I can't solve the problem.' " |
