Fatal Hugs

Restraining enraged kids puts youth workers in legal, moral morass

”You’re holding me too tight.”

Youth worker Bernadette Wilson wondered if she should loosen her grip on Timithy Thomas, a nine-year-old foster child who was, quite bluntly, being a pain to everyone at the Grandfather Home for Children in Banner Elk, N.C.

The 62-bed campus of cottages specializes in abused and disruptive kids that other youth agencies would not accept. But Timithy had so disrupted class that March day that Wilson had to literally chase him from the room. He ran across the hall to the padded “time-out” room, shut the lights, hid behind a door and knocked a book from Wilson’s hand. She grabbed him in a “basket hold,” whereby an adult holds a child’s forearms from behind and crosses them at his chest or stomach.

The basket hold is commonly taught to youth workers around the country to restrain out-of-control kids. It has been blamed in several deaths.

“My arm hurts,” Timithy said. “My nose is running.”

Wilson asked a supervisor if she was doing the right thing. Don’t worry, the supervisor said; the boy “says those things to get out of the hold.” Wilson also didn’t worry when Timithy made sounds “like someone trying to vomit” and like “a fake snore.”

The boy relaxed; the woman released him. They sat on the floor and briefly discussed the incident. Wilson then sat in the hall to read while Timithy silently served his time out.

When another youth worker walked in minutes later and touched the boy’s shoulder, he toppled to the floor. His face was the color of slate. His nose was specked with vomit. The youth worker tried CPR. Timithy was dead.

Now Wilson stands criminally charged with manslaughter, patient abuse and neglect. The Council on Accreditation on Services to Families and Children, Inc., has suspended the home’s accreditation. And North Carolina has issued new guidelines for group homes in restraining out of control kids.

For many youth workers, this is a “there but for the grace of God go I” story. Countless times each day staff and volunteers in every type of youth facility — from schools, after-school programs and foster homes to group homes, psychiatric facilities and juvenile prisons — must decide whether and how to restrain physically aggressive kids. If they don’t do it right, the youth or the staffer can get hurt or killed.

But there are no uniform standards on when and how to restrain children. Restraint laws vary among states. Many of the workers are trained poorly if at all. Training techniques are routinely ignored or misapplied in the heat of altercations. Staffers make decisions in a flash that can have a lifetime of consequences for the child, the worker and the agency.

In the wake of numerous reports of injuries and deaths, the federal and state governments are stepping in to curb restraint use in youth facilities: Congress is considering two laws to curtail the use of restraints on children in hospitals and other mental health facilities; the U.S. Health Care Financing Administration (HCFA) announced in June new proposed standards governing the use of restraints in hospitals and plans to issue rules later this year on other facilities, such as residential treatment centers for children; Connecticut, Massachusetts and North Carolina are among states that recently enacted laws or regulations to dictate when youth workers can use certain restraints, or to ban some restraints altogether; the U.S. Office of Juvenile Justice and Delinquency Prevention has awarded $2.6 million in grants to the Council of Juvenile Correctional Administrators (CJCA) to change procedures, including restraint use, at juvenile detention and correctional facilities; the U.S. Substance Abuse and Mental Health Services Administration is developing an action plan to “address problems with the misuse of seclusion and restraints in health care facilities.” (See story, page 44.)

This activity has been spurred by a rash of abuse allegations against youth workers who have restrained kids. Among them:

-In Virginia, a 16-year-old retarded boy at the Oak Ridge Juvenile Correctional Center in suburban Richmond died of a heart attack in April after being restrained by seven corrections officers; they had bound him with handcuffs and a leather belt and strapped him face down on his bed. Wallace Dandridge had thrown a cup of what he said was urine on one officer and punched another. The officers were suspended and the county prosecutor is considering criminal charges.
-In rural Massachusetts, the Devereux Center for mentally and emotionally disturbed youth recently paid a “very substantial” sum to settle a lawsuit by the family of 12-year-old Robert Rollins, who died there last year after he became “rambunctious,” according to family attorney Leonard Levy. A staffer at the 123-bed residential school in Rutland held the boy face down on the floor, and interpreted his “barking noises” as playful. He was choking.
-In Tucson, Ariz., 15-year-old Edith Campos got into a fight last year with youth workers at the Desert Hills Center for Youth & Families after a staffer at the psychiatric hospital demanded that she hand over an unapproved personal item. She was held face down on the floor and died of oxygen deprivation. Four employees were placed on leave, and a subsequent state investigation of restraint abuse allegations led several agencies (such as the state Department of Juvenile Corrections and Department of Health) to withdraw youths they had placed there. The once 108-bed facility closed in June.
-In Ohio, the biological family of Dustin Phelps filed a wrongful death suit in March against his foster parent after the 14-year-old died in the foster home, where he had been placed by the Tuscarawas County Department of Human Services. Phelps, a behaviorally and emotionally disturbed boy who frequently acted out, was stuffed into a mattress that was shaped like a U and held together with belts. A grand jury is considering criminal charges.
-In Sunrise, Fla., a Broward County judge appointed a lawyer this spring to investigate restraint use at a residential facility for emotionally disturbed adolescents after the judge, during a visit, saw a youth worker twisting the arm of a screaming youth who had been misbehaving. The 30-bed Brown Schools of Florida (run by the Austin, Tex.-based Brown Schools) also came under investigation this year by the state’s Department of Children and Families after allegations of excessive restraint use.

These incidents and the government regulatory activity come at a time of debate in the youth work field about when it is appropriate to restrain a youth, what restraint techniques are safe — and even whether youth workers should try to abandon restraint use altogether.

“This is a volatile issue right now,” says Malcolm Smith, founder of the Peaceful Intervention Program (PIP), which promotes the latter option.

A Risky Routine

Holding, pinning down or even strapping down unruly kids have long been routine in many youth facilities, especially those for youth with behavioral problems. “When I first started in the field, for me to do 20 restraints a week was an average,” says Lloyd Bellard, who worked in residential facilities in Virginia in the 1980s and is now director of residential care at the Child Welfare League of America (CWLA).

But this tool for maintaining order and safety has had a price. When the Family Life Development Center at New York’s Cornell University started researching institutional abuse of kids in 1979, it found that “the vast majority of allegations of abuse coming out of institutions was around front-line staff trying to manage aggressive and challenging behaviors,” says Martha Holden, the center’s senior extension associate.

Managed health care and the continued de-institutionalization of mental health patients through the 1980s and 1990s brought more youth with mental, emotional and behavioral disturbances into non-hospital facilities such as shelters, foster homes, juvenile prisons, community-based group homes and non-residential programs (like alternative schools for expelled students). “This is becoming an increasingly difficult problem because the clients who are coming into these agencies are more complicated in terms of their difficulties,” says Floyd Alwon, director of the Walker Trieschman Center, a Boston-based agency (now a division of the CWLA) that advocates for improved youth worker training.

Youth worker training often does not keep up with those complications. In Ohio, where Phelps died, foster parents who take in children with multiple behavior problems get no special training on how to deal with them. In Virginia, the Oak Ridge Juvenile Correctional Center (where Dandridge died) is for mentally retarded and learning disabled youth, but the corrections officers get no special training for dealing with them, either. The officers are, however, trained in martial-arts based tactics such as “the whip kick” and “the rake and stomp.”

Correctional and mental health facilities appear to rely on restraints the most:

-A Hartford Courant investigation published last year found at least 142 deaths in the past decade connected to physical restraint or seclusion in psychiatric or mental retardation facilities nationwide. More than 26 percent of those deaths involved patients 17 and under, although that age group makes up less than 15 percent of the population in the facilities studied.

Those were only reported deaths, “the tip of the iceberg,” says Curtis Decker, executive director of the National Association of Protection and Advocacy Systems, funded (at $50 million annually) by the U.S. Department of Health and Human Services to investigate abuse and neglect in facilities for people with disabilities. And “what about the thousands of people who are restrained and just injured?”

-In the five moths after the Courant series, the National Alliance for the Mentally Ill received five more reports of restraint deaths. Four of the victims were under 18.
-When the Council of Juvenile Correctional Administrators surveyed 30 juvenile detention and correctional facilities last year, the facilities reported an average of about two restraints for every 100 “person days of juvenile confinement” — or twice a day in a full 100-bed facility. The highest number was 20 for every 100 person-days, or 20 restraints daily in a full 100-bed facility.
-When the Civil Rights Division of the U.S. Department of Justice investigated Georgia’s juvenile detention and correctional facilities in 1997, it found (among numerous atrocities) that “staff persistently used excessive physical force against youths, in the form of hitting or slamming youths onto the ground and into walls, or otherwise injuring youths.” Staffers relied “almost solely on discipline and force to manage the facility,” and “in some of the facilities routinely use mechanical restraints as a form of punishment for behavior that does not represent a threat to the safety of the youth or others.” To avoid a lawsuit by the Justice Department, the state agreed to spend $75 million over the next three years to hire and train staff and to improve conditions at its juvenile facilities.

CJCA Executive Director Edward Loughran cites three common factors in overuse of restraint: overcrowding, high staff turnover and insufficient staff training.

Hodgepodge of Guidelines

To be sure, working with convicted, mentally ill and emotionally disturbed people can be dangerous. Many a youth worker has been attacked by a youth under her care; sometimes that youth is bigger and stronger than the worker.

Last year, a state caseworker in Atlanta was allegedly raped by a 14-year-old whom she was driving from a state facility to a group home. The youth, who was arrested, had been previously convicted of theft. In an opinion piece in The Richmond Times Dispatch in April, state Juvenile Justice Department Director Gerald Glenn wrote of an increase in assaults on guards that “demonstrate the danger of the job and the violent nature of some of the inmates.” He cited one youth who “bashed an officer’s head with a fire extinguisher,” another who tried to strangle a female officer with his hands, and a 16-year-old whose attack left a guard with “a metal plate in his jaw.” (It is unclear what precipitated those altercations.)

Last year Handle With Care, a restraint training program taught to numerous youth-serving agencies, created HWC Plus, a martial arts-based program designed for “life-threatening” situations. In such situations staff “need an effective offensive strategy,” Glenn wrote in a letter to department superintendents last fall announcing that his corrections officers would go through HWC Plus training.

The death of Dandridge sparked a public debate over restraint in youth facilities. Although Handle With Care President Bruce Chapman says Plus tactics “had nothing to do” with the Dandridge altercation, Plus is now under attack from youth advocates such as the Virginia Poverty Law Center and the Youth Law Center, and the state’s Board of Juvenile Justice. “You’re talking about authorizing them [guards] to hurt” kids, says Youth Law Center President Mark Soler, who is based in Washington, D.C.

In May Glenn rejected a board vote to suspend Plus training. The board plans to tackle the issue again at its September meeting.

The Virginia debate reflects the lack of consensus over what kinds of restraints are appropriate in various situations. State laws and regulations on restraining kids vary among and even within states, depending on the type of facility and the agency that places the youth there. A survey that the CWLA started last year found that “there is no consistency” in the laws that youth workers must follow, Bellard says. Restraining a youth to stop her from hurting herself or others is always allowed. But Kentucky also allows restraint “to prevent serious disruption of the facility’s program.” Michigan and Maine allow restraint to stop property damage.

Some laws are vague enough for youth workers to get in trouble. Virginia says restraints can be used “only after less intrusive interventions have failed or when failure to restrain a resident would result in harm to the resident or others.”

“That leaves a lot of gray area for judgment by the staff,” says Michael Farley, executive director of Elk Hill Farm, a 50-bed residential program in Goochland County for 11-to-18-year-old boys with emotional and behavioral problems. “If a kid is trying to run away, does he have the potential to hurt himself?” Elk Hill is surrounded by woods and fields, and the nearest main highway is two miles away; Farley has held kids to stop them from fleeing into that environment.

Similarly, there is no consensus in the youth work field over what restraints are proper for which youth and when.” It’s different from agency to agency,” says Bellard of the CWLA. “One agency can say we only restrain kids when they endanger themselves or others. You have others say if a child won’t go to his room after repeatedly being told to do so,” staffers can physically move him.

At some agencies, not all staff are clear what the policy is. When David Mandt & Associates held an advanced restraint training course this year for trainers from agencies, “we said we would like you to bring your policy and procedure manuals on restraint and use of force,” says company president David Mandt. Out of about 30 trainers who came, “very few” had such a manual. One common explanation: “We may have one but we don’t know where it is.”

“The big losers in this are the direct care staff,” Mandt says. They’re caught between doing nothing and risking a kid hurting himself or someone else, or stepping in and possibly harming the youth and risking legal action.

“There’s been a lot of litigation around restraint in juvenile facilities over the last 10 years,” says Randall Hines of San Antonio, Tex., a former youth worker who now serves as a consultant on youth restraint and has testified as an expert in restraint death cases.

“As soon as you put a scratch on a child, you’re dead in the water,” says Clarence Small, director of training at the Kansas City, Kans.-based Kaw Valley Center, which provides mental health, foster care, shelter and adoption services to 3,500 youth throughout Kansas. “It’s important that people have some type of training.”

The question is, what type?

A Menu of Tools

“We’re booked through this year and almost all of next year,” says Mandt. While Mandt and several other widely used restraint training programs have been around since the 1970s, the demand for their services has never been greater. “I just see it as the cost of doing business,” says January Scott, program director of the Kansas Children’s Service League, based in Topeka, which runs an array of youth programs including shelters, foster homes, adoption and family preservation.

That cost can be significant. The 49-year-old Texas Baptist Children’s Home — which has 78 long- term residential beds at two sites (Round Rock and Brenham), two emergency shelters and foster homes in several communities — figures that with registration fees ($800) and travel, it costs $2,000 to send a staffer for one week of training at the National Resource Center (NRC) in Tulsa, Okla. Then there are “recertification” and “refresher” courses, typically every two years. Therapeutic Crisis Intervention (TCI), run by Family Life Development Center at Cornell, charges $150-300 for one- and two-day update sessions for those who’ve already been through the five-day Training of Trainers.

To help allay the costs, most of the programs are actually “train the trainer” courses; staffers learn not only de-escalation and restraint techniques but also how to teach those techniques to staff back at their agencies. But the youth work field’s constant turnover means that trained staff, including the trainers, are constantly leaving agencies. “Over the last 18 months we’ve had significant turnover with our staff,” says Scott of the Kansas league. “One of the key areas is to stabilize your staffing and make sure they’re all well-trained.”

What are the agencies buying? Primarily, lessons in de-escalation: how to read the signs that a youth is agitated and how to calm her before she physically strikes out at someone.

“Once you put your hands on someone who is out of control, you’re in a very high risk situation,” says Holden of TCI. “We spend most of our time figuring out how to avoid getting into that situation.”

Sometimes that’s just a matter of noticing early when a youth is getting uptight, says Linda Steiger, president of Crisis Prevention Institute (CPI), based in Brookfield, Wis.: “It could be as simple as saying, ‘Hey, John, what’s up today?’ In a few moments he may be telling you, ‘My dad’s coming, my mom’s coming, I’m going to see doctor so-and-so and he makes me nervous.’ You’ve just de-escalated the situation.”

“If I walked up and said, ‘John, you’re making everybody nervous, sit down,’ I’m adding fuel.”

Even as the youth gets more agitated, throwing objects or threatening people, the stress is on calming him without grabbing him. Physical intervention is taught as the last resort.

Last Resort

Defining “last resort,” however, can be tricky. The easy standard is when the youth is “endangering self or others”; that is the standard that agencies and training programs commonly profess to follow. But while many facilities have “a policy about restraint being used as a last resort, that behavioral management and de-escalation techniques are supposed to be used first, that is not always the case,” says Christine Siegfried, senior community mental health consultant at the National Mental Health Association.

There is a gray area of behaviors that are not imminently dangerous but would prompt physical responses in all but ardent pacifists. “People say, ‘What if somebody spits on you?’” Mandt says, citing a common question in training courses. “I say, ‘I’d wipe it off.’ Just because you’re making faces at me and spitting on me doesn’t mean I have to run in and restrain you.”

Then there’s the TV room scenario: a youth is causing such a ruckus in a common area that it’s impossible for the other youths to do whatever they’re supposed to be doing. Efforts to calm and escort him out without touching him fail. Is it okay to physically remove him?

Although Steiger of CPI preaches the “endangering self or others” standard, she says holding and removing the youth in the above situation can be justified in order to avoid disrupting the facility, inciting other youths, or unwittingly teaching the other youths that one unruly person can control the environment. “What’s the alternative?” Steiger says.

“We may move the kids to another room,” says Mark Jones, director of Treatment for Group Homes at Boys Town, Nebr. Last year Boys Town served 1,561 youths in long-term residential programs around the country. “We would never physically intervene in the case of just noncompliance” with a staffer’s order.

He and directors at other programs agreed that no matter how good the staff is at de-escalation, some kids are going to get physical. Thus the training programs teach defensive moves to block punches and kicks and to release yourself from a grab or choke hold. When it comes to holding an out-of-control youth, they teach holds that rely on body position, balance and leverage.

Some moves are to be used with caution or not at all because of the risk of injury. (See story, page 43.) But no restraint is risk-free. “Anytime you put your hands on a kid it’s never going to go down the way you were trained,” says Farley of Virginia’s Elk Hill Farm, where staffers attend CPI classes. “In the classes it’s all simulated. You’re restraining an adult who’s role playing. When a kid is angry, acting out, he’s not role playing. There are body parts moving all over the place.

“The kid is not cooperating. He didn’t take the class.” That’s why some agencies try to avoid restraint altogether.

Restraint Free?

A “restraint free” movement is spreading among some youth-serving organizations. In Kansas, where the 26 member agencies in the Kansas Children’s Alliance have adopted Smith’s Peaceful Intervention Program, which teaches that physical intervention should not be necessary. Smith, a former teacher at the Menninger Clinic and former director of the defunct National Youth Care Training Center (part of the Villages, Inc., in Topeka), started PIP in 1994 after serving as a consultant to youth-serving organizations about how to deal with angry kids.

Smith charges that most training programs “empower [staff] to use force” on kids. “We’ve got to be the ones who don’t ever get physical with kids.”

Several Kansas agencies say they adopted PIP because of the increasing behavioral problems of their clients. “The kinds of kids we were getting were exhibiting behaviors where we had to restrain them more than we used to,” says Michael Patrick, former shelter manager for the Kansas Children’s Service League and now manger of its quality management center. The League wanted to restrain kids less.

Smith’s program is built on understanding youth anger and acting out, and on defusing situations through anything — negotiation, humor, time outs and diversion — other than grabbing a child. It instructs staff to use mattresses, pots and pans to shield themselves from attacks.

Boys Town teaches staff to block attacks and call police. “We would prefer that staff get themselves out of the dangerous situation, versus adding fuel to the fire by grabbing the child,” says Dan Daly, associate executive director of home campus operations for Boys Town.

At the Kaw Valley Center, where staff are trained in PIP, the non-intervention principle goes so far that training director Small says a kid throwing things around a room “is not considered dangerous to themselves or others” and therefore does not trigger restraint — unless “they’re throwing knives around the room.”

What if they are? The restraint free philosophy seems Pollyanna-ish considering that some kids won’t follow the de-escalation script. At Elk Hill Farm in Virginia, Farley recalls a youth trying to cut into his wrists with a pen. “A staffer had to remove the pen and hold his arms,” Farley says.

In Virginia, corrections officers testifying before the Board of Juvenile Justice in June cited a common problem in youth facilities — too many kids and too little staff — as a rationale for physical intervention. They said youth-to-staff ratios on some shifts were 40:1. “The bottom line is staffing,” one officer said. In Georgia, the Justice Department found that much of the excessive restraint “occurs during the lightly staffed third shifts.”

Priscilla Boudeiri, a lawyer with the Virginia Poverty Law Center, says overcrowding and understaffing spark confrontations between youth and staff: “Tempers are going to flare when you’re in a non-air conditioned, overcrowded room. You can’t sleep. There are not enough staff. The staff are asked to do double shifts. They’re exhausted.”

“The department [of juvenile justice] needs to address the root of the issue,” she says, “not try to add more tension” by teaching more ways to restrain kids.

Culture Shift

But while being restraint free is a goal, Mandt says, “having a 100 percent restraint-free environment is probably not going to happen.”

At Kaw Valley in Kansas, staffers who go through PIP get supplemental lessons on six holds for use when all else fails. While those holds are not taught by PIP, even the 60-page PIP “participant’s manual” has four paragraphs on stepping in to stop a youth who is hurting someone.

The point, say non-restraint advocates, is to talk about restraint as little as possible. “If you train people in the use of restraint, you find they tend to use it because it’s something you have authorized,” says Daly of Boys Town. “If you give people a hammer, everything begins to look like a nail.”

Reducing restraint use takes ”more than training,” says Holden of TCI. “You have to have some kind of organizational philosophy and support. You need monitoring and supervision” to establish de-escalation and non-restraint as the culture of the agency.

Simply sending staffers to class leaves lots of room for error. “You have a skill you learned a couple of years ago that you haven’t used, and all of a sudden you’re in a life or death situation,” says Hines, the consultant from Texas. “You’re going to use what instinctively comes to you.”

Another problem, Hines says, is that agencies stray from the training techniques they were taught. That appears to be what happened in the death of Timithy Thomas.

The Grandfather Home, founded as an orphanage in 1914 and now serving kids age 5-to-18, has been taking on an increasing number of youth with severe mental health needs. In the year prior to Timothy’s death, staffers restrained youth there 406 times, according to a report from the state’s Division of Social Services. The agency told investigators that it used Cornell’s TCI.

But a representative from Cornell’s Residential Child Care Project visited the home after Timithy’s death and discovered that the facility had created its own restraint system from various sources, creating a dangerous mix of sometimes contradictory lessons. The home’s included little of TCI’s de-escalation techniques, and included restraints that “had little or no relationship” to those taught by TCI and which “may be inherently dangerous,” according to a letter from TCI’s Holden to the Division of Social Services. While TCI’s training instructs the staffer to adjust her hold “if at any time the child says, ‘I can’t breathe,’” Holden’s letter says the home saw “I can’t breathe” as “part of the child’s manipulation repertoire.” While TCI instructs that a child be taken for a medical exam immediately after a restraint, and “should never be permitted to sleep or lay on the floor,” the staffer who held Timithy left him sitting on the floor alone.

The agency had to rewrite its behavior management policies, seek licensing as a mental health facility and try to reduce the use of restraints. Its accreditation — which some government agencies and managed care operations require — was suspended by COA. (The Joint Commission on the Accreditation of Health Care Organizations downgraded the home’s accreditation and recommended procedural changes.) The 27-year-old youth worker awaits trial for involuntary manslaughter. She faces up to 20 months in prison.

Resources

Dan Daly
Boys Town National Training Center
Boys Town Center
Boys Town, NE 68010
(800) 448-3000
www.boystown.org

Diane Kohn
Crisis Prevention Institute
3315K N. 124th St.
Brookefield, WI 53005
(800) 558-8976
www.execpc.com/ncip

Bruce Chapman
Handle With Care
Behavior Management System, Inc.
184 McKinstry Rd., Ste. A
Gardiner, NY 12525
(914) 255-4031
www.handlewithcare.com

David Mandt
David Mandt & Associates
P.O. Box 831790
Richardson, TX 750831790
(972) 669-1362
www.mandsystem.com

Martha Holden
Therapeutic Crisis Intervention
Cornell University
Martha Van Rensselaer Hall
Ithaca, NY 14853-4401
(607) 254-5337

Sidebar:

Fatal Hugs: The Most Dangerous Moves

Fatal Hugs: Restraint Laws Changing

Boyle, Patrick. "Fatal Hugs." Youth Today, September 1999, p. 1.

©2000 Youth Today. Reprinted with permission from Youth Today. All rights reserved.