IN HARM'S WAY
By Barbara White Stack, Pittsburgh Post-Gazette
Third in a series
Tuesday, September 20, 2005
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.
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.'