Restraints still cause injuries in DCF psychiatric facilities

Todd was agitated, and the effort of the staff at Riverview Hospital to calm him down weren’t having any effect. As the confrontation escalated, aides did what they were trained to do: physically restrain him, face down against the floor, in hopes that would defuse the situation.

But as in many similar cases, during the 25 minutes of being restrained Todd was injured, according to a serious injury report filed by the Department of Children and Families in August. The 14-year old boy with numerous psychiatric disorders was put in a wheelchair and taken to his room to be treated for a sprained ankle and injured wrist.

“Purple bruises, lacerations, broken arms, broken legs, a child ending up unconscious, I’ve heard it all,” said James McGaughey, director of the Office of Protection and Advocacy for Persons with Disabilities. “There’s always that risk every time you use physical intervention. It’s a violent struggle between two people and kids end up hurt.”

The harmful affects of using physical restraints have been well documented; national experts, child advocates and officials at the Department of Children and Families all acknowledge that children should be restrained only when there is immediate risk of bodily harm.

But McGaughey and the state’s child advocate Jeanne Milstein say even after the high-profile death of Bridgeport foster child Andrew McClain more than a decade ago while being restrained by workers at Elmcrest Psychiatric Institute in Portland, not enough has changed.

Data provided by the Department of Children and Families show the agency has reduced the number of times children with mental illness were restrained at the two state-run psychiatric facilities over the last five years. At Riverview Hospital in Middletown, for every 1,000 days of care they provided children there were 52 incidents of a child being restrained in 2006. By 2010, that number was cut to 32 incidents for every 1,000 client days, or 878 incidents throughout the year. Connecticut Children’s Place in East Windsor used 29 restraints for every 1,000 client days in 2010 compared to 45 back in 2006.

There has been considerable progress in one area: The department has significantly reduced the use of mechanical restraints, where children are strapped down to a bed for extended periods of time. This type of restraint is the most troubling to child advocates.

According to DCF records, there were 485 instances at Riverview of children being tied down in 2005. By 2010 there were only 20 instances.

But McGaughey said even with these improvements, the incident reports DCF is required to file show children continue to be seriously injured at the institutions. In 2004, there were two reports of “serious injuries” caused by restraints at the two institutions, in 2008 and 2010 there were three a year and in the first three months of this year there was one.

“And we just get the reports about the serious injuries… This pattern of children being seriously injured in DCF [custody] has remained unchanged,” said McGaughey. “There is this generic and cultural response from the facility staff when situations escalate and the problem of children ending up injured because of that is still there this many years later.”

He says face-down restraint techniques like that used on Todd, known as prone restraints, are the No. 1 cause of injuries.

“It’s dangerous. There is no shortage of evidence from experts that this is not the best approach,” he said. “After all this time there really hasn’t been any real change on how they are restraining kids.”

State Child Advocate Jeanne Milstein agrees.

“This is a very dangerous technique. It needs to end,” she said. “It’s a violent interaction 100 percent of time. They should not be laying their hands on a child.”

Prone restraints are blamed for the deaths of at least 48 juveniles from 1998 through August 2006 nationwide, according to the Coalition Against Institutionalized Child Abuse, a nonprofit organization that monitors the use of restraints.

Death is most often caused by adults accidentally compressing a child’s chest and cutting off his air supply. A Cornell University study cited this as the reason for death in 28 of the 44 cases reviewed.

McGaughey said because the child is face down, it is hard for staff to see signs of distress or they improperly apply pressure that leaves the child with bruises or broken bones.

States including Pennsylvania and Ohio have banned the practice altogether, but not without opposition: Some officials in Pennsylvania argued against the ban imposed in 2008 that psychiatric workers would be injured as a result of being forced to use a less-restrictive option where a child can still physically harm staff or themselves.

The Connecticut Connecticut Department of Developmental Services, which provides care to children with mental health needs that are not in the state’s custody, outlawed the use of prone restraints back in 2007.

McGaughey and Milstein said they are still waiting for DCF to follow suit with an identical prohibition–or, even better, for state legislators to create a law to ban the practice statewide so schools and prisons are also forbidden from doing this.

“They haven’t been very receptive,” McGaughey said.

But Muhammad Waqar Azeem, the medical director at Riverview, and Michelle Sarofin, the new superintendent of the recently merged Riverview and Connecticut Children’s Place, indicated during a recent tour of Riverview that may soon change at DCF.

“We don’t disagree that we need to end that [practice]. That is the next step,” Azeem said.

DCF officials announced last month they plan to release a report on the use of restraints on Oct. 1.

Changing a culture

There is no dispute that the use of restraints at DCF-operated facilities has declined in recent years, but Milstein says the department is still far behind the private providers.

“They still rely on restraints, it’s engrained in the culture at DCF,” said Milstein. “If private hospitals can have only one or two incidents [a month] then why can’t we?… I’m afraid they are using it as a first resort instead of a last.”

Numbers provided by OCA and DCF show the use of restraints at DCF facilities has declined, but a June 2009 report on the topic from Milstein showed DCF was still relying too heavily on restraints. She says that still is the case.

“There is no reason for their numbers to still be this high,” she said. “We are talking about little children being held down by two or three adults. How therapeutic do you think that can be?”

Sarofin said DCF is still committed to bringing the numbers down even more.

“It is something we try our hardest to avoid,” she said. “Our goal is to reduce how often it happens.”

Janice Gruendel, the deputy commissioner of DCF overseeing mental health, said there is much more work to be done.

“We don’t want to ever do this. It’s no where near as low as we want,” she said.

Azeem highlights the Department’s approach to reduce the use of restraint in a recent report in the Journal of Child and Adolescent Psychiatric Nursing.

His report shows during a 33-month time frame one out of every six children admitted to Riverview was at some point physically restrained. And these incidents weren’t one-time events: During the average 71-day stay, these children would be restrained or put into seclusion about three or four times each.

He said the department has begun implementing strategies recommended national experts to help them make a sizable reduction.

But Milstein said she is still waiting for this new strategy to result in a significant reduction.

“Training staff to use other methods is only as good as the implementation, and it hasn’t been implemented effectively,” she said.

Sarofin said regardless of the fact that every employee that deals with children will receive training on how to defuse volatile situations, it’s difficult to change employees’ mindset.

She recalled an incident from when she first started at Riverview in 2006.

“A child was getting upset and instead of trying other proven successful things to get the situation under control, staff automatically pulled the [mechanical restraint] bed out,” she said. “We made it clear early on that bed would no longer be the routine.”

That bed has since been disassembled, painted and turned into “healing” bench for residents to relax on at the Middletown campus.

“We turned something bad into something good,” Azeem said.

But Milstein and her associate child advocate Mickey Kramer said that’s still not enough.

“They still have one of those beds,” Kramer said. “They need to get rid of it.”