State requires youth treatment facilities to tally use of force and isolation; data now made public
At 10 months of age, Jovanna Flenna picked up a hard plastic toy and threw it at the head of her sleeping father.
At 3 years old, an out-of-control Jovanna could terrorize an entire waiting room of children and adults - no matter what her mother did.
By the time Jovanna was ready to begin school, she had been diagnosed with Asperger's syndrome, which is a form of autism, and a mood disorder. Within a couple of years she went through 13 child-care providers and seven treatment programs, both residential and day treatment.
'Either we were told she could no longer attend there or there was abuse,' says her mother, Carrie Leavitt, who also is regional director for the Oregon Family Support Network in Multnomah County. 'When I look back, I think the abuse happened because her behaviors pushed the typical skill-level caregivers beyond the skills that (they) have.'
Leavitt says her daughter, who is now 11, was being physically restrained on a nearly daily basis at the psychiatric day-treatment facilities she attended between the ages of 6 and 8. Sometimes, those restraints would involve Jovanna being held face down on the ground with her arms held behind her for hours at a time. Staff members at the facilities would readily explain to Leavitt what they had done each day to her daughter, and tell her that there was nothing else they could do.
They were wrong.
Restraint, classified as physical contact that restricts the child's movement, often appears to the staff in treatment facilities as unavoidable. But experts say, there are alternatives. And restraint exacts a price.
New data is alarming
Until a few weeks ago, nobody in Oregon knew how frequently restraint and seclusion was used in children's psychiatric facilities in Oregon. But earlier this year, the Oregon Department of Human Services began requiring psychiatric facilities to report how often they were restraining children, and how often they were secluding them in secure, locked rooms. In November, the department began publishing the data on its Web site.
Human Services officials say the numbers, which cover the first three months of 2008, are alarming - not only for the frequency of restraint use they detail, but because they are so variable.
The Grants Pass-based Southern Oregon Adolescent Study and Treatment Center, for instance, has reported to Human Services that its staff restrained children 185 times and secluded children 181 times at the residential facility.
Jasper Mountain Safe Center School in Springfield and Trillium Family Services Parry Center for Children in Southeast Portland also reported high numbers.
Some facilities reported no restraints or seclusions at all for the same time period, and that also worries Bill Bouska, child and adolescent mental health services manager for the Human Services Department. Bouska says even the best trained staffs occasionally have to resort to physically restraining children, so he's guessing that some facilities have not reported accurately.
In fact, Human Services took steps in November to close down Pendleton Academies, a psychiatric facility for children. Among the reasons, Bouska says, was the facility's failure to report restraints.
The strict definition of a reportable restraint includes a hand on a shoulder or elbow trying to guide a child to where he or she needs to go.
But Carrie Leavitt says that, many times, the restraint episodes involving her daughter would begin with just that. Jovanna, like many children who suffer severe psychiatric disorders, would always fight against that touch - both at home and in facilities.
'As soon as you put your hands on her, she would become almost animalistic,' Leavitt says. 'She would appear completely focused on survival and getting out of the people holding her.'
Leavitt says every day Jovanna would return home from her day-treatment facility bruised 'from head to toe.' Today, in addition to treatment for her other psychiatric disorders, Jovanna also receives therapy for post-traumatic stress disorder brought on by years of being restrained against her will, Leavitt says.
Jovanna attends a day-treatment center and school that discourages restraint in favor of a model called collaborative problem solving. She has not been restrained or exhibited violent behavior in more than a year, her mother says.
Tracking data is important
Being able to track restraint and seclusion is an important step in bringing down the frequency of their use, Bouska says. He already has contacted at least one of the facilities that reported high rates of restraint. He says the facility is taking steps to decrease its use.
In addition, Bouska says, the first-time reporting numbers probably are inexact because facilities are not all using the same criteria when they decide which incidents constitute restraint. Those details, he says, will be worked out in the coming months.
Mark McKechnie, executive director of the Juvenile Rights Project, a Portland-based nonprofit that represents children in foster care and the juvenile justice system, says he is representing children who are being legally prosecuted after assaults on staff - incidents that began with restraints of the children.
'A lot of restraint, in my experience, resulted from power struggles, especially when working with adolescents,' McKechnie says. 'It's the training and the attitude of the staff that makes the big difference, not the issues that the kids bring.'
The Department of Human Services, McKechnie says, does not have enough staff to oversee facilities properly and ensure they are not overusing restraint and seclusion. Bouska agrees somewhat. Currently, he says, Human Services inspectors visit each facility for a site review approximately once every three years.
Also, McKechnie says Human Services is caught in a conflict of interest. More than half of the children in the facilities are wards of the state - foster children for whom the department is responsible and has a hard time finding placements.
'They're both overseeing these programs but also collaborating closely with them,' McKechnie says. 'They (Human Services) are part of the system. They want to maintain the infrastructure of their system, they want to have places for children to be served, and they can't go around shutting them down or closing off their referrals.'
But Bouska points to the department's moves to close the Pendleton facility as evidence that Human Services is willing to take harsh action when warranted.
Better systems being tested
McKechnie and Bouska agree that there are alternatives to restraining even the most emotionally explosive children. Locally, the Children's Hospital child and adolescent treatment program at Legacy Emanuel Hospital and Health Center is often cited as a leader in reducing the need for restraint among children.
John Custer, program manager for the Legacy program, says the collaborative problem-solving program instituted at his facility is not easy to maintain, and it is costly. But within a year of bringing in consultants who helped train staff in the program, restraint use dropped by 76 percent.
In November, Legacy's 17-bed psychiatric program, which treats some of the most severely disabled children in the state, did not have to resort to restraint at all. In some months, Custer says, restraint will be used a few times because it is unavoidable.
The collaborative problem-solving program is based on the idea that children have different sensitivities and triggers. For some, like Jovanna Flenna, that trigger can be a touch on the shoulder.
If staff members can learn what triggers out-of-control behavior for each child and avoid those situations, they have won half the battle. The other half is teaching children the skills they lack to be able to deal with their own triggers.
'You don't say, this kid is out of control, we're going to take him down,' Custer says. 'You move things out of the way. You try to decrease the stimulus around the person, and you give a little more leeway. A scream or a yell or spitting - that's not a reason to take someone down. In some programs they do that.'
Custer says Legacy's change took an upfront investment of tens of thousands of dollars, and a continuing investment as each new hire for the child and adolescent program receives specialized training as well.
The Department of Human Services believes in the collaborative problem-solving model, according to Bouska, and has held training seminars attended by a number of psychiatric facility employees. But the bulk of the expense of training staffs as thoroughly as Legacy's will have to come from the facilities themselves, Bouska says.
'It's costly, but it's the right thing to do,' Legacy's Custer says.
State threatens to decertify Pendleton Academies
Given the shortage of psychiatric facilities for treating children and adolescents, the state Department of Human Services is reluctant to close one down.
But three weeks ago that's exactly what the department proposed, when Human Services sent a notice of intent to revoke the certification of the Pendleton Academies.
The list of accusations against Pendleton Academies reads like a 'One Flew Over the Cuckoo's Nest' for the younger set. The facility first caught the attention of Human Services and the nonprofit advocacy group Disability Rights Oregon for its alleged inappropriate use of restraint and seclusion on children.
Jim Wrigley, staff attorney for Disability Rights, says that restraint led to a client being arrested by Pendleton police.
Police, Wrigley says, should only be called to a psychiatric facility as a last resort.
But apparently police were called to Pendleton Academies frequently. According to Bill Bouska, child and adolescent mental health manager for the Department of Human Services, the Pendleton police chief identified the facility as Pendleton's hottest spot for police activity - with more than 100 police calls in a six-month period.
'It wasn't the local bar, it was this program,' Bouska says.
Pendleton Academies was not reporting its restraints and seclusions to Human Services as state law requires, Bouska says.
In August, the Human Services department told Pendleton Academies it had found numerous problems that needed fixing. The department shut down new admissions to the facility, which normally has about 40 residents. But that didn't seem to have the desired effect, Bouska says.
Two major incidents were alleged to have taken place since. In one, a 17-year-old boy resident coerced a 13-year-old girl resident to have sex. The facility's lack of supervision, according to the Human Services notice, allowed the event to occur.
According to the notice, on Nov. 19 the department received a report of a Pendleton Academies proctor parent 'dragging a child by his arm, on the ground, from his car to the program's residential unit.' Proctor families, part of the Pendleton Academies program, board children who attend day treatment at the facility.
Terry Edvalson, who took over as interim executive director in August, says Pendleton Academies reported both incidents immediately to state officials.
Edvalson says he was told by authorities that the dragging incident did not 'rise to the level of abuse.' And, Edvalson says he is making sure that the children are being removed from the proctor family. Staff members who were responsible for oversight when the sexual incident occurred have been fired, Edvalson says.
Edvalson says Pendleton Academies is appealing the proposed decertification.
'We operate on complete transparency,' Edvalson says. 'I think we're being judged by the actions of previous administrators who were dismissed by the board of directors.'
Bouska says that if Pendleton Academies had addressed Human Services' original concerns, the proposed decertification, which would essentially close down the facility, would never have been sent out.
In response to accusations that Human Services is reluctant to close facilities it desperately needs for children who are wards of the state, Bouska says, 'I think our actions with Pendleton Academies show we won't sacrifice children's safety for maintaining a resource.'
- Peter Korn