Kids restrained at Staunton mental health hospital for safety

If anyone in the area knows what restraint means, it’s the trained staff of the Commonwealth Center for Children and Adolescents.

If anyone knows what it means to be restrained, it’s the teenagers who reside there.

This year alone, children staying at the Center have been placed in mechanical restraints 621 times. The state facility serves children who need mental health in-patient care, and often don’t have access to a hospital using private insurance.

That’s almost three instances a day of the use of mechanical restraints in a facility that houses no more than 48 children at a time.

This does not count uses of physical restraint (a staffer using their body) and seclusion, which are also used on-site.

The Commonwealth Center is not your average educational environment. A patient in, for instance, a full schizophrenic episode, might not be fully aware of where she is or what her body is doing. It’s a challenging environment to keep the children and staff safe in — hence the use of these methods.

However, the children who are patients sent there to get well continue their education in-patient and teachers operate classrooms there. It is a clear example of how the culture of restraint is still in existence in Virginia, where upward of 80 percent of incidents of restraints in some years have occurred in special education environments and with “challenged” students. That’s based on statistics from the Civil Rights Data Collection.

The kids at the Commonwealth Center have been “pre-screened and determined to be in danger,” according to the Center’s website. They are ill — like children at Augusta Health with a physical illness — but require psychiatric health care due to the diagnosis they have.

They may have threatened or attempted suicide. They may exhibit aggressive and even assaultive behavior due to their mental illness; and there’s a need for evaluation and medication management, according to the site.

The Commonwealth Center for Children and Adolescents
(Photo: File/The News Leader)

There’s also a need for safety on the part of the staff, who work under the daily concern of injury on the job perpetrated by sick children who need care.

Critics of the use of restraint and seclusion point to studies showing that seclusion and restraint can be negative reinforcement for continued self-destructive and violent behavior. Oversight of the use of these strategies is not transparent to the public, a News Leader investigation found.

In a part of Virginia with a long history of disputed psychiatric and medical practices, the debate over treatment — in this case, restraint and seclusion — is nothing new.

“Seclusion and restraint has been used in hospitals for many many years,” says Marion Greenfield, director of facility quality and risk management at the Department of Behavioral Health and Development Services, which oversees the operation of the Commonwealth Center. “I don’t know how far back it goes. They have used one form of restraint or another well over 100 years in our facilities. However, in the last few decades it has been highly regulated.”

Restraint has been used at state Behavorial Services facilities for a very long time. Anyone who is part of a patient’s clinical care — nurses, doctors, anyone with contact with a patient — receives training through a contractor about how to manage the children.

The two-day training for new employees, which stands for Therapeutic Options for Virginia, includes a written test, which trainees must score 85 percent or better on, and an exam based on the physical restraint demonstration.

The TOVA training covers more than just restraint. It’s about having “verbal listening and relationship skills to use before any restraint or seclusion is used — that’s the last resort,” says Mary Clair O’Hara, quality and risk program manager for the state. “Physical restraint is only used if that person is going to harm themselves or others.”

There are 10 instructors in the patient crisis management training system, and they are the only people who can train the classes. Administrative staff gets the training too, says O’Hara.

O’Hara’s description of the restraint training affords one of the only glimpses the public is likely to get into the techniques of restraint.

Even admitting the existence of the possibility of restraint in public schools was something that the head of communications of the state Department of Education, Charles Pyle, was reluctant to say during an interview with The News Leader.

The names of the restraints are a rare glimpse for the public into these techniques: trainees are taught the standing restraint, the side body, the lift-and-carry.

Something called the “standing wall restraint is used at facilitates to administer court ordered medication, according to Greenfield.

Greenfield would not share the instructor manual on the restraint methods — because of the contract they have with the training provider, she said.

Greenfield and O’Hara stress that the decision to apply restraint is not made lightly.

“It’s a clinical judgement that has to be made by the physician along with the nurse,” says O’Hare. They determine the safest approach for that individual, seclusion or restraint.

“If you have someone who is trying to harm themselves, you would not put them into seclusion,” O’Hara says. “A nursing assessment is required and a physician assessment is required before any physical restraint takes place.”

When a person is trying to harm others, both seclusion and restraint are options.

“There are regulations regarding what seclusion rooms look like. They must have a window, must be safe so there is no risk to the individual like the hinges to hang themselves. They have to be a minimum size,” says O’Hara.

If staff must step in after non-physical options have failed to de-escalate a situation, what determines the method that will be used?

“That determination is a clinical determination based on the physical well-being and the type of behavior they are expressing. It’s important they (staff) always select the least restrictive option,” says Greenfield.

TOVA training covers that attempt at de-escalation before any restraint is used, says O’Hara, “because it emphasizes the relationship, the communication, listening. There’s a lot to the prevention and intervention leading that is used as training prior to any kind of form of restraint is used.”

A staff member could help redirect behavior, help a teen in crisis regain composure based on talking to them or engaging them in something else.

“The goal is always to not use restraint-“ Mary Clair O’Hara started.

“— or to use it as a last resort, and to use it for the shortest time possible,” Marion Greenfield finished.

Restraint is something on the books in standard public school in the area also:

How ‘restraint’ is defined in your school district’s policy

The News Leader reported in the first story in our series on restraint and seclusion that all three local school districts — Augusta County, Waynesboro, and Staunton — have policies on the books dealing with restraint and seclusion.

All three districts reported that they currently make use of the MANDT System to de-escalate crisis situations and that they no longer use restraint or seclusion of any kind in dealing with crisis situations with students.

All three reported no incidents in the last five years.

Staunton and Waynesboro’s policies mirror proposed policy language crafted by the Virginia School Board Association, and here’s how they define various forms of restraint:

Physical restraint. According to the Staunton and Waynesboro policies, physical restraint “means the use of physical force to restrict the free movement of all or a part of a student’s body.”

There are a list of specific plans and “procedures to provide assistance, guidance, support and protection from harm” to students that are excluded from that definition — for instance, grasping a student to help them regain their balance and other commonplace uses of physical intervention.

Mechanical restraint. Simply put, mechanical restraint means “the use of any device or material attached to a student’s body that restricts freedom of movement or normal access to any portion of the student’s body and that the student cannot easily remove.”

The key elements are that the device or straps are not easily removable by the student and that they restrict freedom of movement. Again, the use of devices that are part of a consent-based individualized education plan, or of more commonplace forms of helping a student temporarily maintain balance if they are disoriented or dizzy is not considered a use of a mechanical restraint.

Seclusion. Seclusion is defined as “the confinement of a student alone in a separate enclosed space, in a manner that prevents the student from leaving.”

According to the policy language, seclusion should only be used when necessary “to prevent injury to the student or others.” Even then, a student in seclusion should be monitored constantly by a staff member in close proximity, and released whenever the student stops the behavior which caused them to be placed in seclusion.

Placing a student in a room alone to wait for their parents or a teacher, or in detention, is not considered seclusion.

The Augusta County policy, added in 2006, mentions only physical restraint in its language.

Staunton and Waynesboro policies, dated 2010 and following the design of the Virginia School Board Association, state that restraint and seclusion can be performed only by trained staff. Augusta County’s language does not define physical restraint or require training for a school employee to use physical restraint.

All three policies require notification to parents of any use of restraint or seclusion “within a reasonable time,” although that time frame may be up to 15 days from the incident.

The three local policies can be found in full here: Staunton policy, Waynesboro policy, Augusta County policy. 

Avoiding even talking about restraint

Nobody likes to talk about the use of restraints on children. 

Local school districts appear to be ahead of the curve on the elimination of restraint as an active measure taken against students in crisis.

But only Waynesboro responded to requests for more information on what steps are taken if they cannot de-escalate a crisis situation in a hands-off manner.

“When a situation cannot be de-escalated, our staff calls the office for assistance, removes other students from the classroom, and monitors the student’s behavior,” Waynesboro Schools Director of Student Services Ryan Barber wrote in an email. “If at any point the student attempts to injure themselves, others, or significantly destroys property then a trained MANDT System staff member intervenes.”

Barber stressed that the purpose of the training is to limit those situations. “As always, our goal is to maintain the learning environment while keeping our students and staff safe.”

“The student’s parents are always notified if a significant incident occurs,” Barber wrote. “On a rare occasion, the police department is contacted for assistance.”

Meanwhile, at the Department of Education, it’s hard to get an answer to an even simpler question than Barber had to answer.

In response to the question “Is mechanical restraint still allowable in public schools?” Julie Grimes, Communications manager for the Virginia Department of Education wrote: “Not if it constitutes corporal punishment or child abuse or a criminal assault.  There may also be grounds for a civil action by a parent. It is possible that there might be some instance of mechanical restraint that is none of the above.”

In other words, if it’s not some other recognizable crime, then it’s allowable. The thousands of incidents reported by public schools each year fall into that category.

Charles Pyle, director of communications for the Virginia Department of Education, added in an email: “There is currently no prohibition in state special education law or regulation. However, as Julie pointed out, there are other state laws that prohibit corporal punishment and abuse.”

An entire chapter of new regulations to the Virginia Administrative Code has been proposed that would explicitly prohibit mechanical restraints and further define the role of seclusion in public schools.

But passage of that proposed chapter, which has been making its way through the regulatory process for years, is still “months away,” according to Pyle.

Parents, don’t try this at home

This is not to say that you should consider it OK to strap your child to a chair at home any time soon.

In Virginia police are sensitive to parents’ rights to discipline their children. But police responding to a call and finding a child bound by their parents in a chair would have to do a lot of work to ascertain what was going on, according to Sergeant Katie Shifflett of the Staunton Police Department.

Police try to understand what Shifflett calls “the totality of the circumstances” in such a situation.

“Why was the child being  restrained? There’d be a lot of questions the officers would have to investigate,” Shifflett said in a phone conversation. “Certainly the officers would be trying to determine what would cause this situation to escalate to the point where a child is being restrained like that by their parents.”

Outside agencies such as Virginia Community Service Board or Child Protective Services could become involved, according to Shifflett.

In the case of an attempted suicide, an emergency custody order could be generated to provide the child proper treatment.

“Officers can develop probable cause, they can make an arrest, but in a situation like this, I as a supervisor would want to see clarification from the Commonwealth’s Attorney” about potential charges, Shifflett said. “It all depends on the totality of the circumstances.”

For the children at The Commonwealth Center it’s not clear yet if changing regulations will diminish the frequency with which they are exposed to methods of restraint, either on themselves or seeing other residents restrained or secluded. 

And the police won’t be trying to figure out the totality of circumstances behind each incident, either. 

More: Thousands of kids put in restraints or seclusion each year in Virginia schools

Coming up: Will proposed changes to regulations be enough to rein in use of restraints against children?

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