The Arizona Daily Star, Manch 8, 1998No method of restraint totally safe, experts say
By Rhonda BodfieldThose who make their livings teaching others how to restrain unruly children agree on a few points:
There is no such thing as a safe restraint.
Patients should be physically controlled only as a last resort.
The intent of the restraint should be therapeutic and not to cause pain to the patient.
At the Desert Hills Center for Youth & Families in Tucson, 15-year-old Edith Campos was restrained by employees on Feb. 2. She died two days later at a hospital, where she had been on life support.
According to a police report, she was restrained after refusing to give employees a family photograph she was holding.
According to Child Protective Services records, a male employee ``laid over'' Campos, trying to restrain her arms and upper body, while a female employee held her legs and feet. Police are investigating whether Campos died of asphyxiation.
Officials at Desert Hills, a behavioral treatment center for youths, won't comment until the investigation by police and state agencies into Campos' death is completed.
However, the center filed a draft action plan Friday with the state, pledging to review and revamp its restraint policies.
The center accepts patients from sources including the Department of Juvenile Corrections, Child Protective Services, the health insurance plan for the military, managed care companies and other hospitals.
The facility has maintained in materials provided to state licensing agencies that it uses force only when the patient is creating a danger or attempting to run away.
State records, though, show some Desert Hills employees have been quick to use force to get the upper hand in power struggles.
For example, CPS determined that a teacher engaged in a fight with a girl because she refused to cooperate in math class in November 1995. The teacher - who threatened to drop the girl ``like a sack of potatoes'' before bringing her to the ground - was Desert Hills' trainer in the use of physical restraint. The girl received injuries to her nose, lips and back.
Desert Hills, which changed owners last November, told the Department of Economic Security on Friday that it restrained patients 107 times in January. The facility had about 140 patients.
Desert Hills' parent handbook stresses that although restraint may be used, it is ``only as a last resort and is not to be employed in a manner that may cause risk or pain.'' Yet state investigations have confirmed cases of abuse where the restraints were clearly painful.
Crisis Prevention Institute Inc., the company that trained some of Desert Hills' employees and certified the teacher in the 1995 incident, emphasizes exhausting alternatives before turning to force. CPI materials warn of potential liability because restraints can be dangerous to the patient and to the staff.
``But equally important, you don't want to use a hands-on approach until it is absolutely necessary because you run the risk of escalating a situation which might have been defused through verbal means,'' the chapter states.
Linda Steiger, president of the Wisconsin-based CPI, said the program does not train behavioral health employees to take patients to the ground. But that method, commonly used at Desert Hills, was the position in which Campos was restrained on Feb. 2.
CPI materials also forbid causing patients pain during a restraint.
Steiger refused to provide information on Desert Hills' training, saying those documents belong to the facility. But she said she has spoken with Tucson police detectives and private attorneys and will cooperate with their investigations.
The CPI program, founded in 1980, trains instructors who then go back to their communities to teach the control methods. Steiger estimated that 30,000 instructors have been certified and have in turn trained more than 2 million others in the United States and Canada.
The course teaches ``that if you're doing a hold, you're doing it because that individual has demonstrated they are injuring themselves or someone else,'' she said.
Wright Randolph, a CPI instructor and a Rural/Metro firefighter, agreed. He never worked at Desert Hills, but previously worked as a psychiatric technician at other mental health facilities.
``My mind-set was I got paid whether I was wrestling with someone on the floor or watching a movie. I'd rather keep it pleasant, because I've seen too many people hurt,'' he said.
Restraints usually do not improve children's attitudes, he said. Often it can become a show of force or a statement that the staff member is tougher. And if it is a one-on-one restraint, it can escalate into a fight - which has been the case in at least some Child Protective Services-verified abuse claims at Desert Hills.
A floor restraint takes away dignity, and that's how the majority of injuries occur, he said.
The children at such facilities are not easy to handle. Randolph recalls one patient threatening to kill him when he got out. Another girl jammed a pencil under the skin of her arm along the vein.
But, Randolph said, most of the time skilled employees don't have to touch the children. He had a few basic rules. Let them go if they haven't done anything to hurt themselves or others. Never touch someone in a defensive mode. Remember that words are just that.
``If you're wound up and yelling at me, my touching you is only going to make things worse. It's all a matter of how you talk to these kids,'' he said.
Deaths during restraints are not unheard of.
In San Antonio last August, a 16-year-old girl died after struggling with staffers at the Laurel Ridge Residential Treatment Center, which has no affiliation with Desert Hills. The girl had been pinned to the floor, face-down, with her arms crossed in front of her. She was given a tranquilizer injection and died within minutes.
Bexar County Medical Examiner Vincent DiMaio ruled the death natural. He said in an interview that the autopsy and toxicology reports failed to show a cause of death. The girl did not react to the medicine, he said.
Since the girl's father had died at a young age from an irregular-heartbeat condition, he made the assumption that she, too, died of a cardiac problem, even though there were no physical signs of heart disease.
In June 1996, a 31-year-old woman died after being mechanically restrained at a Virginia state hospital. Her doctor warned the workers not to restrain her, saying, ``Those in charge must always remember that following physical struggle and emotional strain, a patient may die in restraints.'' He wrote that her asthma and epilepsy could make that more likely.
David Mandt is the creator of the Mandt System of physical restraint, which is used by various juvenile corrections and behavioral health facilities throughout the country.
Mandt said no restraint is entirely safe, no matter how much training people have. Typically when people are restrained, their blood pressure and adrenalin increase, Mandt said.
``Unless somebody's life is in danger, we feel the best thing to do is to back off and give a person a chance to calm down,'' he said.
He said the staff's interaction with the patient could determine whether the patient calms down or loses control. Typically, the loss of control corresponds to whether the facility is understaffed, whether employees get adequate training and whether direct-care staff members are paid menial wages, he said.
Mandt said his program does not teach employees to take patients to the floor, because of fear the employees will throw or trip people to get them there.
So what happens if a patient is mouthing off? Let him, he said.
And what if a patient is being held and continues to struggle?
``Let go and back off. If they're trying to get away from you, sometimes all they want to do is get away, and then they de-escalate because they won. But staff sometimes doesn't get that concept, and it becomes a tug of war,'' he said.
Maj. Mark Phelps, chief of security for the Arizona Department of Juvenile Corrections, maintains that restraints are used only when juveniles pose a risk to themselves or others or state property.
Phelps also said the department discourages employees from doing solo restraints. For that reason, it doesn't teach the basket hold, which is one of three physical controls used at Desert Hills. In that restraint, an employee stands behind a patient, holding the patient's arms in a crossed and locked position.
``With just one (employee), I might have to use more force than I wanted to get you under control,'' Phelps explained. He also said that when employees are tested in physical restraints, the instructors ensure they don't lean their body weight into the juvenile.
But the bottom line, he said, is ``any time you have to physically restrain someone, no matter how good you are or how good the technique is, there's a danger something physiologically can go wrong with you or the person you're trying to restrain.''
Still, the Department of Juvenile Corrections in 1997 had to use physical force 979 times throughout its four juvenile facilities - Adobe Mountain, Black Canyon, Catalina Mountain and Encanto. In 1996, it used physical force 560 times. The system now houses about 950 juveniles in its facilities.