Something as simple as a dispute about a piece of cake or as ugly as a trash can planted on a spitting child's head can lead to confrontation, injury and trauma for children in state-licensed facilities.
In moments of danger, workers in residential programs are permitted to physically restrain the youth in their care. Laying hands on a child almost always involves a struggle, though, and it is not uncommon for children -- and staff -- to get hurt. Sometimes, they walk away with bruises. Other times, they leave in ambulances, nursing concussions or fractured bones.
In 2006, the Pennsylvania Department of Public Welfare began a campaign to reduce such incidents in the private residential facilities that care for abused and neglected children, juvenile delinquents and other youth with profound needs.
"Nobody goes out and wants to hurt kids. I believe that in my heart," said DPW policy director Angela Logan. "I believe it was a perfect time for the providers and the state to get together -- and the family members -- to learn from one another."
In many of Pennsylvania's 767 residential programs, staff restrain children less often now. The total number of youth injuries reported to the state declined 7 percent between 2008 and 2010, though the number of youth in residential care also dropped significantly over that period.
But 361 incident reports obtained by the Post-Gazette show that children in residential facilities continue to face danger at the hands of staff members and peers, as well as their own. According to these reports, there were at least 264 injuries to children living in Western Pennsylvania programs between January 2005 and December 2010, including 17 bone fractures, four broken bones and 18 lacerations deep enough to need stitches. Most of these injuries were related to restraints. Recent reports show that some staff members still restrain youth for offenses like "aggressive posturing," despite repeated state bulletins reminding providers that restraint is "an emergency measure of last resort."
"We haven't moved as much forward with it [as I'd like]," said Marcia Sturdivant, head of Allegheny County's Office of Children, Youth and Families. "They have some challenging work. And it's not the worst, but it can certainly get better."
Dr. Sturdivant gasped as a reporter read some of the incident reports to her. "Oh my goodness," she said, reacting to documentation of a supervisor who "removed child from his personal space" during a verbal dispute. The girl's back hit a file cabinet; a laceration to her head was stapled shut.
"You don't remove kids from abusive situations to be re-abused," Dr. Sturdivant said. "It makes the people who work very hard to do the right thing; it makes the work that much more difficult for them."
A Post-Gazette review of the reports, as well as interviews with officials, parents, youth and staff, suggests that years of good-faith efforts to make institutionalized children safer have collided with practical barriers, entrenched staff cultures and, increasingly, a bleak financial reality for these publicly funded entities.
Complicating the matter, the DPW requires providers to report just a small subset of restraints and youth injuries, and did not compile the injury data until the Post-Gazette requested it, making it hard to evaluate state initiatives.
"I think we've done a lot better over the last six or seven years," said Allegheny County Common Pleas Judge Kim Berkeley Clark, who sits on juvenile court. "But we still have a ways to go."
Cynthia Allen, who lobbied for reform after her 16-year-old son died in a restraint in Lancaster County in 2006, said she is losing patience.
"This could have been your child," said Ms. Allen, of Bethlehem. "This could have been his son, or his brother, or his nephew. Anyone has the capability of having a relative go to one of these places."
No one disputes that the work of residential providers is tough.
"One of our typical clients is a combative client," said Gene Wisinski, CEO of Bethesda Children's Home in Meadville. "When they get frustrated, or feel disappointed or rejected, they've got a lot of issues that can bring about that aggressive behavior."
If a child moves to hurt someone, workers are permitted to use their hands to restrict the movement of the child or hold the child on the floor. The procedures are intended to protect; Restraint should be used only "to prevent a child from injuring himself or others," according to state code.
In this unpredictable line of work, restraint is a necessary tool, said Peggy B. Harris, president and CEO of Three Rivers Youth, a Pittsburgh-area provider.
"If somebody just mandated we would never put our hands on a child, I think that is an admirable goal to set, but not a realistic one ... ," Ms. Harris said. "Some of the work that we do in group home care, it's a contact sport."
From 2005 to 2010, children in Allegheny County facilities were hurt at least 123 times during restraints, according to incident reports and individual stories. Some injuries were minor: scratches, brush burns. Others were serious.
Danny's case fell in the middle. A boy removed from his mother's care after she developed a drug addiction, Danny was living in McKeesport last June, at a facility called Auberle, when he argued with a staff member about cleaning his room, he said. The staff member restrained him. Danny, then 12, ended up with a painful, bloody-looking eye: a blotch of red eclipsing the white. (The Post-Gazette is withholding Danny's last name to protect his privacy.)
The way Danny, now 13, tells it, the staff member flipped a chair over during the restraint, hitting him in the face.
Auberle does not dispute that Danny was hurt. Nurses evaluating the boy found a scabbed abrasion above his eye, abrasions and pink skin below and bleeding underneath the eye's membrane.
The facility's documents note nothing about a chair, though. Nothing about a messy bedroom. Danny was restrained because he hit a peer with a trophy, Auberle CEO John Lydon said.
Before restraining a child, staff must "anticipate and de-escalate" the situation using other methods, according to state regulations. Mr. Lydon said his staff tried other ways to calm Danny, but failed.
"DPW's been called, done an investigation and long since left," Mr. Lydon said. State investigators determined that report of abuse was unfounded.
To Danny's grandmother, a Penn Hills woman with custody of five of his younger siblings, the result of the investigation felt deeply unfair.
"I gave them to CYF so that they could take care of them for me, not abuse them," Dorothy Guy said, referring to Danny and his older brother, who has also lived in a residential facility. "They gave me their word that they would not injure them."
Each year in Pennsylvania, there are more than 1,000 reports of alleged child abuse at residential facilities. Incident reports indicate that many of these, but by no means all, are related to restraints. The state requires "substantial evidence" of abuse to deem a report "indicated" and a criminal guilty plea or conviction to deem a report "founded." All other reports are marked unfounded. Last year, 98 percent of the reports from residential facilities fell in the last category.
"Most of these allegations are not valid," said Charles Lockwood, president and CEO of Glade Run Lutheran Services, a provider in Zelienople. "It's part of the psychology of the kids at times."
Indeed, numerous incident reports obtained by the Post-Gazette describe children trying to get staff members in trouble.
During a 27-minute restraint last year at the Bradley Center in Robinson, a girl told staff members: "I'm going to get you fired. I'm very good at it. I know what I'm doing," according to the facility's report. The next day, she claimed that a staff member had punched her in the eye, kicked her, choked her and bashed her head against the wall.
Staff do not always tell the truth either, though, according to a former worker at a local facility, who spoke anonymously.
The former staff member, still in the child welfare field, said there was an "unwritten rule" in residential care: "It's never what you do, it's how you and your partner write your report."
"I have definitely wrote my share of reports where, you know what, did it really happen that way? No it didn't," the former worker said. "Was there a thing or two omitted? Yeah, maybe."
Sometimes, staff bribe children to stay quiet, promising perks or privileges, said Antonio McCaskill, a former foster child from Philadelphia.
Mr. McCaskill, now 21, said he was frequently restrained and sometimes hurt while living at a facility in Hazleton: "I got slammed into a pool table. I got choked. It was very brutal."
He did not talk about it.
"I really wasn't able to tell my people," Mr. McCaskill said. "Either I was afraid or I was afraid of the repercussions of the situation."
Judge Clark said it can be complicated to get to the truth.
"The bottom line is, if I feel a kid's not safe, I'm going to pull a kid from a program," she said, "And sometimes, quite frankly, I have chosen to accept the word of a child over the provider."
In 2005, a Post-Gazette investigation found that children suffered repeatedly at homes licensed by the DPW. The state did not keep computer records or analyze data about such incidents, but the Post-Gazette determined that there were numerous injuries at Allegheny County facilities during the previous seven years, many related to restraints.
At the time, DPW Secretary Estelle Richman told the Post-Gazette that she wanted to reduce restraints "to practically zero."
The DPW took action in January 2006, issuing a "special transmittal" to providers clarifying that restraint is "an emergency measure of last resort." The bulletin advised providers that the DPW was working to create a data system "to measure the reduction of restraint statewide."
Officials began to travel around the state, engaging providers in tough debates, said Ms. Logan, the DPW policy director.
"The challenge that we had is it's so easy to come in after an incident and second-guess everything that was done," said Bernadette Bianchi, executive director of a membership association of private providers, the Pennsylvania Council of Children Youth and Family Services.
"At one point, the edict was 'no,' no hands-on anything," Ms. Bianchi said. "And then there was a lot of dialogue: 'Well, what do you expect staff to do if a youth is on the verge of hurting someone else?' "
In 2007, the DPW created the Home and Community Services Information System, a computerized process to replace pen-and-paper reports.
The same year, the DPW introduced a program called the Sanctuary Model to providers here. Participating agencies said Sanctuary certification helps facilities change their cultures, cultivating a nonviolent and "trauma-informed" environment.
The DPW sent the offer to join in to every provider in Pennsylvania, Ms. Logan said. Twenty-nine agencies were eventually selected to go through the process.
"It was a real partnership," Ms. Logan said. "It was tense, it was hard, but it was a partnership."
Ms. Logan said the initiative has been successful, with Sanctuary-certified sites experiencing less staff turnover, a decline in restraints and a drop in injuries from restraints.
Over the years, the "zero-restraint" goal was tempered, Ms. Bianchi said.
"I think that was kind of taken a little bit out of context," Ms. Logan said. "I think in a perfect world, nobody ever wants to be in a position where you have to restrain anyone. Just like I would want to win the lottery."
Ms. Richman, now chief operating officer of the federal Department of Housing and Urban Development, left the DPW in 2009. Through a spokesman, she declined to be interviewed, saying she believed her position and that of the current state administration are not aligned.
To participate in the Sanctuary Model, providers agreed to report every restraint.
Overall, the participating agencies reduced their monthly use of restraints more than 34 percent between January 2008 and February of this year, according to data provided by Ms. Logan. The average number of restraints per month per 100 residents declined 18 percent, meaning that the number of youth served must have fallen as well.
"These sites are proud of their restraint numbers," Ms. Logan said. "It's not like 10 years ago."
For the rest of the state's facilities, the DPW gathers information only on "reportable restraints," typically cases in which a child is hurt or someone makes an allegation of abuse. Providers must log all restraints for review during licensing inspections, but they do not need to submit that information to the state, DPW spokesman Michael Race said.
It would be impractical to require every facility to report every restraint, Ms. Logan said.
"If I put my hand on Mike and move him a little bit, technically, that could be considered a restraint. That's required in our regulations," she said. "They haven't been rewritten since 1997. They are rather an archaic package. The amount of reporting would be way too much."
As a result, DPW officials cannot say if the number of restraints has declined statewide.
Though the Sanctuary Model yielded results, the DPW has no plans to require the certification, Ms. Logan said.
"The thing about trauma-informed [care] is you can't require it," she said. "They've got to buy in. We sent the initial invitation to the providers, all 900 of them. Only 35 applied."
Part of the reason only a handful of institutions applied was likely cost-related, Ms. Logan said. During the same years that many providers worked to make facilities safer, undertaking ambitious training programs, they hit a financial wall, hobbled by declining populations and stagnant rates of payment, according to numerous facility directors.
"You've got workers that want increases, you've got health care costs going up, you've got insurance going up, you've got utilities going up, and you get no increase in your revenue stream -- and you get more regulations thrown on top of you?" said Mr. Lockwood, the Glade Run CEO. "It becomes very difficult to provide a quality program, to have the adequate staffing you need for safety."
In July 2007, a staff member at Bridgeville's Southwood Psychiatric Hospital was fired after pulling a boy out of bed and pouring water on his head, according to the incident report. "She continued to instigate the resident to the point of restraint," the report noted.
In June 2008, a boy at Glade Run Lutheran Services was sent to a psychiatric hospital after staff restrained him twice in quick succession. The second procedure ended when staff saw the boy "foaming at the mouth" and struggling to breathe, according to the incident report. A staff member later reported to a supervisor that staff had placed a trash can over the boy's head.
In April 2009, a counselor at Holy Family Social Services in Emsworth "secured" a boy's pants around his ankles and pulled him down some steps, according to the incident report. State investigators deemed the report of abuse unfounded, but Holy Family fired the staff member, finding that his actions did not comply with facility policy.
These incidents are rare, providers said. But they do occur.
Mr. Lockwood said his staff members had used the trash can as a "spit guard."
"That is still not acceptable," he said. "And they did get terminated."
Such stories illustrate the difficulty of reducing restraints and injuries: to do so requires a shift in institutional culture.
"You've got to retrain people in the way they think," said Jim Rieland, former director of Allegheny County probation and a consultant in the field.
Increasingly, facility staff are taught to try numerous techniques to calm children down before using physical force. Staff are also trained to recognize problems before they start, alleviating situations that might trigger an outburst.
These shifts are not easy, said Mr. Lydon, the Auberle CEO.
"People who are here a long time sometimes don't adjust well as we're doing all these things to change things," he said. "The biggest complaint I get is, 'This isn't the way we used to do it.' "
Allegheny County CYF closely monitors the performance of residential providers. But ultimately, sending children into facilities requires "some confidence," Dr. Sturdivant said: a leap of faith.
"We only know what's reported to us through either the children or the facility," she said. "The monitoring of those kids is everyone's responsibility. Caseworkers need to be there to visit the legal representatives, parents. It should be a very open system."
Allegheny County's juvenile court judges tour facilities regularly, Judge Clark said.
"The ones that seem to be the most successful have longevity in their staff," she said, pointing to a Harrisburg agency, Alternative Rehabilitation Communities.
"That is a model that you want to look at, ideally what congregate care should look like or be like," Judge Clark said.
"I think we all need to have the opinion of 'What if it were my child?' " said Ms. Harris, the Three Rivers Youth CEO. "And this needs to be good enough, safe enough, for my child."
Vivian Nereim : firstname.lastname@example.org or 412-263-1413. First Published June 26, 2011 4:00 AM