How Some Schools Did Away With Restraint And Seclusion
WINCHESTER, Va. — When the student burst out of the school and bolted through the parking lot, workers followed closely but did not try to grab him.
Clutching his teddy bear, the 18-year-old scrambled to the top of a brick pillar at the school gate. He spit in the adults’ faces, yelling that he was going to hurt himself.
The commotion drew neighbors and police to the entrance of the school, employees later recalled about the incident, which occurred earlier this year. Even then, they didn’t pull the teenager off the pillar, order him down or threaten to punish him.
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Instead, they asked how they could help. After a few minutes, he came down on his own. He had wanted to call his mother, the workers later learned, but got upset and ran off when he couldn’t express that.
Back inside the school, the teenager returned to class. He was not locked in a room alone as punishment or to prevent him from attempting to leave again. Nor did anyone try to physically restrain him at any point in the process.
Secluding and restraining students was once standard procedure at the Ruth Birch School, much as it is now at many schools across Illinois and elsewhere. And just as Illinois currently finds itself in turmoil over the use of these practices, Ruth Birch grappled with the same dilemma 17 years ago. But the nonprofit organization that runs this private school and two others, as well as other residential and psychiatric facilities in Virginia, did what Illinois has not yet chosen to do: stopped using seclusion and restraint.
“He would’ve never gotten to the parking lot. … You grabbed whoever was having a problem and put them in a restraint,” said Darren Lambert, who has worked for 28 years at Grafton Integrated Health Network, where he oversees safety and emergency situations at Grafton’s facilities in Winchester. Grafton serves children and adults with autism, intellectual disabilities, emotional disabilities and psychiatric needs.
A Chicago Tribune/ProPublica Illinois investigation last year revealed widespread misuse and overuse of the practices in Illinois, finding that schools statewide had shut children with disabilities in seclusion rooms or physically restrained them more than 35,000 times in a 15-month period beginning in the fall of 2017.
In response to the investigation, the Illinois State Board of Education immediately banned locked seclusion and facedown, or prone, physical restraint, and began monitoring schools’ use of behavioral interventions.
But some school groups and districts have pushed back, saying that they can’t continue to serve students with challenging behavior unless they can restrain and seclude them.
Recently, state education officials agreed to allow schools to continue to use prone restraints until July 2021, but some lawmakers have vowed to introduce legislation to outlaw the practice. Though school buildings are closed now because of the pandemic, the rules will affect students once they return.
Such a ban can be arduous to implement, and it took years for Grafton employees to fully embrace the philosophy that they should comfort and help their residents regulate their emotions through a crisis instead of physically restraining them. But other schools across the country have been using Grafton’s system and say it works.
Ed Nientimp, who oversees pupil services at the Millcreek Township School District in Erie, Pa., attended a training program at Grafton five years ago. Initially skeptical, Nientimp was won over and led implementation of the system at Millcreek. They eliminated restraints within three years at the district’s public schools.
“I think we’re 1,000 times better than we were then,” he said. “I think our staff is happier … having that mindset of not yelling, not getting in somebody’s face, not scaring them, threatening them, startling them, grabbing them.”
Finding a new path
Back in 2003, Grafton used seclusion and restraint so often and so poorly that the network lost its workers’ compensation insurance. Too many school employees were getting hurt.
That year, workers at its psychiatric, residential and educational facilities documented more than 1,500 seclusion incidents and 6,600 physical restraints involving 220 children and adults.
Students viewed some staff members as adversaries and enforcers. Teachers and other employees felt beleaguered, according to several employees who have worked there for 20 years or more. The leader of Grafton at the time issued an edict: Find another way.
Some employees objected, saying that eliminating seclusion and restraint would reward bad behavior. Then, as Grafton’s administrators were working on a plan to replace those practices, a 13-year-old boy from one of the network’s group homes died after being restrained facedown. He asphyxiated on his own vomit two days before Christmas.
Finding a new way became even more urgent. How could the organization keep everyone safe without resorting to physical restraint?
Grafton’s leaders brainstormed ideas and launched experiments. What if, they asked, staff members could use something soft to block kicks and punches when students lashed out, instead of forcibly escorting them to a seclusion room or physically restraining them?
Lambert, the manager who handles emergencies and safety, and Kim Sanders, now a vice president at Grafton, recounted how they went on a shopping run to Kmart and filled a cart. They bought foam pads, the kind people use for kneeling in the garden. An umpire’s vest. Bean bags. Throw pillows and sofa cushions. Soft gloves and car-washing mitts. Blocking pads used for martial arts.
Sanders said she told Grafton workers: “I care about you. I don’t want you to get hurt. We’re going to try something new.”
At the same time they were learning new physical techniques, staff members were trained to recognize how students’ past trauma could influence their emotions and behavior. The network adopted a philosophy of “comfort vs. control.”
Workers in the group homes, schools and psychiatric facilities were told to hold up the makeshift blocking devices if a child attacked. They were to use calm voices. They should reassure the child that they were there to help.
In the past, workers would often warn students that they would be restrained if their behavior continued. This was stopped. Spitting was no longer considered an act of aggression that warranted restraint.
“We knew it could be washed off,” said David Alley, a case manager at Grafton for 33 years.
Not all employees were on board. Of the 300 or so workers at Grafton’s facilities in Winchester, about six employees quit outright, Sanders said. Another half-dozen were what Sanders called “snipers.” They nodded in agreement when instructed on the new approach, then privately undermined it to colleagues. Those employees were asked to find work elsewhere, Sanders said.
But Sanders said she realized Grafton could successfully end seclusion and restraint after hearing that a group home resident on an outing to the public library had gotten upset and “basically destroyed the library.” He had pulled books off the shelves, overturned objects and yanked papers off the wall. She rushed to the group home, where she expected to find him still upset and being restrained.
Instead, he was calming down in a bath that Grafton employees had drawn for him.
“He did all of that, and these people took him and gave him a bubble bath. They found it in their hearts,” she recalled, clapping her hands together.
Though most of the seclusion rooms across the Grafton network were taken out of use quickly, some in facilities that served people with greater needs were phased out over time. The last doors came off Grafton’s seclusion rooms in 2008. Staff members focused on their efforts to phase out restraint, and the Winchester facilities, including the school, eliminated physical restraint by 2015. The garden kneelers and sofa cushions have evolved into custom-made — and sturdier — blocking pads to be used in a crisis.
Even Grafton’s residential psychiatric facility in nearby Berryville is moving toward zero restraints, although a standing restraint is still used for occasional extreme incidents when residents try to harm themselves.
The organization called the new system Ukeru, a Japanese word that means “to receive.”
Other institutions began asking Grafton for guidance on how to stop using seclusion and restraint. The organization developed training for the system, which costs about $825 for a two-day session. The system has been purchased by more than 250 other facilities, including schools, across 36 states and Canada, according to Sanders.
“I often say there is no magic wand, so stop looking for one,” said Denise Marshall, chief executive officer of the Council of Parent Attorneys and Advocates, a national group that works on behalf of students with disabilities. “Educators need training, leadership and commitment.” Several national groups, including the council, recommend Ukeru in part because it helps change the way workers think about children with challenging behaviors, Marshall said.
“Until they move from the ‘control and compliance’ model to an ‘understanding and prevention’ model,” she said, “it’s nearly impossible to reduce the use of restraint or seclusion.”
Happier employees, happier students
One morning in February, students in a music therapy session at Grafton’s Ruth Birch School sang along as their teacher strummed guitar. In other classrooms, harsh fluorescent lights were draped with soft fabric, and students, some of whom rely on assistive technology to communicate, tapped on devices as they worked.
Ukeru’s light blue custom-manufactured blocking pads sat in the school entryway, against the wall in the hallway, next to tables in classrooms.
But they mostly go unused these days, workers say, because employees have learned how to focus on what students need to avoid a crisis.
Most of the Ruth Birch School’s roughly 75 students live in nearby group homes that Grafton runs and have bounced through six or seven different school and institutional placements by the time they arrive. Often, they have been regularly restrained and secluded.
But Grafton is different. Here, crisis response often surprises new students, who expect to be restrained, employees say.
If, for example, a child gets upset and flips a table, employees will try to comfort the individual and figure out what he needs instead of removing him to seclusion. Workers understand that students with disabilities who are in crisis can’t respond appropriately to commands or calm themselves.
“If I know that kid loves a Pepsi, I go get a dang Pepsi,” said Allyson Bateman Davis, the school’s executive director. Resolving the crisis quickly and without conflict leaves more time to teach, she said.
Some students with autism display repetitive aggressive behaviors, such as pinching or scratching others, especially when they’re trying to avoid a task. For those students, there’s a pad with a sleeve that slips over the employee’s forearm so the employee can safely sit next to the student and keep teaching.
Grafton workers had worried they would be injured more often without seclusion and restraint as options. But total staff injuries from students and other clients decreased by 64 percent from 2003 to 2019, according to Sanders. Grafton says it has saved at least $19 million in lost time expenses, turnover costs and workers’ compensation costs over the same time period.
Some educators who want to maintain seclusion and restraint as options in Illinois schools say adopting the Grafton model would be expensive and require more employees. Extra staff would be needed, for example, to take a student outside to swing or take a walk if the student needed a break.
But according to the restraint methods most commonly taught in Illinois schools, a standing restraint takes at least one staff member and more often two or three. Someone, by Illinois law, is required to document the incident, and often that person is an additional employee acting only as an observer.
Most methods that teach more complex floor restraints require a minimum of three people to execute them, plus a documenter. A child in a seclusion room must be monitored by a staff member at all times, and it often takes more than one employee to put a child into the room.
Some school officials argue that their students have such severe behavioral needs that ending seclusion and restraint is not realistic. Tony Reeley, whose district in the Charleston, Ill., area operates three public therapeutic day schools for students with disabilities, sent employees last year to visit a Pennsylvania school for students with emotional disabilities that ended seclusion and restraint. He told reporters that the Eastern Illinois Area Special Education District employees found the school’s turnaround inspiring but said their own students were too physically aggressive to replicate it.
Shifting the focus
Some schools don’t seclude because it’s illegal in their states. That’s true in Hawaii, Georgia, Pennsylvania and Nevada, and for students with disabilities in Texas.
As Illinois worked over the last few months to change its rules, some schools already had taken a hard stance against seclusion. When Jim Nelson became the executive director of the North DuPage Special Education Cooperative in July 2016, he had the door taken off the seclusion room at Lincoln Academy, a public therapeutic day school for students with emotional and behavioral disabilities. The prior school year, students had been secluded 181 times, according to federal data.
Staff members still use physical restraint at Lincoln, but there’s more of a focus on understanding what is causing an outburst or other challenging behavior, Nelson said. To help students manage their emotions, the school is using a Yale University-based program called RULER (the acronym stands for recognizing, understanding, labeling, expressing and regulating emotions).
Employees also try to develop relationships with students to better help them work through problems, including understanding challenging situations at home that could affect their behavior and ability to learn at school, Nelson said.
“We are just doing our own thing for our students’ needs,” Nelson said. “I don’t know why others are thinking they don’t have any other options.”
In March, the Illinois State Board of Education announced plans to encourage districts to explore alternatives to restraint and seclusion using $7.5 million in grants over the next three years. The funding will go toward workshops, conferences and coaching for educators in districts with the greatest need.
As Illinois schools scramble to understand and comply with the changing seclusion and restraint rules, some educators have sought insights from Maine child psychologist Ross Greene.
Greene has been training employees at schools, residential facilities and psychiatric institutions in his method, Collaborative and Proactive Solutions, for more than a decade, and he recently delivered the keynote address at the Illinois Alliance of Administrators of Special Education conference.
His philosophy takes a “nonpunitive, nonadversarial” approach based on the premise that difficult behavior usually arises when a student lacks a skill. It’s the educator’s job to identify the lagging skill and then teach it.
Heidi O’Leary is director of special services at Maine Administrative School District 75, which serves towns near the southeastern coast of Maine and operates therapeutic day programs for students with behavioral challenges.
Greene’s model, she said, teaches educators to change the way they talk about children’s behavior.
Workers might initially think, “Well, we can’t let them get away with that. They have to have consequences. They’re doing it because they’re looking for attention. They’re just bad kids,” O’Leary said.
As the new methods start working, educators’ thinking changes. “Johnny gets in trouble every day walking to the bus” becomes “Johnny has difficulty walking to the bus after school when all students are outside.”
The district, which has seclusion rooms in all of its eight schools, secluded children 177 times in the 2015-16 school year and consistently tallied at least 100 seclusions annually.
But seclusions started tapering off after the district went all-in on Greene’s approach two years ago. From November through January, district workers secluded children only 11 times. They used seven physical restraints in the same period.
Educators often refer to restraint and seclusion as necessary “tools” to manage challenging children. But, said Scott Zeiter, chief operating officer at Grafton, there’s good reason to avoid viewing restraint in that way: “If you give everybody a hammer, all they see are nails. We know there’s another way.”
Kim Sanders was 19 when she joined Grafton to work in its group homes. In her first year, a resident seized her by the hair and lifted her off the ground, separating her scalp from her skull and requiring a visit to the emergency room.
Her mother begged her not to return to work. But Sanders did go back, encountering more crises, more injuries, more tense moments of trying to do what she’d been taught, which included restraining and secluding students.
She can still recite, word for word, the script she used 30 years ago as she placed a teenage girl in seclusion. “Maria, when you spit, you can’t be part of the group. Please sit at the back of the booth. When you can show me you’re not going to spit, you can rejoin the group.”
She’d say this over and over, but Maria kept spitting and going back to the seclusion booth.
It didn’t work then; it doesn’t work now, Sanders said.
“Things we did to people in this country 50 years ago, we’re appalled at now,” Sanders said. “I think — I hope in my life — we’ll see these things and we will be appalled that we stuck kids in rooms and held kids on the ground until they couldn’t breathe.”
Smith Richards is a Chicago Tribune reporter. Cohen is a reporter for ProPublica Illinois.
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