VT: Compliments Abound at Wheeler School in VT

December 6, 2009

By Molly Walsh

From BurlingtonFreePress.com: http://www.burlingtonfreepress.com/article/20091206/NEWS02/91205009

Teachers at Wheeler are finding that by making more of a fuss over children who do the right thing, the number of children who do the wrong thing has dramatically declined. The school is among 54 in Vermont that have implemented an approach to discipline known as the positive behavioral support (PBS) model. Beneath that jargonish moniker lies a simple premise - set the rules, teach them and lavish praise on kids when they follow them.

After the program was instituted at Wheeler last year, suspensions dropped by more than half, from 74 days to 21 days. Less serious discipline problems are also way down. In the 2007-2008 school year, children were required to leave the classroom for misbehavior 600 times at the school, compared to 198 times last year.

These numbers illustrate a dramatic turn-around, said Jim Drown, a behavior specialist at Wheeler who vividly remembers how frantic his early days were at the school ten years ago. “There was no expectation on behavior. There were kids literally running out the doors,” he said. Drown struggled to help teachers maintain order. “It was just run from one room to the next, put out one fire after another and not be able to do anything.”

To read the rest of the article, please click the following link: http://www.burlingtonfreepress.com/article/20091206/NEWS02/91205009

VA: Mental patients isolated for years despite laws

By DENA POTTER

The Associated Press 
Tuesday, December 23, 2008; 2:01 PM

http://www.washingtonpost.com/wp-dyn/content/article/2008/12/23/AR2008122301458.html?hpid=sec-health

STAUNTON, Va. -- Mental patients sprinkled throughout the nation's psychiatric hospitals are being locked up alone for years despite laws aimed at preventing the practice, because medical workers say they're too dangerous to handle any other way.

Health officials call them outliers _ rare, unpredictably violent people who don't respond to medication or other treatment. Advocates call them victims of a system that has lost patience and creativity in caring for those who are most difficult to treat.

Loopholes in federal and state laws and impotent oversight allow hospitals to lock some patients away for the safety of staff and other patients. Some cases involving seclusion and restraints have resulted in costly lawsuits, yet they are so rare that many advocates had no idea there were similar situations in other states until The Associated Press inquired about it.

No one tracks such cases. However, through interviews and records from advocacy groups and state and federal agencies, the AP found at least a dozen patients who were held in seclusion for months or years at a time.

"I think it's just a wink and a nod and some people are looking the other way," said Charlie McCarthy, an advocate with Disability Rights Montana, who nevertheless said he understands what drives hospitals to work around the law.

"Everybody's frustrated with what do you do with somebody like this? The patient has rights, but the other patients have rights to be safe and free from abuse."

In Virginia, one man was locked in a three-room suite for 15 years and another patient was held in a similar setup for five years. Connecticut and Florida have paid millions over allegations that they tethered patients to furniture for years.

Federal law requires that seclusion or restraints _ including drugs _ be used on patients covered by Medicare or Medicaid only in emergencies to protect other patients and staff. Such measures can be used for more than 24 hours only if a physician deems it necessary, and only if a doctor updates that assessment daily.

Moreover, the U.S. Supreme Court has ruled it unconstitutional to restrain or isolate patients for extended periods.

The laws and court rulings don't cap the consecutive days a patient can be isolated or restrained, though, so hospitals can hold a patient indefinitely by simply signing off on it every 24 hours.

The Supreme Court also has ruled that hospitals must treat people who are involuntarily committed. So Stuart Grassian, a psychiatrist who has studied the effects of solitary confinement on prisoners, and others question whether outliers are being held legally.

"Once a person is locked up, the state has to provide them with adequate and appropriate treatment, otherwise they lose any authority and any legitimacy to keeping the people locked up against their will," Grassian said.

Seclusion, he said, can intensify patients' paranoia, agitation and delusions.

Advocates insist that with proper training and sufficient staffing, hospitals can eliminate the need for seclusion and restraints in nearly all cases, not just outliers.

In 1997, Pennsylvania enacted stricter policies against those techniques, trained staff in crisis management and established minimum staffing levels for its psychiatric facilities. Today, the state does not seclude or restrain patients for extended periods and rarely uses either method at all, according to the state mental health agency.

Such efforts can be costly, but proponents cite them as proof that with the right support, any mentally ill person can improve enough to safely interact with others.

"People can make progress and they do get to a point where they can be reintegrated into the community," said Deborah Dorfman, deputy director of the Los Angeles-based Disability Rights Legal Center. "You just need the right treatment and the right expertise."

A spokesman for the Justice Department's Civil Rights Division, which investigates complaints concerning institutionalized individuals, would not comment on the use of seclusion and restraint. According to its Web site, the division wrapped up two probes this year that found improper use of seclusion and restraint in Oregon and Georgia and recommended policy changes to the governors of those states.

At Oregon State Hospital, investigators found four patients who had lived in prolonged seclusion, some for at least a year. In a report, the Justice Department called the practice "unrefined and unlawful" and said it had never "encountered the use of continuous seclusion as a planned treatment strategy."

Since 2006, the Justice Department has entered into settlements with California, Vermont and the District of Columbia over violations that include improper seclusion and restraint at mental hospitals.

At Western State Hospital in Staunton, Va., the state stepped in after staff placed Cesar Chumil in a three-room "limited containment suite" in 1993, where he has remained since. Chumil averaged 300 assaults against staff and another 100 against patients over seven years before he was placed in the suite, according to records from a closed administrative hearing obtained by the AP.

Hospital officials claim the 58-year-old has more freedom than before, when records show he spent thousands of hours in a small seclusion cell or restrained to a bed or chair.

"It's a big step to put somebody in a room like this and say, 'You can't come out,' but we had so many people getting injured and so many staff were out of work," said Stephen Johnson, the psychologist on Chumil's ward. "It just got to the point where it was just untenable ... so we had this one solution."

Last summer, a state oversight committee determined that the hospital should move Chumil out of seclusion. The hospital moved all other patients off Chumil's ward this month and unlocked the door to his suite so he could go out into an activity room when he wanted. Hospital workers in padded gear and helmets must be present _ for everyone's safety, but also so that he is no longer alone and therefore no longer technically in seclusion.

In Connecticut, a 23-year-old man has lived in a two-room cell since 2001, said Nancy Alisberg, an attorney for the state's Office of Protection and Advocacy. When he behaves, staff take him on walks around the grounds and sometimes take him to church and other places, she said, declining to identify the man because of privacy laws.

Often, the rooms where patients are held for months or years at a time are more pleasant than traditional seclusion rooms _ usually tiny block rooms containing only a mattress. They have TVs and personal items. Chumil even has a phone.

"In a situation like that, the best you can do is to create a living environment that is as safe and contained as possible," said Kevin Huckshorn of the National Association of State Mental Health Program Directors. "And while yes, you could call it seclusion, the only other options are going to be things like restraint, which is even more restrictive."

Patients have been removed from long-term seclusion in other states, including Massachusetts, Oregon and Maryland, after advocates stepped in, some threatening lawsuits. Other states have paid millions of dollars for breaking restraint and seclusion laws.

In Florida, the state lost a lawsuit in 1998 and was forced to pay $18 million for strapping a man to a bed or wheelchair for 2 1/2 years.

Connecticut has paid $600,000 a year since 2002 to house a former patient at a special facility in California as part of an out-of-court settlement. He had been tied to a bed in a small, concrete room at Connecticut Valley Hospital in Middletown for more than a year, said Susan Aranoff, an attorney with the nonprofit Connecticut Legal Rights Project who fought for his transfer.

Wayne Dailey, senior policy adviser for the Connecticut Department of Mental Health and Addiction Services, denied holding any patient in restraints for such a long a time.

Federally mandated advocates in each state protect the mentally ill and disabled but don't have the manpower or money for constant monitoring, said Curt Decker, executive director of the National Disability Rights Network, which represents advocates.

Like other groups that look out for the mentally ill, Decker said he didn't know patients were being held in long-term seclusion but that it was something his organization will begin looking into.

"We put these people sort of out of sight and out of mind," Decker said, "and bad things can happen."

Vermont - Restraint and Seclusion Regulations

Model Policy on Restrictive Behavioral Intervention

Section 1. Statement of Purpose

1.1 It is the policy of this school district/supervisory union that students not be subjected to the unreasonable use of restrictive behavioral interventions, and that there be a common understanding within the District/Supervisory Union of appropriate interventions by District staff.

Section 2. Definitions

2.1 Timeout room. A timeout room is a designated room apart from a student’s assigned class or activity. It is used to separate a student from others for the purpose of eliminating, or at least reducing, the occurrence and/or intensity of harmful behavior or to enable the student to regain composure and return to class or other activity. A planning room or other area used as a place in which to meet with a student to discuss his or her behavior is not a timeout room.

2.2 Physical restraint. Physical restraint is the use of physical means by a trained staff member to prevent imminent harm to a student or other persons, or damage to property.

Physical restraint does not include the following:
a. Brief periods of physical restriction by direct person-to-person contact,
without the aid of material or mechanical devices, accomplished with minimal
force and designed either (i) to prevent a student from completing an act that
potentially would result in physical harm to him or herself, or another person,
or damage to property, or (ii) to remove a disruptive student who is unwilling
to voluntarily leave an area; or
b. Holding a student’s hand or arm to escort the student safely from one area to another.

2.3 Mechanical or chemical restraint. Mechanical or chemical restraint is the use of any device or substance to restrict a student’s movement or limit a student’s sensory or motor functions. The term does not include devices used in accordance with prescriptions by health professionals for the purpose of maintaining body alignment or support, or to limit sensory stimuli.

2.4 Positive Behavior Intervention. A positive behavior intervention is an approach to a student’s behavior designed to teach and support socially appropriate conduct and tosupplant socially inappropriate conduct.

2.5 Functional Behavioral Assessment. A functional behavioral assessment is an analysis of a student’s behavior patterns before, during, and after rule-breaking or other incident of inappropriate behavior for the purpose of guiding the development of a behavioral intervention plan.

2.6 Behavioral Intervention Plan. A behavioral intervention plan prescribes strategies for dealing with a student before, during, and after rule-breaking or other inappropriate behavior.

Section 3. Generally
3.1 Except with respect to documentation requirements set forth in Section 8.1, when a student is the subject of an individualized education program (IEP) or §504 plan
addressing, among other things, responses to the student’s dangerous behavior, that plan shall take precedence over the guidelines set forth in this policy. A written explanation shall be contained within the IEP or Section 504 plan for any specific deviation from the requirements of this policy.

Section 4. Timeout Room
4.1. Purpose. A timeout room may be used to aid a student to compose him or herself. It shall not be used for staff convenience or student punishment.

4.2. Duration. A timeout room may be used only so long as is necessary for the student to compose him or herself. If the student’s behavior remains dangerous after 30 minutes, continued use must be authorized by the principal or his or her designee.

4.3. Observation. A student in a timeout room shall be appropriately monitored. If the circumstances suggest that a student poses a risk of harm to him or herself or others, he or she must be kept under the direct observation of a staff member.

4.4. Characteristics. A timeout room shall:
a. be large enough to permit safe movement;
b. permit safe entry and exit and shall not be locked in any way that would
prevent the student from leaving, unless the room is equipped with automatic
releases for fire alarms; and
c. be adequately lit, heated, ventilated, and free of sharp or otherwise dangerous
objects.

Section 5. Physical Restraint

5.1. Purpose. The purpose of physical restraint is to reduce or eliminate imminent risk either of harm to a person or of damage to property. Physical restraint may not be used for staff convenience or student punishment.

5.2. Use. Physical restraint may be used with a student only when there is imminent risk either of harm to the student or others or of property damage. Additionally, reasonable and necessary force may be used to quell a disturbance, obtain possession of weapons or other dangerous objects upon the person of or within the control of the student, for the purpose of self-defense, or for the protection of persons or property.

5.3. By trained staff. Only staff trained in the proper use of physical restraint may apply it, unless no such staff member is available. The District will endeavor to provide training to an appropriate number of staff members in each school that includes instruction in (a) a continuum of prevention techniques; (b) a continuum of de-escalation techniques; (c) environmental management; (d) nationally recognized methods of physical management and restraint; and (e) appropriate documentation and notification procedures.

5.4. Duration. Physical restraint may be used only so long as is necessary for the student to compose him or herself. If the student’s behavior remains dangerous after 30 minutes, continued use must be authorized by the principal or his or her designee. If continued use of physical restraint is ineffective, the principal or his or her designee shall contact the student’s parent(s) for assistance, or seek assistance from law enforcement or other emergency service personnel.

5.5. Limitations. No physical restraint may be administered in such a way that the student is prevented from breathing or communicating, or that causes the student unnecessary pain.

5.6. Observation. To the extent practicable, physical restraint may not be used by any staff member except in the presence of another staff member.

Section 6. Mechanical restraint
6.1 Except as otherwise set forth in this policy, mechanical restraints may not be
employed.

Section 7. Pattern of Behavior
7.1. When a student’s IEP team or Section 504 team determines that, based upon a
pattern of behavior, the use of a timeout room or physical restraint is likely, the team shall consider ways to address the student’s behavior, including, where applicable, performing a functional behavioral assessment and formulating a behavioral intervention plan which makes provision for the use of positive behavior interventions.

Section 8. Documentation and notification
8.1 Documentation. The principal or his or her designee shall prepare a report of each use of a timeout room or physical restraint as soon as practicable, but in no event later than two school days after its use. The report shall be used to maintain data on the frequency and use of restrictive behavioral interventions, and include at least the following information:
a. Name of the student;
b. Date of events leading to use;
c. Location of events leading to use;
d. Description of events leading to use;
e. Description of the student’s behavior immediately prior to use;
f. Description of use;
g. Name of staff member(s) involved in use; and
h. Time and duration of use.

8.2 Notification
8.2.1. Of all parents. Before the start of each school year, the school shall inform parents or guardians of all students about this policy.

8.2.2. Of a student’s parents. Unless otherwise requested by a student’s parent(s) or
guardian(s), the school shall take and document reasonable steps to notify them that the student has been subjected to use of a timeout room or physical restraint, ideally on the same day but in no event later than two business days after such use.
8.2.3. Of Principal. The report of each use of a timeout room or physical restraint shall be submitted upon its preparation to the principal or designee.