In Tucson, Ariz., a 15-year-old girl died from asphyxiation in 1998 after being pinned face-down by two workers at a youth psychiatric center.
In Chula Vista, Calif., a 16-year-old girl stopped breathing and died last year after four workers at a psychiatric hospital pinned her face-down to the floor.
In San Antonio, a 14-year-old boy stopped breathing and died in March after three workers at a psychiatric hospital pressed him to the floor for about 12 minutes.
However tragic the story of Tina Winston, the emotionally troubled 11-year-old resident of a Little City Foundation home in Palatine who died last week when caseworkers tried to restrain her during an outburst, it is hardly an isolated incident.
Indeed, mental health advocates said there are problems across the nation with restraining children at facilities that care for the mentally ill or developmentally disabled.
An investigation by the Hartford Courant in 1998 found 142 deaths across the nation over a 10-year period related to restraints at such mental health facilities. A study by the General Accounting Office found 24 deaths in fiscal year 1998 alone.
Though not all involved children, experts said many did.
“Many of these deaths are asphyxiation of children by two or more adults holding kids down,” said Clarke Ross, deputy executive director for public policy at the National Alliance for the Mentally Ill, which tracks such incidents.
“You go into a residential treatment program as a safe haven,” Ross said. “We want to restore a safe haven.”
Advocates for the mentally ill attribute the deaths to inadequate training and insufficient standards in some states on how and when mental health workers should rely on restraint to control patients.
A bill called the Compassionate Care Act of 1999 would bar staff at federally funded mental health facilities from using restraint unless it was needed to protect a patient or others. The bill passed the U.S. Senate and is awaiting action in the House.
Some cases where patients died involved mechanical restraints, such as straps. Others involved staff members pinning down patients.
Illinois doesn’t keep precise numbers on deaths that happen while a person is under restraint. But the Illinois Department of Children and Family Services said it has had no such deaths in the past 10 years.
The number does not include the case of Tina, whose death is still officially under investigation by DCFS and Elgin police.
Federal regulations are already strict on the use of physical restraint by hospitals and nursing homes, mental health advocates said. In addition, homes for the mentally disabled that receive federal Medicare or Medicaid funding must follow tough federal rules that limit the use of restraint.
But federal standards do not apply to group homes or other facilities that operate only on county or state funds, they said.
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State standards are often lacking, said Brian Coopper, senior director of consumer advocacy for the National Mental Health Association. “That’s one of the problems,” he said. “There’s this patchwork of regulations.”
Officials in Illinois said there are already strict regulations in place regarding the use of restraints in residential care facilities.
Little City cares for children in the custody of the DCFS, so it must meet their rules, which specify that restraints be administered so as “to avoid provoking [the child] further and escalating incidents” of misbehavior.
“Everybody understands that restraint is inherently dangerous,” said Ron Davidson, a DCFS senior administrator who deals with the placement of children. “That’s why the rule says you’re supposed to try everything else first.”
Davidson said he couldn’t comment on the Tina Winston case because DCFS had not yet received reports on the incident.
“Any death is a tragedy,” Davidson said. But overall, “we’ve been very fortunate.”
Two years ago, a 40-year-old ward of the state died at Lincoln Developmental Center in Lincoln, Ill., while being restrained.
Michael Lane, a severely developmentally disabled Chicagoan and longtime resident at the facility, died of suffocation while being held face-down on the floor by five staff members for nearly an hour.
A coroner’s jury ruled the death an accident. But investigators for the Illinois Department of Public Health criticized the staff for restraining Lane in a stomach-down, face-down position, in which their ability to monitor his condition was limited.
The Department of Public Health classifies Little City Foundation as a “community living facility,” said Jena Welliever, spokeswoman for the department. That means that to maintain its license, the facility must not physically restrain patients for punishment or for staff convenience.
Facilities that don’t care for DCFS children still must comply with the Illinois mental health and development disability code, experts said.
That code also sets limits on the use of physical restraints, said Marsha Koelliker, public policy director of Equip for Equality, a non-profit group that monitors the state’s compliance with disability laws.
“I think we have a pretty good set of laws,” she said. “The mental health code doesn’t have any enforcement mechanism. That is one of the problems.”
The Department of Human Services can withhold funding for facilities that deal with the mentally ill or developmentally disabled, but it lacks the power to levy fines, she said.
“It makes it difficult if they don’t have an array of penalties they can use,” she said.
In the Winston case, experts can only speculate about what might have gone wrong.
Details about exactly how Tina was restrained are sketchy. Tina became agitated while in the waiting room of Northwest Treatment Associates in Elgin. Caseworkers tried to calm her, but she threw a shoe at one and began scratching the legs of the caseworkers. The caseworkers pinned her on the floor and released her when she calmed down.
But Tina, described as 5-foot-1 but 143 pounds, erupted again and began trying to hit and bite the staffers, according to reports. The caseworkers, who haven’t been identified, restrained her again. Law-enforcement officials have said Tina was pinned face-down by the caseworkers. Paramedics were summoned, but the child was pronounced dead at an area hospital.
The child had a history of violent outbursts, according to child-welfare records.
Little City is required to report to DCFS and the Cook County public guardian’s office all unusual incidents, which include physical altercations resulting in injury, restraint of a resident, or sexual abuse or activity.
At least seven such reports had been filed on Tina since January, a number that includes the report made after her death July 10.
In five of the incidents, Winston had to be restrained before calming down. A report from Feb. 8 explains “Tina was restrained for 8 minutes. During the restraint, she was crying and yelling.”
Little City also reported that at one time in May 1998 they illegally restrained another person, causing a burn to her knee. The caseworker in that case was fired, according to Little City incident reports.
Experts said there are specific rules, in Illinois and most states, about when and how to subdue a person who has lost control. The guidelines, outlined in mental health codes in each state, typically guide caretakers at institutions, like hospitals, prisons and residential care facilities.
The state’s mental health code says that those who apply restraint must be “trained in the application of the particular type of restraint to be utilized.”
DCFS says those who apply restraint must have completed a basic competency training program and that their certification be updated every 12 months.
No information about the background or level of experience of the two female caseworkers involved in Tina’s death was made available by Little City officials, although they did say the two women had training in how to restrain a patient.
The initial approach when faced with an out-of-control patient is “you try to talk with the person to reason with them to establish some type of bond with them so you can help them gain more of a sense of control over themselves,” said Dr. James Cavanaugh, president of the Isaac Ray Center for psychology and law at Rush-Presbyterian-St. Luke’s Medical Center.
Restraint must be used judiciously, said Mark Moses, a supervisor at Ada S. McKinley Community Services in Chicago. Moses said his staff, which works with 350 children with mental illness or developmental disabilities, gets restraint training when they’re hired, then annual refreshers.
The state mental health code prohibits a patient from being placed in restraints for more than two hours without written instructions from a doctor or nurse. The patient must be constantly monitored and re-evaluated by a psychiatrist before the isolation or restraint can continue.
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All staff workers must be trained in proper restraint techniques, but there are no licensing requirements.
Jan Holcomb, executive director of the Mental Health Association in Illinois, said incidents like the Tina Winston case simply shouldn’t happen.
“I just can’t even imagine how somebody can be smothered,” she said. “I think what happens sometimes is the staff aren’t adequately trained or there’s not enough people around to ensure that it’s done safely.”