The state report concludes with recommendations that the process of communicating Behavioral Support Plan information to staff be improved, that the facility modify its Seclusion and Restraint Policy to address issues of monitoring the child carefully, and that it ensure that de-escalation and physical management techniques be conducted in accordance with the CP/I training manual.

Devereux Cleo Wallace has until Aug. 1 to respond.

Mark Ivandick, an attorney with the Legal Center of Colorado, designated by the governor to provide protection and advocacy for people with mental illness, says the Center is also investigating Orlena Parker's death and restraint practices at Devereux Cleo Wallace.

"Any report of a restraint-related death has to come to us; we follow up with an investigation," said Ivandick. "Also, we follow up on complaints, usually by clients who have been restrained, to look and see whether there's any system or policy that needs to be changed to protect other residents.

"We have special access to any internal investigations at the facility, to patient records, et cetera," he said. "We make recommendations to the facility on how they do business; if they refuse to change their policy and we believe it's important enough to protect others, then we can file an injunction."

As the state agency in charge of protection and advocacy, Legal Center attorneys report any licensing violations to licensing entities such as the Board of Nursing, the Board of Medical Examiners, or in this case, the state of Colorado Department of Human Services Mental Health Division.

"It's more or less a licensing issue," said Ivandick. "If they're violating the law or regulations for Residential Training Centers, for 24-hour facilities for children, they can be subject to having their license pulled."

The Legal Center report on Orlena Parker's death and restraint practices at Devereux Cleo Wallace is currently pending.

Good faith

Nancy Lanning, manager of Residential Services for El Paso County Department of Human Services, says that Cleo Wallace responded well to complaints made in 1999.

"There was a time [a few years back] when we were very concerned," said Lanning. "It kind of seemed as if restraint was sometimes their first resort rather than the last resort.

"Cleo was very responsive to hearing our concerns. I know they underwent some very serious policy making, training and retraining of the staff. The number of incidents of use of restraints really did go down."

Lanning emphasizes equally the difficulty of managing children with serious mental illness and behavior problems, and the mandate of the county to monitor use of restraints and potential abuse.

"The kids they take have serious, serious problems," she said. "I don't know how it must feel when one of those kids gets out of control."

A child welfare intake team, ISAT (Institution Safety Assessment Team), investigates any allegations of child abuse from use of restraints. "We investigate them all," said Lanning, "but we don't actually keep a record of the number of times restraints are used in all our facilities."

Most of the investigations, she said, are "fairly routine" and most are handled by the workers. If an accusation of abuse or neglect is confirmed, the team meets with managers and supervisors from DHS, representatives from the facility in question and representatives of the licensing agency.

"We come to a conclusion -- what are the actions that need to be taken?" said Lanning. "Do we (DHS) want to say that we don't want to use this facility any more? We could suspend using them for three months and in that time we expect this, this and this to happen.

"We don't just shirk it off and say, 'Oh, that's a difficult kid' or 'Would you want to take care of that kid?' Our people are very well trained. And the state has improved its training and expectations."

Still, says Lanning, despite safeguards, things happen. At particular risk are kids placed out of state.

"We don't have the wherewithal to monitor our kids placed out of state face to face," she said, adding that DHS tries not to place kids out of state. "As a system, we don't have a way to see them. The caseworker is in contact by telephone with the kid as well as with the facility; the CASA [Court Appointed Special Advocate] worker is in contact, but none of us are seeing him. The worker accompanies the child when they're placed; you have a sense of where you're leaving them. But it's not the same as, 'Oh, I'm in the neighborhood I think I'll pop in.'"

Each institution decides for itself how and when to use restraints, says Lanning, and there's no way to predict when or how often restraint might be used.

"You never know when this particular child is going to push somebody's buttons despite all the safeguards in place," she said.

Caseworkers with clients in residential treatment facilities, says Lanning, have to be notified after a physical restraint is used.

El Paso County DHS Child Welfare Administrator Lloyd Malone said the county's role in the Stage I report following Orlena Parker's restraint and death was to determine "whether the action or inaction on the part of the staff was directly responsible for the outcome." They concluded it was not.

"We look for abuse and neglect, not policy infractions," said Malone. "It's an interesting and difficult dilemma in our society how you handle these very difficult kids. These facilities become the flash point for public interest after an incident like this, but ultimately it's a public policy issue."

Malone believes that Devereux Cleo Wallace has made significant improvements in their use of restraint since 1999.

"A kid this big that gets out of control so quickly, things happen so fast. That's why it becomes an interesting public policy issue," he said. "Sometimes these little events happen and it appears that something could have been done. I think the facility was doing everything they could for this kid."

A big damn deal

Proper use of restraints on children in mental health facilities is literally a matter of life and death, says Judith Schubert, president of Crisis Prevention Institute, an organization whose Nonviolent Crisis Intervention Training Program has been taught to more than 4.5 million people worldwide.

Though she could not speak specifically about Orlena Parker's death or Devereux Cleo Wallace's restraint policies, Schubert spoke openly about the mortal danger physical restraint can pose.

"When you restrict movement of the diaphragm, you restrict a person's ability to breathe," said Schubert. "An open airway is just one part of breathing. It's interesting that you'll still see in [an institution's] policy -- no covering of the airway, meaning the mouth or nose. That's where the policy stops."

The physical risk of restraint cannot be ignored if there's a chance it's going to be used in a treatment setting, says Schubert. And it's important that staff understand -- someone could die.

"It's risky to say it'll never happen here. We give a little book to all our instructors, all our staff. I guess in that way we put it out there -- if you restrict someone's breathing, you're going to kill her.

"My guess would be that most people who work in a place where a death occurs don't know that it can actually happen," she said. "Adrenaline kicks in, we revert to a primal nature. You have to retrain that -- your body may want to get down on all fours and fight back. That's survival.

"You're really talking about human behavior in extreme, chaotic moments and how to prepare people for scenarios they're most afraid of."

Martha Holden of Cornell University agrees. Her mission is to prevent institutional child abuse, trying to determine the root cause by conducting research on incidents of abuse and death by restraints.

Holden cites several root causes coming together at the same time when a fatal incident occurs, not just an incorrect hold. For example, she said, staff might abandon the agency's accepted crisis intervention process and make their own decisions about how to restrain an aggressive patient.

"Another thing that generally happens is that signs of distress are ignored, like throwing up, because that's what kids do," Holden said.

In addition, she says, out-of-state placements put certain kids at additional risk, because of less direct oversight by caseworkers and family members. And in institutions where physical restraint is routinely used, the danger is often underestimated.

"The more people rely on physical intervention, the less aghast they are," Holden said. "They're not thinking this is a high risk, dangerous intervention. It loses the edge it should have.

"It's a big damn deal," she said. "Everyone in the system should be figuring out how we can manage this kid without doing this."

Mental-health workers must be trained in proper, safe restraint techniques that are appropriate to the setting, says Schubert, but more importantly, if restraints are to be used, they must be seen in context of the entire treatment picture.

"We speak more to assessing all situations," she said. "That should all happen on intake -- medical conditions, history of acting out behaviors, signs of anxiety, all of those things should be known in an assessment process. Obesity is one of those things -- the treatment plan should include early warning signs. [Staff should say], 'Let's consider the size of this person. What are we going to do when she's out of control?' Talk to her about it, you know, 'We don't see a history here of you becoming physically aggressive, but if a situation arises, what can we do?' Sometimes the kid will say, 'Here's what helps me.'"

Holden's training program, Therapeutic Crisis Intervention, recommends that every child with aggressive behavior have a crisis management plan that identifies the triggers, the best way to de-escalate and the safe way to restrain if restraint is required.

"I understand that the organizations we work with sometimes have state regulations that motivate them to improve policy. But other times it's from within; it's [them saying that] we don't want to do it this way any more. We've been in what I would call best practice institutions that have very lax state requirements," said Schubert.

The Devereux Cleo Wallace facility, on the grounds of the Myron Stratton home in south Colorado Springs.

Photo By Creighton Smith

"[Those organizations] put a philosophy in place. They say this is how we treat our kids, even in dangerous moments. They tell their staff, 'We're going to give you training, we're going to review incidents; it's all going to be out in the open. It's going to be something we're going to test you on and we're going to provide you with the tools.'"

Orlena Parker's death by restraint at Devereux Cleo Wallace has triggered a state investigation, but the question remains: Will her death motivate DCW and other facilities to rethink their use of physical restraint and their philosophy of patient management?

"It's a matter of putting resources, training and staff into the problem," said Holden. "There are some places where good things are happening. There are some facilities that work really, really hard at improving their practice."