They are sent away for help. ¶ But when they act out, some troubledchildren are controlled with potentially dangerous mind-numbing drugs.¶ No one knows how often residential centers for hard-to-control kidsuse psychiatric drugs to subdue them. Privacy laws shroud the centersin secrecy. ¶ But a three-month investigation of thousands of stateinspection records as well as more than 80 interviews withchild-welfare workers, doctors, families, lawyers and industryofficials reveal growing concerns that pills and injections, most ofthem untested on youths, have become a quick fix to stifletroublemakers.
‘‘At its worst, it’s like a scene from the movieOne Flew Over the Cuckoo’s Nest with Nurse Ratched chasing after kidswith syringes of psychiatric drugs," said Gayle Channing Tenenbaum,legislative director for the Public Children Services Association ofOhio.
At best, it’s a rare problem being addressed through better training, says the Ohio Department of Mental Health.
Butan advocacy group says Mental Health is making it easier for treatmentcenters to force powerful drugs on kids without reporting it.
OhioLegal Rights Service, which is leading the charge for change, says theopposite should be done. Mental Health needs to impose far stricterrules to limit the use of medications and hold centers accountable forabuses, it says.
Both sides agree that psychiatric drugs canhelp kids suffering with anxiety, depression or a host of other mentalillnesses. The question in these cases is whether medications are beingused to treat children or as a chemical straitjacket.
LegalRights, an independent state agency, has examined nearly 500 casesinvolving chemical restraints during the past five years, including:
• A 5-year-old boy who was so doped up that he couldn’t stop battingthe air, complaining about imaginary bugs and smacking his lips. Adoctor ordered him off all medication.
• A 10-year-old boy who was chemically restrained 69 times over 80days. Doctors prescribed up to six drugs at a time — and neverconducted trials to determine which pills worked for what symptoms ordisorders.
• A 12-year-old girl who was injected six times over nine months withhigh doses of Thorazine, a powerful sedative that can knock kids outand cause muscle spasms and twitches. She also was physicallyrestrained 31 times by as many as three men, despite a history of beingphysically and sexually abused.
‘‘It’sscandalous that medications are used to subdue kids for overworked andunderpaid staff or as punishment for bad behavior," said CarolynKnight, the group’s executive director.
Children alreadytraumatized by abuse, neglect or mental illness can be hurt further bybeing forced to take a medication, especially when held down byadrenaline-pumped adults, said Dr. Ellen Bassuk, an associate professorof psychiatry at Harvard Medical School who has reviewed Ohio cases.
‘‘Themental-health system is a mess," she said. ‘‘Not only are these placesgiving chemical restraints, but they’re prescribing risky combinationsand dosages of drugs that are as dangerous and inhumane."
Stateofficials say Ohio law prohibits chemical restraints except inemergencies when a child or worker is in danger. Even then, they’resupposed to be used only after lessforceful options fail.
‘‘It’s been outlawed," said Thomas Wood, chief of licensure and certification for the Department of Mental Health.
Criticssay the state’s 52 private residential centers often skirt the law bycalling the restraints emergency medications or a PRN order — short fora Latin term for giving drugs as needed.
‘‘No one wants to callit a chemical restraint because it is too emotionally charged a term,"said Curtis Decker, executive director of the National Association ofProtection & Advocacy Systems in Washington.
Others say the practice is protected by an unspoken rule: ‘‘Don’t ask, don’t tell."
‘‘Ithappens underground all the time," said Steve Eidelman, executivedirector of the ARC of the United States, a national advocacy group forthe developmentally and mentally disabled, based in Silver Spring, Md.
‘‘It’s all about what’s easiest for the treatment providers, not what’s good for the kids."
Inresponse to that concern, workers at these centers increasingly arebeing taught ways to prevent power struggles instead of how tophysically control children.
‘‘It can be as easy as sittingdown with a kid and telling them you hurt my feelings when you calledme a name instead of tackling them to the ground," said Bob Bowen,chief executive officer of David Mandt and Associates, a Texas-basedtraining company that Bowen runs from his Canton office.
Injections as threats
Concerns about overmedicated kids are being heard nationwide.
Achildren’s psychiatric hospital in Louisville, Ky., was chastised in2003 for giving drugs to children before they could cause problems —sometimes while still asleep. Kids who refused to take pills were toldthey would receive a shot of Thorazine.
In May 2000, anonprofit group filed a class-action lawsuit on behalf of 9,000Tennessee children in large institutions who were given psychiatricdrugs and other restraints without proper legal consent.
‘‘There’sno reason to think that Tennessee is an aberration," said Doug Gray, alawyer for the New Yorkbased, nonprofit Children’s Rights.
Defenders say drugs sometimes are needed to control the increasingly unruly, violent youths being sent to the centers.
‘‘Theybite, hit, kick and spit," said Penny Wyman, executive director of theOhio Association of Child Caring Agencies, which represents residentialcenters. ‘‘They curse, yell and throw furniture. They’re angry and havea lot of issues to work out."
Many of the children need thekind of intensive care they’d get at a hospital, but there aren’tenough beds, Wyman said. The state closed most of its mentalinstitutions in the late 1980s and early ’90s but sent little money tocommunity health centers to help with increased caseloads.
Shesaid Ohio Legal Rights’ leaders don’t understand the challengesproviders face and are on a ‘‘witch hunt," even though treatmentcenters use psychiatric drugs only as a last resort.
Others say they don’t understand the fuss.
‘‘It’sshocking that we focus so much attention on the residential treatmentcenters, which have fewer than 1,000 beds," said Michael Hogan,executive director of the Ohio Department of Mental Health.
Thedepartment licenses the centers, four- to 115-bed facilities thattogether can house 919 children. Thousands of kids flow through thecenters in a year, and many more are closed out.
Hogan says thebiggest danger facing children is depression. There were 168 youthsuicides statewide in 2002, the most-recent figures available.
‘‘Nocase of abuse or neglect is good," he said. ‘‘But it would be wrong forus to ignore the bigger issues, especially as our money gets tighterand tighter."
Most treatment centers are doing their best, hesaid. They’re adding psychiatrists, reducing overall restraint use,training staff members and trying new, positive methods for respondingwhen kids blow up.
Hogan’s department thoroughly inspects the centers every two years, or when concerns arise.
Thecenters typically charge $100 to more than $1,000 a day. But most stillhave few hiring standards and are plagued by high turnover, Knightsaid. Workers often are fresh out of college and are paid about $7 anhour.
The department’s assistant medical director agrees thattreatmentcenter workers often are too quick to push drugs because theywant calm, obedient children.
‘‘It’s human nature. A lot ofadults think children should be seen, not heard," Dr. Patricia Goetzsaid. ‘‘It doesn’t help that we’re a culture where you can manageeverything with a pill."
State intervenes
Last April, the state ‘‘strongly recommended" that Belmont PinesHospital, in Youngstown, stop using emergency medications after Goetzuncovered several troubling trends.
She reviewed 11 cases inwhich a total of 27 shots of the powerful drugs Haldol and Thorazinewere given to calm angry children.
In a letter, Goetz notedthat the medications ‘‘have effects that last far longer than requiredfor a patient to regain self-control."
Sleepiness can persistfor hours or days. And unlike the use of other restraints, such aspadded handcuffs or physical holds, there are no limits on how longkids can be drugged, said Laurel Stine, director of federal relationsfor the Bazelon Center for Mental Health Law in Washington.
‘‘It’s just another way to abuse children who have already been victimized," Stine said.
Twoyears earlier, the Department of Mental Health placed Belmont Pines onprobation for five months and barred the 45-bed center from admittingmore children.
The agency took action after Ohio Legal Rightsand several Belmont Pines employees complained that the facility gavetoo many shots of Haldol, Thorazine and Vistaril, an antihistamine usedfor sedation.
One man reported that his son was so drugged upduring visits that he couldn’t talk or walk. The boy essentially wasbeing treated as a ‘‘pincushion," said Judy Jackson-Winston, aclient-rights officer for the Cuyahoga County Mental Health Board whospoke with the father.
Belmont Pines officials said they havestopped using emergency medications and had reduced their use by 86percent before the state warning.
‘‘We had already made adecision that we were going to reduce, then eliminate their use," saidDr. Phillip Maiden, the group’s medical director. ‘‘The Ohio Departmentof Mental Health just made us do it a little quicker."
Althoughhe regrets that the center was placed on probation, Chief ExecutiveOfficer George Perry said, ‘‘There’s no question, we’re better for it."
Multidrug co*cktails
Last summer, Goetz warned about the use of ‘‘drug co*cktails" atPomegranate Health Systems, which runs a center in Byesville inGuernsey County and plans to open a $5 million, 60-bed facility inFranklinton next year.
She questioned why five drugs wereneeded for a 15-year-old with posttraumatic stress disorder andintermittent explosive disorder, which leads to sudden outbursts ofviolence.
‘‘It is very concerning that this child is on threemood stabilizers — Depakote, Topamax and Trileptal — and twoantipsychotic medications — Haldol and Seroquel," Goetz wrote. ‘‘Thereis no evidence that Topamax or Trileptal decreases aggressivebehavior."
Few scientific studies have explored the risks associated with using multiple psychiatric drugs.
However,experts and researchers agree that drug co*cktails increase thelikelihood of death or bad side effects. Also, many behaviorial-healthdrugs agitate children, so workers respond by giving them moremedication.
Goetz also criticized Pomegranate for using Haldoltoo often and in high doses, even though the drug can cause potentiallyfatal side effects, including involuntary muscle contractions, lowblood pressure and rapid heartbeat.
Pomegranate officialsdefend their medication practices, saying they treat the mostdifficult, disturbed children, including those who are victims ofviolence or attempt suicide.
On average, the kids they see havebeen through 20 foster, group and residential homes, administrator BobHall said. Some have had as many as 33 placements.
Most havebeen to a different physician or psychiatrist with each move, and eachdoctor has prescribed multiple drugs. Complicating matters, thechildren’s medical records often don’t keep pace with their moves.
Pomegranatedeals with the problem by creating medical and mentalhealth work-upswithin 30 to 45 days of each child’s arrival, Hall said.
‘‘Wejust received a 71-page package on a kid, and there wasn’t one factabout the kid’s medications in all that paper," Hall said.
Thistype of slip-up proves the system is broken, said Yvette McGee Brown, aformer juvenile court judge who is now president of the Center forChild and Family Advocacy at Columbus Children’s Hospital.
But it doesn’t take residential centers off the hook.
‘‘They should get those files," she said. ‘‘Anything less is malpractice."
While on the bench, McGee Brown frequently called the doctors of children she thought were overmedicated.
‘‘Ihad a 10-year-old who was so doped up he was walking around like azombie," she said. ‘‘Sure, he wasn’t creating any problems. But he wasbarely conscious."
Problems with staff members
Chelsey Kennedy, 15, of Gahanna, never will forget the effect ofbeing given three shots of Haldol one afternoon at Kettering HospitalYouth Services in Dayton.
‘‘I slept for four days and was in a drug-induced fog for a week after finally waking up," she said. ‘‘That’s just wrong!"
Chelsey,who has bipolar disorder, admits being combative and mouthy at times.But she said residential staff members often egg on patients.
State records reflect that.
Forinstance, the Mental Health Department reprimanded a southern Ohiocenter in January for creating a ‘‘culture of fear and intimidation."State inspectors said the children at Oak Ridge Treatment Center, nearIronton, complained about being cursed at, called names and insulted bystaff members.
They also reported being choked, kneed,‘‘slammed" and put into a ‘‘sleeper" wrestling hold that temporarilycuts off their breathing.
Wendy Kennedy, 40, said teens are‘‘manhandled" at Residential Treatment Centers of Ohio, a South Sidefacility where her daughter has lived since early March.
‘‘WhenI went to visit Chelsey recently, one of the girls had a black eye,bloodied nose, busted lip and she couldn’t move her shoulder — allbecause of a restraint," Kennedy said. ‘‘Using brute force is sowrong."
Residential Treatment officials denied using excessiveforce and said no children have been hurt. ‘‘Franklin County ChildrenServices has found nothing to substantiate any abuse," Chief ExecutiveOfficer Jeff Beasley said.
But in March 2003, Children Servicespulled 11 teens from the center after a worker bruised a girl’s wristduring a restraint. The state also placed Residential Treatment Centerson probation for failing to meet rules.
Beasley said the center doesn’t use any emergency medication — ‘‘only drugs ordered by the doctor."
However,state mental-health officials cited the facility in August for using a‘‘medication as a restraint to control behavior."
Kennedy is concerned that Chelsey might be on too many and maybe even the wrong medications.
Beforeentering residential care a year ago, Chelsey was on two drugs. She’snow prescribed 14 — 11 psychiatric and three for diabetes.
‘‘Theside effects are terrible," said Kennedy, who turned over custody ofher daughter to Franklin County Children Services in 2004 to get hermental-health help. ‘‘She has joint pain, reflux and no hormone levels,which have baffled doctors."
Chelsey also hasn’t been herself.
‘‘Shecan be normal one minute and like a small child another," Kennedy said.‘‘I just don’t understand why they give her so many drugs but nomeaningful counseling. It kills me."
Gwen Malcuit, 33, ofStrasburg in Tuscarawas County, understands Kennedy’s pain. Her16-year-old son, Nick, was misdiagnosed four times and given more thana dozen medications before doctors concluded he has bipolar disorder.
One drug made him sleep 18 hours a day. Another caused him to gain 50 pounds. A third made him fidgety and hyper.
‘‘Ireally believe the medications impaired his learning," Malcuit said.‘‘He was angry, out-of-control and thought I had betrayed him."
Today,Nick is on one medication and enjoys life as a 10 th-grader. He isdoing well in school, has a girlfriend and is looking for a part-timejob.
‘‘Look at what happens when you give a child what he really needs: appropriate services in his own home," Malcuit said.
She lays part of the blame on the confusing system.
Forexample, four state agencies license residential centers: thedepartments of Health; Job and Family Services; Mental Health; andMental Retardation and Developmental Disabilities. Each has differentlicensing standards. The Ohio Department of Alcohol and Drug AddictionServices also certifies some programs.
‘‘It’s a maze that leaves families feeling left out," Malcuit said.
Itdoesn’t help that families often relinquish custody of their childrento county child-welfare agencies because mental-health care is soexpensive. And when they do, they frequently lose the power to makedecisions about medications. They’re also afraid to challenge decisionsout of fear their children won’t be returned.
Fewer reports
Finding out how often treatment centers use drugs to restrain children has become more difficult.
InJanuary 2004, the Department of Mental Health stopped requiringtreatment centers to fill out incident reports for restraints unlessthey involved abuse or neglect, or resulted in an attempted suicide,injury or death, Knight said.
As a result, the number ofreported restraints — both emergency medications and physical holds —dropped from 6,815 in 2003 to 113 last year. Reports of emergency drugsdeclined from 118 in 2003 to 10 last year.
Mental Healthofficials say providers now have to log the use of restraints daily.The department regularly reviews them and compiles totals every sixmonths.
But advocates say the centers aren’t required to note the use of emergency drugs.
Meanwhile,state developmental disability officials have toughened their reportingrequirements, causing their figures to spike from 12 reportedrestraints in 2001 to 542 last year.
The Department of MentalRetardation and Developmental Disabilities also considers the use ofany unapproved psychiatric drug — whether in an emergency or not — achemical restraint.
‘‘They’re well ahead of the Department of Mental Health on this issue," Knight said.
MRDDofficials admit they toughened their requirements after a scathingaudit by what is now the federal Centers for Medicare & MedicaidServices in Washington.
‘‘It’s tough asking the painfulquestions, but if you don’t you’ll never know if a provider is doping aclient up with a powerful psychotropic medication just forconvenience," Director Kenneth Ritchey said.
Since 2000, thedepartment has added 14 people to its investigative unit, created anonline registry of caregivers who have abused people with disabilities,and developed a Webbased reporting system for incidents.
OhioLegal Rights would like the Department of Mental Health to be equallyvigilant, particularly in requiring treatment centers to report the useof all restraints.
Legal Rights points to an incident atKettering Hospital in Dayton last July in which a 14-year-old girl wasrestrained — with drugs, handcuffs, other devices and physical force.Eight staff members, a guard and two police officers were involved inthe episode, which stretched over ‘‘eight horrendous hours," accordingto Legal Rights.
Details remain sketchy, but the agency’s investigation found:
• The teen became agitated and was put in a seclusion room. State officials say she was spitting and threatening staff members.
• While in the room, she managed to pull a mattress cover off a bed andzip herself inside. Police were called and put her into handcuffs untilshe calmed down. Staff members replaced the cuffs with other restraintsand kept her tied up for more than seven hours, against state rules.
• The girl was given three shots each of Haldol and Cogentin, amedication used to offset potential side effects from the Haldol,including stiffness and tremors. The child-welfare agency responsiblefor the teen had never consented to the use of Haldol.
Inthe end, the guard filed charges against the girl because he had thrownout his back during the restraint, and she was discharged to anotherfacility.
Executive Director David Drawbaugh said Kettering is now committed to a zero-tolerance policy for restraints and seclusion.
Statemental-health officials said the incident ‘‘raised a lot of concerns"but was not reportable as a ‘‘major unusual incident" under thedepartment’s standards.
‘‘This is the kind of human-rightsabuse that occurred in the back wards of psychiatric hospitals 25 yearsago," said Laura Wissler, a parent advocate for the Mental HealthAssociation of Summit County.
‘‘If this isn’t reportable, what is?"
epyle@dispatch.com
