OLRS' Kids MH Survey
A Snapshot of the Way Residential Services are Provided to Children
A publication of the Ohio Legal Rights Service (OLRS)
July 2000
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Copyright © 2000 Ohio Legal Rights Service. All rights reserved.
The intent of the survey was to gain a better understanding of the residential services available to Ohio's children who have mental health issues. This booklet reflects the findings of a survey conducted by Ohio Legal Rights Service (OLRS). OLRS Survey Teams toured fifteen facilities, met with Program Administrators and reviewed written documents. Residential facilities surveyed were located throughout Ohio, in metropolitan areas, mid-sized cities and rural areas.
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Facility Administrators described many of the kids as "the most difficult" and "kids no one else wanted."
A majority of kids were either referred through Children's Services Boards and/or received cluster funds. A large percentage of kids were from out of the county or state. Children in facilities surveyed ranged in age from 3 to 21 years. Kids are entering facilities at a younger age. Seven facilities had children 6 years old or younger.
Administrators estimated that 70-95 percent of the children in their facilities were there because they were exposed to violence in their lives. Facilities report an increase in sexual offending behaviors among the child residents.
Studies show that children, whether victim or perpetrator, are entering the system demonstrating an inability to manage anger and other emotions and that children have multiple needs that cannot be addressed solely with existing, traditional mental health intervention models.
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Ohio Legal Rights Service (OLRS) conducted a survey of fifteen children's residential mental health treatment facilities. This report is a "snapshot" of the way services are provided to children who live in them. This Survey found the following.
Our kids are institutionalized young
Staff of facilities surveyed reported more children are experiencing violence, and the trauma associated with violence, at a very young age. These children develop tremendous mental health needs. Children are entering residential treatment facilities at a very young age. A children's service system must have a wide variety of coordinated family support options so that these young children are not placed in residential facilities.
Our kids are victims of violence
The effects of violence are manifested in many ways.
It was reported by facility staff that 70-95 percent of the children in facilities had a history of violence in their lives. Children have needs as victims of violence, but they also
develop needs when they themselves perpetrate violence. Disconcertingly,
facilities reported to OLRS surveyors that there has been
an increase in sexual offending behaviors among their residents.
Our kids don't get the help they need
Children have multiple needs that cannot
effectively be addressed solely with existing,
traditional mental health intervention models. don't get the help they need
Children do not get the help they need. While facility administrators recognized
the need to address issues of violence and trauma, only some facilities have
employed trauma specialists or developed violence prevention programs.
Trauma specialists in a facility are be er able to meet the unique needs
of children through appropriate assessment, identification, diagnosis and
treatment planning, and can provide staff training on intervention techniques
for children who have experienced violence in their lives.
Our kids are restrained and secluded
All but one of the facilities surveyed use either
mechanical, chemical or physical holds to restrain children.
In some facilities, children are
restrained and medicated concurrently. Restraining and secluding children is
a common daily practice in Ohio.
State policy in Ohio permits restraint and seclusion.
Our kids are injured and die
Facilities use restraint daily, yet do not adequately address the needs of children who suffer
trauma as a result of violence. A federal report published in September of 1999 by the U.S.
General Accounting Office (GAO), "Report to Congressional Requesters-Mental Health: Improper
Restraint or Seclusion Use Places People at Risk," found that 142 patient deaths were related
to the use of restraint or seclusion over the past 10 years. The report also indicated that these
numbers are underreported due to the fragmented reporting mechanism. A study conducted by
the Harvard Center for Risk Analysis estimated that between 50 and 150 such
deaths occur every year across the country.
In addition, the GAO report states: "Even if no physical injury is sustained, people in treatment
se ings can be severely traumatized during restraint, especially those who had been sexually
abused in the past. ... the use of restraints on people who have been abused often results in those
people re-experiencing the trauma and causes setbacks in treatment."
Children subjected to restraint and
seclusion are at great risk of injury.
The national findings of the GAO report steer us to conclude in Ohio, we are exacerbating the
"trauma effect" on children by restraining them:
Ohio fits squarely within the "problem area" identified by the GAO report.
Our kids are not protected
State law requires that facilities file Major Unusual Incident (MUI) reports
when children are restrained, secluded, abused, neglected or injured while living
in a residential facility. Facilities use different interpretations of
what an MUI is and when to report an MUI.
Children cannot rely on the MUI
reporting process to help protect
them from abuse and neglect.
Ohio does not require a statewide, standardized reporting format which could
permit analysis and use of MUI data to be er identify problems and
protect children.
Our kids have no choices
In some facilities, children all wake up at the same time, eat the same
food, follow the same daily routine, and go to bed at the same time.
Children living in facilities have few opportunities
to learn how to make day to day decisions
about their surroundings and daily life.
Facilities should empower children to make decisions about as many
day to day aspects of life as possible, including, as examples, meal
planning and preparation; rule development and chore selection;
activity and field trip planning; and choosing games, books, videos, and
snack foods.
Our kids aren't asked for input
Children are not asked for their input or participation in the service planning
process. Person Centered Planning is a planning model which requires agencies
to listen to children to help them shape their future. This holistic planning
approach addresses all aspects of a child's life, focusing on a person's
strengths, gifts and choices.
Children do not lead their own team
and do not shape services and
supports for themselves.
Facilities should commit to the values and underlying principles of Person
Centered Planning, with the child as the team leader.
Our kids can't be kids ... and deserve better
Institutional culture has little tolerance for children being children.
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Some fast facts about life on the inside:
- Play areas were in 13 facilities, but freely accessible to kids in only 5 facilities.
- Free access to snacks in 4 facilities.
- Staff turnover is high. Who's watching the kids?
- Computers in a11 facilities.
- "Rules rule," such as:
- "don't touch the art supplies or you will be 'heavily consequenced'"
- "no children past this line"
- "don't touch the television"
- Telephone use restricted in 14 facilities; condentiality limited in 6 facilities; no pay phones anywhere
- Kids stay inside when there are limited options outside
- No much privacy
- Pets in 3 facilities
School
Almost all children:
- attend school at the facility
- facilities operate under an agreement with the local school district
- one facility operates its own Charter School
Fewer children:
- attend the local school (only 1 facility)
- transportation is provided if necessary
Other children simply have homework.
How Long Kids Live in Facilities
In locked units the average stay is 86 days, ranging from 8 - 270 days. In unlocked units, the average stay is 302 days, ranging from 105 to 860 days.
Beds
Fifteen facilities serve 585 children. Administrators speak of kids served in terms of "beds." Kids may be served if and when there are available beds. The largest facility had 72 beds licensed by the Ohio Department of Mental Health (ODMH). The smallest facility had 9 beds licensed by ODMH.
Children Live in Units
Facilities housed children in "units." Units were either locked or unlocked. Of 42 units, 22 were locked; 20 were unlocked. In 7 facilities, all the units were locked. In 3 facilities, all the units were unlocked. In 5 facilities, there were both locked and unlocked units. 254 kids lived in unlocked units; 331 kids lived in locked units. It is not possible for a child to leave a locked unit, for example to go outside and play, unless the door is unlocked by a staff person.
Information Postings
Client's rights must be posted 12 out of 15 facilities surveyed posted client's rights. In addition, facilities must post important telephone numbers and information about the Client Rights Advocate (CRA). Only 3 facilities posted all required phone numbers. Ten facilities did not post phone numbers for the Ohio Legal Rights Service. One posted OLRS' toll-free number and one posted OLRS' toll number. Only 9 facilities posted all required information about the CRA. Four posted nothing about the CRA. One did not post the CRA's work hours and one posted only the CRA's name. Fifteen facilities had a CRA, but 13 CRAs also had other significant job duties.
Major Unusual Incident Reporting (MUI)
The Ohio Administrative Code requires facilities to report major unusual incidents (MUIs) that involve a child in the facility's care. The survey found that:
- Interpretation of the definition of an MUI varied widely
- Interpretation of MUI reporting requirement varied widely
- Reporting of MUI data was not uniform among facilities
Here are some specifics from the surveys:
- one facility did not know what an MUI was
- one facility did not know that there was a reporting requirement
- some facilities seemed to report every incident, no matter how minor
- one facility operated a full year with no MUIs
- one facility average 2.86 MUIs per day
- one facility reported MUIs and UIs (unusual incidents) as a group
- some facilties maintained data on a fiscal year; others, a calendar year
Seclusion and Restraint
Eleven facilities used seclusion rooms; 4 facilities did not use seclusion rooms; and 1 used a seclusion room on locked unit only. There were 11 seclusion rooms with lights, 10 with locks, 9 with windows, and 3 with padded walls.
Restraint is a common daily practice in Ohio and was used in 14 of 15 facilities surveyed.
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The following are some of the noteworthy practices in one or more of the 15 facilities surveyed.
- Facility had a trauma specialist on staff
- Facility continuously looked to reduce the use of restraints
- Facility used a behavioral treatment model instead of a medical model
- Facility had a Foster Care program which facilitates transition to
the community
- Facility's staff orientation includes a panel of children
- Facility had a student government whose recommendations are
implemented
- Facility staff cooked with the children
- Facility policy included "no eject/no reject"
- Facility had a "Secret Partner" program to make holidays and
birthdays more special for the children
- Facility used satisfaction surveys for children and families
- Facility posted a sign stating: "Confidentiality is a client right and
a staff responsibility"
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- Foster community cooperation and increase resources for noninstitutional
supports.
- Conduct a trauma assessment for each child admitted to a
residential mental health facility.
- Hire or consult with trauma specialists and sexual offender
consultants to address the multiple needs of children.
- Evaluate seclusion and restraint regulations, policies and
practices in children's mental health facilities.
- Eliminate the use of restraint and seclusion.
- Standardize the MUI reporting process: a centralized data collection
point, electronically generated, would produce more reliable information
for policy makers. Provide full time Client Rights Advocates who
can advocate effectively without conflict of interest.
- Empower children to make decisions about service planning
and other aspects of their lives. Ensure that all children
have residential options outside the institution.
- Adopt a Person Centered Planning approach to service planning.
Ensure that each child is actively involved in developing an individual
discharge plan immediately upon admission to the facility.
- Create and maintain an environment in which children have greater
freedom to play, snack, be private, make phone calls, enjoy pets
and live by reasonable rules.
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This publication was produced by the Ohio Legal Rights Service, 50 West Broad Street, Suite 1400, Columbus, Ohio 43215-5923. Telephone 614-466-7264/800-282-9181 TTY 614-728-2553/800-858-3542 Web site: http://olrs.ohio.gov
Ohio Legal Rights Service and this publication are funded in part by grants under the following federal laws:
- Developmental Disabilities Assistance (DD) Act, administered by the Administration for Children and Families;
- Protection and Advocacy for Mentally Ill Individuals Act (PAIMI), administered by the Center for Mental Health Services of the U.S. Department of Human Services; and the
- Rehabilitation Act of 1973 as amended, administered by the Office of Education Services and the Rehabilitation Services Administration of the U.S. Department of Education.
Ohio Legal Rights Service does not discriminate in provision of service or employment because of race, color, religion, sex, sexual orientation, national origin, military service, disability, or age.
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