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N.H. wants to stop restraining children in state custody. Some wonder what took so long.

Becca Soulia
Alli Fam
/
NHPR
Becca Soulia spent her childhood in and out of New Hampshire’s foster care system, including some residential treatment facilities. Today, she’s pursuing a degree in health sciences with the goal of becoming an occupational therapist.

Editor's note: This story was updated with additional comments from David Villiotti, executive director of the Nashua Children's Home, on Tuesday, May 24.

Sitting outside Nashua Children’s Home, Becca Soulia, 17, was hurting. She felt abandoned, again. Her mom was dropping her off at the Nashua Children’s Home, where Soulia had previously been a resident.

Looking back, Soulia said her mother struggled to manage what she now calls her childhood meltdowns. Soulia, who is autistic, used to get upset and aggressive. Sometimes, Soulia said, her mother would call the police. It meant Soulia spent her childhood in and out of New Hampshire’s foster care system.

On that day in Nashua, in 2012, Soulia refused to go inside the Nashua Children’s Home. Instead, she sat on the ground behind her mother’s blue car.

“Was I hurting anybody? No.” Soulia said in an interview. “Why not just let me sit behind the car until I calmed down?”

But that’s not what happened next.

Instead Soulia said she was physically restrained. She remembered two staff members flipping her over, forcing her to lie face down on the ground, and straddling her. Then, they took her inside.

“I was already triggered. And being restrained only made that worse.”
Becca Soulia, former resident of Nashua Children's Home

“I was already triggered,” Soulia said, “And being restrained only made that worse.”

NHPR spoke to Soulia’s mother who witnessed the incident and confirmed details in Soulia’s story. The center’s executive director, Dave Villiotti, did not recall this particular event, but acknowledged that his staff used similar tactics on residents at the same time Soulia was there. (Editor's Note: After publication, Dave Villiotti told NHPR that while staff at Nashua Children’s Home has at times physically escorted children inside the facility, he does not endorse the tactics described by Soulia.)

What happened to Soulia that day was not an isolated incident from a decade ago. The most recent available state data shows there were nearly 2,000 reported incidents of restraints in residential treatment facilities for children in New Hampshire between July 2020 and June 2021.

Trauma experts say restraining children in facilities that are supposed to provide therapeutic care can be especially harmful, because many children there have already experienced significant trauma like abuse or neglect and suffer from PTSD.

New Hampshire law defines restraint as “immobilizing a person” or prohibiting their free movement, which can be accomplished by physically holding a child or pinning them to the ground, using a device like handcuffs to stop their movement, or medicating them. New Hampshire residential treatment facilities typically report physical restraint used against children.

All forms of restraint in residential treatment facilities are supposed to be limited to “emergencies only,” when there is “imminent risk of serious bodily harm” to the child or others. But former residents of some New Hampshire facilities say in practice, physical restraint is often used to curb disruptive or mildly aggressive behavior.

Now, New Hampshire could be on the precipice of restraint reform: The state health department is, for the first time, requiring facilities that contract with them to work “towards a zero restraint practice.” Facilities must use trauma-informed approaches to care, which experts and officials say can help them meet the new restraint policy.

But it’s unclear how facilities will be held accountable for meeting that policy. And former residents, like Becca Soulia, wonder why state-mandated trauma-informed care and restraint reduction weren’t implemented years ago at the Nashua Children’s Home and similar facilities.


If you’ve lived or worked at a residential treatment facility in New Hampshire, we want to hear about your experiences with restraint. You can share your story by emailing voices@nhpr.org. We will not publish anything you tell us without your permission, but your perspective will help make our reporting on this topic stronger.


A closer look: Restraints at Nashua Children's Home

The subject of restraint is at the center of two recent conflicting assessments of Nashua Children’s Home by state agencies that looked at the effectiveness of its care and staff culture. The facility, which currently houses around 40 children, offers therapy and behavioral health treatment, with the goal of transitioning kids back into their communities.

The reviews show state agencies aren’t in agreement about the facility’s ability to consistently meet those priorities. One state watchdog agency, the Office of the Child Advocate (OCA), found significant cause for concern. The other, the Bureau for Children's Behavioral Health (BCBH), which has the power to enforce the state's new restraint policy, has largely dismissed the OCA’s concerns as issues from the past.

In a December 2021 report, the OCA found Nashua Children’s Home used restraint beyond emergency cases, among other concerns.

The report outlines a pattern of restraint similar to that described by former residents who spoke to NHPR, like 20-year-old Courtney Shanyne Jay. She said she was frequently restrained between the ages of 11 and 13 when she was a resident of Nashua Children’s Home; sometimes, she said, it was used after she violated a rule.

“I swore, which was against the rules,” she said of one example.

Staff asked her to go to her room, but she refused, wanting to make a phone call. The encounter escalated, Shanyne Jay said, ending in restraint. Like Soulia, Shanyne Jay wonders if restraint could have been avoided. Maybe she could have made the phone call, then gone to her room.

“I wasn't a danger to anybody or myself. So I shouldn't have been restrained,” she said.

Other former residents said they often witnessed restraint as a measure for clamping down on disruptive behavior, rather than to protect children from seriously harming themselves or others.

Following the OCA report, the state’s Bureau for Children's Behavioral Health, or BCBH, conducted its own review of Nashua Children’s Home.

Rebecca Ross, the BCBH director, said at an April meeting of a legislative oversight committee that her agency “did not come up with any of the same conclusions” as the OCA report.

Ross did not fully discredit the OCA report, but noted its key incidents happened before new contracts (with a near zero restraint policy) went into effect last summer. Ross said she had “no concerns about overall contract noncompliance” and that a “forward focused” summary will be published this spring.

David Villiotti, Nashua Childrens Home
Alli Fam
/
NHPR
David Villiotti, executive director of Nashua Children's Home, says restraint can be used to avoid emergency situations. He says the state's current restrictions on restraint use are too narrow.

But Moira O'Neill, the director of the OCA at the time that office’s report was published, is worried that “forward focus” could come at the cost of meaningful accountability.

“Acknowledging that children have had bad experiences could go a long way to healing for those children,” O'Neill said.

When leadership at state agencies don’t provide more accountability, they can pay in the long run, O'Neill said, referencing the alleged abuse of hundreds of children in state custody at the Sununu Youth Services Center.

And O'Neill also isn’t convinced that past practices are ending. She questions how systemic issues at Nashua Children's Home her report flagged, like an over-reliance on restraint, could have so quickly become a non-issue.

Still, initial data from the OCA show restraint incidents have been declining at Nashua Children’s Home since the contracts went into effect.

Cassandra Sanchez, the agency’s new director is cautiously optimistic, but said the OCA remains concerned about restraint use at Nashua Children’s Home.

“We don’t have enough data to say what is different yet,” she said. One resident who was frequently restrained leaving a facility is enough to dramatically skew data, for example.

Dave Villiotti, director of Nashua Children’s Home for 37 years, takes issue with findings in the recent OCA report. He said the report shows a lack of understanding of the rigors of residential group care and the need for split second decisions.

Villiotti is proud of his staff and the care the home provides. A few former residents NHPR spoke with have stayed in touch with staff years after leaving, and are grateful to the facility.

And Villiotti does agree there’s room to keep reducing restraint. Restraint use at the facility was already declining for several years ahead of contracts, according to state data.

Villiotti said he’s tried to give staff more leeway to monitor disruptive behavior and rule breaking, rather than clamp down on it, which can lead to incidents of restraint. He thinks the type of incidents described by Soulia and Shanyne Jay would be much less likely to end in a restraint now. But the pressure to reduce the practice, he said, has also meant he’s been more hesitant to accept into his facility children with a history of aggressive behavior.

Villiotti doesn’t see a need to fully abandon tools like restraint or hours in the so-called “Quiet Room,” an experience former residents found painfully isolating.

“We also support the value of our own experience with kids over the years,” he said.

Villiotti also finds state restraint law too narrow. He wants it to allow for more pro-active restraint use, as a way to help avoid emergency situations.

It’s a mindset that worries the OCA. The agency said relying on restraint and isolating spaces like the “Quiet Room” to manage difficult behavior runs counter to new state requirements for trauma-informed care.


Read more: How N.H. treatment facilities are rethinking the role of trauma in kids' behavior


Video footage shows teenager confined in a room for hours, restrained when she tries to leave

Quiet Room Nashua Childrens Home
Alli Fam
/
NHPR
Former residents say they and others sometimes spent hours in the Quiet Room until they apologized for breaking a facility rule.

As the state tries to steer facilities away from restraint, advocates say it's key to understand when it's being used in the first place. At the Nashua Children's Home, the Office of the Child Advocate has said that means understanding how certain conditions or spaces — like the facility's "Quiet Room" — may play a role.

In February 2022, a 16-year-old girl spent over six hours in the Nashua Children’s Home’s so-called “Quiet Room.” Video footage viewed by NHPR from Nashua Children’s Home shows she was restrained when she tried to leave (the footage did not include audio). The incident took place over six months after new contracts requiring facilities work towards a zero restraint practice went into effect.

For the first hour and a half, the girl appears to chat with a staff member. Then, the door closes. She has little to keep herself occupied. She gets up. She paces. She lays on the floor next to what appears to be a heater. She eats a slice of pizza brought in for her. She appears to grow increasingly frustrated, confined in the small room.

After over four hours, the girl tries to leave. A staff member blocks her with his body, and when the girl tries to push past, he yanks her arm. She punches him in the face. The staffer wrestles her to the ground, and restrains her in the prone position for eight minutes. Police were called on allegations of the girl assaulting staff. She remained in the room for over an hour until police arrived.

Staff worried about what she would do if she left the room, according to their report.

“I told you I had to pee,” the teen said, according to the report. “I said some comments that were alarming to you, so you didn't feel comfortable letting me go... but you should have let me go.”

The allegation that Nashua Children’s Home has over-relied on restraint requires examining conditions leading up to an incident like this one, O’Neill said. It’s asking questions about alternatives for the child. Did she need to be in the room for that long? Could she instead have been in the facility’s new sensory room, which offers books, a trampoline and other activities?

O’Neill also says she considers it a red flag when a facility charged with providing therapeutic treatment calls in the police.

“What about calling law enforcement is therapeutic?” said O'Neill. Involving the police can also perpetuate a lifelong cycle of involvement with law enforcement, she said.

Villiotti finds these questions irrelevant in this case. He said the girl had recently run away from the facility. She was gone for days, and he worried it could happen again. He also worried she would continue to disrupt other kids had she not been kept separate from them.

Police, Villiotti said, were called to hold the child “accountable” for punching his staff.

Rather than asking how his facility could have handled the situation differently, Villiotti suggested that the girl could have avoided being restrained by behaving better.

“She could have remained there [in the Quiet Room] and then gone back to her unit,” he said.


Data suggests facilities are using restraint less often, but reporting standards are spotty

Nashua Children’s Home is far from the only facility in New Hampshire restraining children with regularity. According to state data, the home accounted for 10 percent of all restraints reported at residential treatment facilities between July 2020 and June 2021. Other facilities, like Spaulding Academy & Family Services in Northfield and Easter Seals Zachary Road in Manchester, reported even more restraints during that time period.

But it’s hard to make direct comparisons between different facilities, or to know whether the reported numbers capture the full use of the practice. New Hampshire has historically lacked clear and consistent standards for reporting restraint incidents.

Facilities also vary dramatically in size, so total restraints isn’t a proxy for frequency. Nashua Children’s Home, licensed for 46 beds, is one of the largest in the state. Facilities work with populations with different levels of behavioral health challenges. Children with aggressive behavior and disabilities are often restrained more frequently, according to those who work in the field.

Getting an accurate snapshot of how many restraints are happening has been difficult, because of differences in how facilities report these incidents to the state.

Between January 2016 and June 2021, New Hampshire residential treatment facilities and the Sununu Youth Services Center reported using physical restraints on children at least 1,900 times per year. As of the start of 2020, the most recent available data, the state reported that about 260 New Hampshire children were receiving treatment in residential facilities in New Hampshire. 80 were receiving that type of care out of state.

The available state data suggests that facilities are using physical restraints less often than they were five years ago, as policymakers, advocates and facilities have tried to move toward more hands off approaches to de-escalate intense situations and manage highly disruptive behavior.

Residential treatment facilities aren’t the only institutions restraining children. Nearly one in four schools in New Hampshire reported restraining a student at least once in the last school year, according to data from the Department of Education.

Broad Street Elementary school in Nashua, which works with students with special needs, accounted for nearly one-fifth of the 672 total incidents reported. In mid-March, a staff member at Woodside School in Concord, a day care center, was terminated for restraining a child and violating state law.

New Hampshire has been collecting data on restraint use for 12 years, but until 2014, the legal definition of reportable restraint was open for interpretation, allowing facilities to not report restraint incidents they considered brief. Many residential treatment facilities reported none at all. Lawmakers clarified the definition in the hopes of having a more accurate picture of how frequently children were being restrained, an effort Villiotti supported. The next year, many facilities that were previously reporting no restraints reported dozens.

But even since those changes, getting an accurate snapshot has been difficult. Facilities used different reporting forms. State staffers still collect restraint reports via email and manually add the data to an excel spreadsheet.

“It isn't ideal, but at least it’s something,” said Joe Ribsam, director of the Division of Children, Youth and Families.

Ribsam said a new portal system is in the works. Better data could make it easier to ensure facilities meet new contract standards. It could also help the state track metrics like the race and ethnicity of the children involved in restraint incidents.

Children of color in New Hampshire are disproportionately represented in residential services, which include treatment facilities and foster care, compared with the general population according to state figures from 2020. But data on the use of restraint by race or ethnicity of the child is not currently available. A report from the U.S. Commission on Civil Rights has shown restraints in schools are applied at a disproportionate rate to children and adolescents of color with disabilities.


How one incident shows the murky legal landscape of prone restraint in N.H.

The exterior of Nashua Children's Home, a white house with a porch, and a front yard with a sign that reads "Enriching the lives of children since 1903..."
Alli Fam
/
NHPR
Nashua Children’s Home is one of over thirty residential treatment facilities in New Hampshire.

Nashua Children’s Home continues to use a tactic known as prone restraint, which is controversial in the behavioral health industry. The only other facility in New Hampshire still using the tactic as of 2020 was the Sununu Youth Services Center, which holds detained and committed youth.

Prone restraint is when an agitated person is held face down. If too much weight is placed on the back of the person being restrained, they can stop breathing. That’s what happened in the murder of George Floyd by a Minneapolis police officer.

A teenager at Nashua Children’s Home was restrained in a prone position for 80 minutes until police arrived in March of 2020. The teen was arrested for assaulting the staff member and for resisting arrest, according to a Nashua police report.

It was one of the longest restraints that year, according to analysis from the OCA. Of nearly 1,500 reported incidents, at New Hampshire residential treatment facilities and the Sununu Youth Services Center, over half were 10 minutes or less. Twenty-three lasted over an hour.

An investigation by the New Hampshire Child Care Licensing Unit determined that the Nashua Children’s Home broke licensing regulations and state law, for not trying less restrictive techniques first. Nashua Children’s Home successfully appealed the decision, on the grounds that it was protecting the child from leaving. The state licensing unit did not respond to requests for an interview, and said records requested by NHPR documenting their decision are exempt from disclosure under state law.

It's unclear if the licensing unit’s investigation looked at whether the 80-minute restraint violated another section of New Hampshire law: whether the restraint itself was too dangerous.

New Hampshire law prohibits restraint that “impairs the child's breathing.”

A referral of suspected abuse/neglect of the teen noted that three adult males sat on and straddled him and inhibited his breathing, according to the OCA report. (Editor’s Note: After publication, Dave Villiotti told NHPR that while three adult males were involved in this incident, all three did not act simultaneously.)

Dr. Thomas Andrew, the state’s former chief medical examiner, said being in the prone position is not inherently dangerous for most children. But the “chaotic environment” in which prone restraint is used adds to the risk, he said.

New Hampshire law is not entirely clear when it comes to the use of prone restraint in facilities that care for children. State law bans any restraint that impairs breathing, but falls short of banning prone restraint outright; the word “prone” was removed from an early draft of the legislation.

A 2021 report from the Dartmouth Policy Research Shop said the technique can be safely employed, but agreed the law was ambiguous. The report was written by undergraduate students, under the direction of professors at the Nelson A. Rockefeller Center.

Some other states, including Maine and Rhode Island, are more explicit in their laws, and ban prone restraint outright.

For Villiotti, the removal of the word “prone” from an early draft of the law is evidence the technique is legal. But others, like Mike Skibbie, former policy director with the Disability Rights Center, think current law prohibits prone restraint even if the technique isn’t named in the law.

“If anybody's ever laid face down on a floor,” he said, “I don't think they can make a logical argument that the movement required for breathing is not impaired.”

Ribsam, director at the state Division of Children, Youth and Families, asked facilities several years ago to stop using prone restraint. But Ribsam said given the gray “state of the law” he didn’t have the authority to enforce the request.


New contracts call on facilities to work 'towards a zero-restraint practice,' but enforcement standards are unclear

The state is changing its relationship with over 30 New Hampshire residential treatment facilities by formalizing the terms of care for children in contracts. It’s a shift from the more casual relationship of years past.

Ribsam said the new process includes a screening tool to assign children to a facility that can meet their needs. This system could help reduce restraint at facilities like Nashua Children’s Home, which under the new model, should not admit residents who require intensive or acute levels of treatment. The contracts also require trauma-informed care, which experts say could help facilities use the practice less.

Facilities must work “towards a zero restraint practice,” but the methods for holding facilities to that standard are vague, in part because the language itself doesn’t require facilities to actually get down to zero, but rather “work towards” it.

State regulators conduct yearly quality assurance reviews and regular reviews of restraint, according to a spokesperson from the state health department.

Villiotti said he hasn’t noticed much new oversight since the contracts went into effect last summer. He finds the Bureau of Children’s Behavioral Health generally trusts him to conduct reviews and debriefs of restraint with staff, and aren’t micro-managing the process. He said many of the new contract requirements, like implementing trauma-informed care and reducing restraint, were steps the facility had already been working towards ahead of the contracts.

Villiotti finds the new restraint policy aspirational, although he agrees it’s a good goal.

“Everyone knows that [zero restraint] is not realistic,” he said.

But a few New Hampshire facilities, like the Dover Children’s Home, reported zero incidents of restraint last year. Ribsam said he believes a number very close to zero is possible, noting it may be necessary in very rare scenarios where children are hurting themselves or others. Based on his experience helping with a similar restraint reduction effort in New Jersey, Ribsam said eliminating restraint can’t happen overnight.

“Whether it's certain triggers or certain staff who struggle in pressured environments, you'll start to see patterns and you'll be able to figure out how to pull back,” Ribsam said.

While the Bureau for Children’s Behavioral Health does have the power to enforce contracts, an agency like the Office of the Child Advocate is powerless to implement policy although they can work with facilities to reduce the practice. The agency Ribsam heads, the Division for Children, Youth and Families, also can’t directly enforce contracts.

The legal debate over prone restraint could be ended by lawmakers, but there isn’t momentum at the State House to do so.

Now 26, Becca Soulia works with children with assaultive behaviors. She said she’s only used restraint once, when a girl was threatening to jump out a window amidst a psychotic episode.

“It should only be used as a last, last, last resort” she said.

She’s trying to make changes where she can. She’s pursuing a degree in health sciences at New England College. She’s written research papers for school on trauma-informed care and the value of spaces like a sensory room. Soulia is involved in the lives of her nieces, aiming to be the stable, supportive adult that was missing in her childhood.

She envisions herself as an occupational therapist, working with kids, like her, who are on the autism spectrum.

“I want to say, you're not alone, I went through this” she said.


If you’ve lived or worked at a residential treatment facility in New Hampshire, we want to hear about your experiences with restraint. You can share your story by emailing voices@nhpr.org. We will not publish anything you tell us without your permission, but your perspective will help make our reporting on this topic stronger.

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