How N.H. treatment facilities are rethinking the role of trauma in kids' behavior
New Hampshire residential treatment facilities used restraint on children at least 100 times per month between 2016 and 2021. Some months saw more than 300 restraint incidents.
State officials are trying to get that number down to zero. And experts say the way to get there is through something called “trauma-informed care”: an approach that focuses less on punishment, and more on understanding why a child might act a certain way in stressful situations and preventing them from repeating behavior that could harm themselves or others.
Read more of NHPR's reporting on this topic: New Hampshire wants to stop restraining children in state custody. Some wonder what took so long.
Many children in residential treatment facilities have experienced abuse, neglect or other significant traumas. The vast majority are involved in the child welfare or juvenile justice systems.
"When they’re having an outburst, it's them trying to speak in a different language and to tell you that something's wrong and they need help."
Trauma-informed care aims to keep these difficult life experiences in mind when responding to a child who’s having an outburst, threatening to run away or exhibiting other challenging behaviors, which are not unusual for children with traumatic pasts. Historically, experts say, residential treatment facilities have tried to manage what has been perceived as “bad” behavior by restraining or isolating children.
But Dr. Kay Jankowski, who leads the Dartmouth Trauma Intervention Research Center, said those kinds of responses can be traumatizing in their own way — especially for children who have a history of abuse and neglect. She says even if staff intend to protect the child by restraining them, what the child perceives may be the opposite.
“If there are enough elements that are similar to what they experienced in the actual event,” she said, “then it ends up retraumatizing that child.”
That’s why Jankowski has worked directly with New Hampshire facilities in recent years to move away from these controlling measures and toward a more trauma-informed approach.
“It’s a different lens to look through,” Jankowski said.
When she’s training staff at residential facilities on trauma-informed care, Jankowski asks them to consider how a child’s history could influence their response during a stressful situation and whether the facility can make changes to reduce that stress. For example, she said, if a child has a history of being abused by men, it might be beneficial to involve more female staff in that child’s care. Certain smells and interactions can be triggers for stress responses, she said.
This shift isn’t just about responding more effectively to difficult behavior in the moment; Jankowski said it can also prevent the behavior from happening in the future.
New Hampshire Child Advocate Cassandra Sanchez is also championing this move toward trauma-informed care at the state’s residential treatment facilities. She said it’s about learning a new way to communicate to better meet kids’ needs.
“When they’re having an outburst, it's them trying to speak in a different language and to tell you that something's wrong and they need help,” 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 firstname.lastname@example.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 at one N.H. facility's mixed progress on taking a more trauma-informed approach
Alexia McMakin says she was the type of kid who could have benefited from a more trauma-informed approach. Instead, the 23-year-old recalls memories of being isolated inside a space called the “Quiet Room” during her time at Nashua Children’s Home in 2016.
McMakin and other former Nashua Children’s Home residents have described the Quiet Room as an austere, isolating space where they were often sent as punishment for all kinds of behaviors: getting into a fight, sneaking in a cell phone, refusing to apologize, getting in trouble at school and more.
The room has small cubbies with metal benches, and a large desk for staff to sit to monitor children. When McMakin was in the Quiet Room, she said she wasn’t allowed to talk to anyone.
“I was in there for hours,” she recalled. “It was very traumatizing.”
Nashua Children’s Home Executive Director Dave Villiotti acknowledges the facility continues to isolate children who are disruptive or in crisis inside the Quiet Room, sometimes for as long as six hours, under the supervision of a staff member. At the same time, Villiotti says they are trying to use less restrictive approaches whenever possible.
Nashua Children's Home staffers say they are trying to adopt more trauma-informed strategies. Some former residents say it's too little, too late.
If a child is acting disruptive but not hurting anyone — for example, throwing things inside their bedroom — Villiotti says staff are less quick to intervene than they might have been in the past.
“In previous years, we would have been less tolerant around allowing that to go on because of the disruption to the whole group,” he said. “Now we're more tolerant of it.”
Daniele Ferreira is among those trying to shift how Nashua Children’s Home cares for its residents. Before she started as the facility’s training and recreational coordinator in 2019, Ferreira spent years working as one of its residential counselors. As a counselor, she said she didn’t receive a lot of training about how to take a trauma-informed approach.
“The knowledge just wasn’t there on our end, back then,” she said.
But now, Ferreira’s trying to make up for lost time. Last year, she created an alternative space to the Quiet Room, called the Sensory Room, that offers a safe and engaging environment for children to decompress away from other residents.
Nashua Children’s Home staffers are also trying to pay more attention to when and how they’re using restraint on their residents. Villiotti said staff look for patterns, like whether certain kids are presenting the same disruptive or aggressive behaviors at the same time each day. Are there ways to proactively calm them down? Are the same kids being restrained over and over again? Each time the facility uses restraint, Villiotti said, they try to check in with the child involved after the incident to better understand what the experience was like from their perspective.
For some former residents, these changes are too little too late. Some say Nashua Children’s Home lagged behind in its implementation of trauma-informed care compared to other New Hampshire facilities they resided at, years ago. Others say the facilities’ continued use of tactics like physical restraint and the Quiet Room compromise its efforts to become more trauma-aware.
Villiotti, who has spent nearly four decades at Nashua Children’s Home, doesn’t think it has to be an either-or situation. He’s on board with adopting more trauma-informed approaches, but he said it’s not realistic to completely abandon tactics like restraint and the Quiet Room.
“We're never going to get there, given the population that we work with,” he said.
While Nashua Children Home’s use of reported restraint has been declining in recent years, even after new contracts that require facilities to move towards zero-restraint went into effect last summer, data from the Office of the Child Advocate show the facility is still restraining children 10 times per month on average. Nashua Children’s Home isn’t required to regularly report its use of the Quiet Room to state oversight agencies, making it difficult to tell how the facility is still using the space.
Both Moira O’Neill, the state’s recently departed child advocate, and Sanchez have said the facility’s continued reliance on tactics like the Quiet Room have the potential to do long-term damage to already vulnerable kids. But Sanchez said she’s cautiously optimistic that its leaders and staff are taking steps to change for the better.
“We know change won’t come overnight,” Sanchez said. “We want to help them get there.”