Regarding the Connecticut Juvenile Training School (CJTS)
(Summary Report)

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July 22, 2004

Darlene Dunbar, Commissioner

Department of Children and Families

505 Hudson Street

Hartford, CT  06106

Dear Darlene:

The attached document was originally developed to be the second follow-up to 2002 report of “The Child Advocate and the Attorney General Regarding the Connecticut Juvenile Training School (CJTS)”.  Given the Department of Children & Families’ (DCF) recent announcement concerning its new initiative to correct and improve operations at CJTS, we are, for now, releasing our summary of DCF’s progress in meeting our earlier recommendations to you.  We hope this review will provide guidance on our continuing concerns as you plan and implement changes within the facility.

We would like you and Mr. DeVore to meet with us on or close to September 7, 2004, so that we assess the progress made in the facility over this summer.  At that time, we will revise the report to reflect the status of CJTS for public issuance.

Sincerely,

Jeanne Milstein
Child Advocate



Richard Blumenthal                                                                
Attorney General

copy:     Don DeVore, DCF Consultant

One of the remarkable things about our prior reports concerning CJTS is that DCF management has always agreed with our recommendations, something that has been repeatedly communicated to us.  Despite this seeming concurrence, virtually no meaningful steps have been taken during most of the life of CJTS to bring about constructive change.  Over the last year, the Child Advocate and the Attorney General have become increasingly alarmed about the operations and management of the Connecticut Juvenile Training School.  In this time, monitors and investigators from the Office of the Child Advocate have observed that many plans for the facility have been only partially implemented, and that a number of worrisome, dangerous conditions appear to have become worse.  These unresolved issues and multiple problems at CJTS appear to have finally reached a climax at the end of May 2004.

Three years and three management teams after the founding of CJTS, and weeks after the appointment of an outside consultant to remedy the dysfunctional conditions in the institution, a review of the recommendations made by the Office of the Child Advocate and the Attorney General during the facility’s first year seems in order.  Given the events of the last few months, we also wish to insure that these issues, identified two years ago, finally will be addressed in the current attempt to correct the serious problems of the facility.

This report seeks to track implementation of these recommendations through use of several sources of information:

1. Observations and data collection efforts made by the Child Advocate monitors during 2003;
2. Complaints and notifications of abuse allegations received by the Office of the Child Advocate as part of its advocacy duties, and the results of the investigations of those concerns;
3. Review of data contained in the facility’s CONDOIT system;
4. Reports and reviews issued by the Quality Assurance division of CJTS; and
5. Ad hoc requests for information about CJTS and interviews with boys and staff at CJTS.

FINDINGS:

IMPLEMENTATION OF PRIOR RECOMMENDATIONS

Recommendation 1:

Proper protocols should be put into place for the assessment of risk of suicide and suicide prevention in order to insure that no child is at risk for attempting or committing suicide.

2002/2003 Findings:

The suicide of a resident of the former Long Lane School provided the final impetus for the DCF to commence planning for the construction of a new facility for youths committed to the agency through the juvenile justice system.  And yet, the first two reports about CJTS found that an effective policy and set of protocols for protecting children who were at risk of suicide had not been fully put into place two and one-half years after youth were moved into the facility.  Further, the second report found that security practice in the facility frequently contradicted the few procedural guidelines that had been carried over from the Long Lane School.

Current Status:

Since the second of the Child Advocate/Attorney General reports, the CJTS administration has implemented a training program to raise staff capacity to identify and deal with suicide risk.  Such training is now stated to be part of the basic training provided to all new staff.  Reports of the OCA Monitors and the CJTS Monthly Critical Incident Reports, however, lead us to conclude that practice within the living units does not yet adequately protect residents, and some methods used by staff to deal with suicidal youngsters may do more harm than good.

Over the course of 2003, Critical Incidents Reports from the facility indicate that boys made 119 attempts to injure themselves.  Unlike Tabitha B, no children died, but one youth was able to seriously overdose on pilfered medication and required hospitalization.  In at least 6 incidents, that the attempts happened at all is of concern, as these seemed to have resulted from the carelessness and inattention to procedures from staff.  In at least three instances the OCA investigators and monitors have found evidence that residents have engaged in seriously injurious behaviors because medical and residential staff have not followed well-established facility protocols to keep dangerous objects and medications from them.  Even in less dramatic incidents, the facility administration failed to follow standard control and disposal practices (e.g., failing to properly dispense medication or to dispose of waste containing sharp instruments), resulting in situations of serious danger to youths with histories of depression and suicide risk.

In most cases, attempts at self-harm consisted largely of head banging or scratching.  Here our concerns focus on the staff’s response to such incidents.  We continue to see little treatment or even direct interaction or personal engagement in response to such incidents. While log sheets do indicate that staff periodically check these youth, neither logs, nor videos, nor clinical notes routinely demonstrate a reasonable effort to assist youth in calming, or in processing their distress either during or following such incidents. Instead, residential and medical staffs tend to react almost exclusively by imposing restrictive interventions such as room or padded cell seclusion or four-point posey restraint.  We have observed that monitoring in these situations frequently consists of observations through room windows or from some distance away.  In both record reviews and our direct observation the quality of post-incident intervention varies.

The Child Advocate and the Attorney General have been most concerned by CJTS staff continuing to use safety suits on the boys.  The safety suit is a quilted vestment that wraps around the arms and trunk and extends to the floor like a long dress.  All of the boys are familiar with the garment and there appears to be a great deal of humiliation associated with its use.  They cause so much resistance among residents that some youth willingly opt to be strapped into four-point restraints rather than to have to wear the protective gear. Over the last two years, we have received numerous assurances that CJTS would severely reduce or eliminate use of these gowns, yet use continues to average about 2 incidents per month.  We have uncovered one instance in which a youth was so resistant imposition of a safety suit that staff cut off the boy’s clothing to force them into one.

The use of seclusion, restraint, and safety suits not only has little or no therapeutic value for suicidal youth, they may in fact intensify the feelings of anxiety, isolation, and despondency at the roots of children’s attempts at self-harm.  Many of the boys have experienced long histories of abuse, neglect, and adult coercion before coming to CJTS.  For these youth, having yet another adult isolate, overpower, and immobilize them, serves as a painful reminder of earlier abusive episodes.  After considerable periods of being isolated, restrained, or humiliated, even the most damaged youth will eventually calm, but the re-injury has been done to set the stage for further episodes.

Recommendation 2:

Connecticut Juvenile Training School policy and practice regarding the use of restraint and seclusion must immediately be brought into compliance with Connecticut law.

2002-2003 Findings:

Our earlier reports found serious reasons to be concerned about the use of restraint and seclusion in the facility.  Those reports concluded that 1) some restraint and seclusion procedures used in the facility were illegal under Connecticut law and improper under DCF policy, 2) legal restraints were being improperly implemented, and 3) restraint and seclusion were over-utilized in the facility.

Current Status:

CJTS administrators have assured us that they have put into place multiple training and review programs to deal with seclusion and restraint issues.  Unfortunately none of these responses have been thoroughly implemented or embraced within the facility.  Most of the problematic practices noted in our earlier reports are still present, and the administration of DCF has gone so far as to seek to exempt CJTS from state statutes that control restraint and seclusion processes in all other adult and child treatment programs.  Incidents of restraint and seclusion show a slight downward trend overall, but monthly variations are very dramatic, leading us to conclude that root causes of such incidents have not been systematically or adequately addressed.

According to Connecticut General Statutes “’Seclusion’ means:

The confinement of a person in a room, whether alone or with staff supervision, in a manner that prevents the person from leaving, except that in the case of seclusion at Long Lane School, the term does not include the placing of a single child or youth in a secure room for the purpose of sleeping.  (Conn. Gen. Stat. §46a-150)

In both of our previous reports we have concluded that seclusion practice at CJTS is not in compliance with Connecticut law regarding use of such restriction.  Connecticut law prohibits agencies from using seclusion as an administrative convenience for staff.  Agencies may seclude children only in three specific situations: because there is reasonable cause to believe that the child or youth may inflict physical injury on another person; to prevent the child or youth from inflicting property damage; or because the child or youth is engaging in uncontrollable disruptive behavior.  Yet, on a daily basis, CJTS practice is to order youths to their rooms, with a threat of sanctions for leaving the room or opening their doors, for shift changes for up to 45 minutes per shift.  DCF administration refers to this as “Periodic Room Confinement”; in fact, under the definitions of Connecticut law, it is seclusion, and it is illegal.

DCF has claimed that as a State facility, CJTS is exempt from the requirements of the law.  Further, it remains the position of the agency’s administration that confinement of youth to their rooms through threats of sanction does not constitute seclusion.  Applying both of these positions, CJTS administration continues to contend that the seclusion of youths to facilitate shift changes does not constitute a violation of state law.  To insure its continued protection, DCF has now sought legislative change to allow this practice.

We are equally concerned that CJTS routinely continues to employ restraint practices that violate policies required of other juvenile programs in the state.  DCF’s own licensing agreements for residential facilities that it licenses and supports outlaw use of mechanical restraints (i.e., "Mechanical restraint" means any externally applied mechanical device which limits the voluntary movement of a child or youth (DCF Regulations, §17a-16-7)).  Yet, at CJTS, use of handcuffs and the practice of securing youth to four-point restraint tables are so commonplace that all unit staff carry handcuffs, and almost every unit contains a special room for restraining youth.

The administrators of CJTS implemented a training program known as Handle with Care, a “verbal de-escalation and physical intervention training program” for all staff except the Agency Police Officers.  This training includes lessons on de-escalation during a crisis, and on a physical intervention method based around a holding method known as a “Primary Restraint Technique.”  Despite that administrators have made this training package the center of the CJTS response to behavioral discontrol, we continue to see problems.

In reviewing both video and written records of incidents leading to restraint and seclusion, we have become convinced that, far more frequently than is acceptable, residential, clinical, and security staff ineffectively implement and prematurely halt verbal de-escalation attempts.  Most restraint incidents begin, not with an out-of-control youth, but with staff trying ineffectively to secure compliance from oppositional adolescents, and the gradual escalation of the interaction to anger and recalcitrance on both sides.

Two years after the Child Advocate and the Attorney General brought to DCF’s attention concern about chest-down restraint of youth, we continue to witness regular use of this dangerous practice.  CJTS personnel regularly force handcuffed youths to the floor and maintain them in such a position while the staff members attempt to gain control.  As is evident in the videos of abuse of CJTS residents, staff regularly brings youth to the floor by kicking youths’ legs out from under them.  Even more seriously, we continue to see in the facility’s own security videos highly questionable instances of restraint imposition.  We have reviewed records of youth having their faces pushed to the ground, or youth lying on the floor, chest-down, bearing the full weight of the CJTS staff restraining them on their torsos.  All of these actions constitute improper restraint.

The developer of the Handle with Care package appears to agree with our assessment.  On two separate occasions, Bruce Chapman, President of Handle With Care Behavior Management System Inc., has complained that the methods used at CJTS are contrary to the procedures outlined in the training package, and that this use of incorrect, dangerous techniques is so systematic, that it must be a direct result of improper staff training (Chapman, 2004).  Whether the training delivered to staff is improper or incompletely mastered by trainees, many restraints at CJTS are dangerous to both youth and staff.

The frequency with which all these methods of restrictive response continue to be used is equally troubling.  The number of restraints and seclusions reported vary widely from month to month.  The general trend has been that the number of reported seclusions (confinement of a youth in a locked room) has dropped from a 210 per month average in the first quarter of 2003 to 110 per month in the same quarter of 2004, as has the average duration of seclusions over the last year, but the variations from month to month remain significant.  While there may be a similar overall decline in restraint use, this is not as clear, as there have been wide variations from month to month.  Two years after both the Bureau of Quality Management and we determined that restraint utilization was too high, the average number of seclusions and restraints per month are significantly higher than the rates at any other facility in the state serving the same juvenile population.

There simply is no understanding at any level within CJTS that severe physical restriction of a child represents a complete failure of all of its programs — rehabilitative, treatment, and behavior management.  Despite the fact that more youth and staff are injured during restraint imposition than results from any other behavior within the facility, staff still looks upon such approaches as the critical piece of its behavioral control efforts.  This attitude persists despite evidence from multiple national studies and demonstrations now available to administrators and supervisors that the techniques that have been successfully used to dramatically reduce restraints and injuries are known, replicable, and relatively inexpensive.  We believe, as do countless other professionals in the field that “restraint and seclusion use is largely a matter of institutional culture, not resident characteristics,” and would encourage CJTS planners and managers to investigate the work of the US Department of Health and Human Services, Substance Abuse and Mental Health Administration’s demonstrations in restraint reduction.  Many of the demonstration sites have had significant success in reducing the imposition of restrictive measures while maintaining high-quality treatment facilities.

Recommendation 3:

All staff at all levels at the Connecticut Juvenile Training School should immediately receive training in their “mandatory reporter” obligations under Connecticut law.

It was clear from our earlier investigation, that the culture of the old Long Lane School followed staff to the new facility particularly in regard to fulfillment of mandated reporter duties.  In both reports, the Child Advocate and the Attorney General discussed multiple instances of questionable treatment of youth that was observed by other staff and that was not reported to the DCF Hotline.

Current Status:

DCF has had some all-staff re-training on mandated reporter requirements as part of its in-service training program.  In the Fall 2003, the CJTS Ombudsman finally began tracking reports made to the Hotline from the facility, but even in the completed quarterly reports submitted by that office, the facility did not track the outcomes of DCF Special Investigation Unit investigation of Hotline complaints.  These minimal responses have not resolved the issues around abuse and neglect reporting in the facility.

Child Advocate staff regularly has viewed videotapes of questionable incidents and subsequently filed Hotline reports.  In each of these, multiple DCF personnel were present as youth were hit, kneed, or otherwise injured, but only the Office of the Child Advocate filed a Hotline report.  In at least two incidents, the Child Advocate investigator on-site during incidents had to remind DCF personnel who were present that they indeed were responsible for filing their own reports to the Hotline.  To date, there has been no disciplinary action taken against DCF staff persons who have failed in their mandated reporter duties.

In a secure facility such as CJTS, it is critical that staff at all levels be aware of their mandatory reporting duties and understand that it is an expectation of their position that they report questionable treatment of the youth in their care.  This is the only safeguard available to youth so separated from any other source of help and protection.

Recommendation 4:

The leadership of the Department of Children and Families should articulate a clear vision and mission for the Connecticut Juvenile Training School, and then enforce their expectations and rules.

2002-2003

CJTS looks and feels like a prison, notwithstanding the oft-repeated vision at its opening that CJTS would be a state of the art center for rehabilitation.  While mission statements are not an end in themselves, we recommended in both previous reports that CJTS at least begin by enunciating a clear vision for itself in a mission statement. We further urged that management and training in the facility be directed at establishing a climate in which such a mission statement could be implemented.

Current situation:

At the beginning of 2003, DCF approved a mission statement for CJTS

To rehabilitate adjudicated youth through education, treatment, and training within a safe and secure environment.

Little has been done to re-focus either the operational parameters at CJTS or the corrections atmosphere of the facility to create a program that favors rehabilitation and community re-integration over sanction and punishment.  Most of the same staff who worked at the closed Long Lane School are operating under the same policies and practices as at Long Lane School.  There rehabilitative mandates were woefully lacking, and that the top management of the DCF Bureau Of Juvenile Justice and CJTS come from the Department of Corrections.  Furthermore, the current facility is physically indistinguishable from a prison.  Therefore, it is little wonder that a mission statement stressing rehabilitation and re-integration is poorly understood or honored.

Three years since DCF opened CJTS, the agency still has not promulgated any official policies for its “cutting-edge” building.  Currently, it operates under the same policies that guided the substandard Long Lane School.  In reviewing the draft policies that have been recommended for CJTS, it is clear that the new proposed parameters still largely focus on internal control, security, and discipline.  We can find little reflection of the mission statement in these draft policies.  Nowhere does the manual set minimal requirements for education, therapy, and recreational programming.  Out of 155 separate policies, only four can reasonably be said to focus on the goals, methods and parameters set for services to assist the boys held in the facility to improve their functioning and live productive lives upon release.

At the level of best professional practices, we see even less evidence of a rehabilitative culture in CJTS.  Training does not contain explicit distinctions between correctional and treatment purposes; supervision of residential staff is minimal, and contains few formal mechanisms for guiding staff beyond issues of control to providing a treatment-based milieu.  Finally, throughout every service, policies, training, supervision, and practice traditions shape decisions about individual youth around security and control, rather than around youths’ individual strengths, needs, and supports.

All of these features lead us to conclude that the mission of CJTS remains ill-defined, and poorly implemented.  At the end of 2003, the Bureau Chief of the Juvenile Justice Bureau of DCF and the Superintendent of CJTS informed us that it would take at least five years to for the mission statement to be fully internalized at CJTS.  Unfortunately, boys are languishing there now.

Recommendation 5:

The Connecticut Juvenile Training School leadership must take immediate steps to provide for the individualized needs of the children in their care.  This will include the provision of appropriate treatment and education.

2002-2003

The Child Advocate and the Attorney General were concerned that individualized treatment and educational assessments were not being completed for all youth.  Therefore, it is unlikely that youth were assigned to programs and services based upon individually defined sets of needs and strengths.  It was our concern that the youth assigned to CJTS represented a broad array of needs and requirements that could not be met with singular models of assistance. 

Current

DCF has finally begun to implement some of the earlier recommendations:

• The intake, clinical, educational, and clinical staffs do gather available background information on the youths during their first weeks in the facility and do a basic initial assessment of their mental health status.  This diagnostic data is used to assign youths to specialized units, if necessary, and to classrooms in the school program.
• Within 7 days of admission, each youth is the subject of a case conference that includes at least an internal team of intake, clinical, and educational staff.
• The agency has created a specialized mental health unit for youth with Serious Emotional Disturbance, a Transition Unit for boys at the highest level within the behavior management program, and a Behavior Management Unit for youths who have demonstrated severely aggressive behavior.

The effect of this imbalance is to make the residential experience the centerpiece of the treatment plan.  Rather than looking at “Who is this boy?  What are his very specific strengths?  What factors contribute to his needs?” planning comes to center on “How to we maintain this youth in this facility until we can release him from commitment?”  Given the lack of supports from, and ties to, outside systems, such a treatment approach is understandable, but it is of little value to the youth involved.  The inadequacy of such an approach is most evident in the number of youths released from CJTS who within months are returned to the facility for additional legal violations.

This inadequacy of individualized care in CJTS is made particularly acute by the lack of options utilized for addressing youth strengths and needs.  During the period of observation within the facility, we became increasingly concerned about the dearth of activity and rehabilitation options available as resources for the youth at CJTS.  During the period from August through October 2003, the Child Advocate monitor conducted a random survey of the time youth spent engaged in activities outside school hours.  The Monitor found that on one unit, youth were engaged in development or recreational activities for approximately one hour per youth per day; in all other units, the total time was far lower than this.  CJTS has a great many tools and resources to engage youth.  It is disappointing, therefore, to see boys who so critically need to become involved in activities that engage them, build on their strengths, and perhaps give them a future, who are left to spend countless hours playing cards, watching television, and just sitting doing nothing. 

Further, while the mission statement emphasizes rehabilitation and re-integration, in the daily decision-making about youth participation in services and programs at CJTS, security and control always trump these goals.  Assignments for every type of programming — vocational education, recreation, and social skill building — are consistently made based upon youths’ status in the facility’s demerit-based behavioral management program rather than on needs or individual strengths.  Many of the academic and vocational education programs are not simply add-ons or prizes for good behavior for these needy youths; they are critical pieces in finding a key to turning their lives around.  Yet at CJTS, because of the emphasis on control, many of the youth who show individual aptitude for activities and who need such programming the most, are the very boys excluded.

When staff talk about instituting Individual Behavior Plans for youth, what we generally find are instructions on application of Behavior Management Sanctions or restrictive measures.  Such plans, except in the case of a few clinicians, do not systematically contain information that identify core pieces of these individual adolescents’ behaviors, dispositions, and perceptions that will help clinicians, unit staff, and teachers work with the youth.  Instead, most focus on how long youth are to remain in various punishments, restrictions, or restraints.

Finally, research on juvenile justice services repeatedly demonstrates treatment of youth while maintaining community ties is critical to successful rehabilitation.  Yet, at CJTS we have found that:

• Family visitation of youth is limited to a 4 hours per weekend, under rigidly controlled conditions, at a site unreachable for many families;
• Youth visits to home are tightly limited for “safety and security reasons” despite that less than 2% of visits result in youth going AWOL;
• Regular, face-to-face clinical sessions to assist families in resuming care for their children are conducted with less than 30% of residents’ parents; and
• Transitional Unit services are provided to only a handful of youth at any given time.  The highest census in that unit was 10 boys.  Therefore, few youth leave the facility with any kind of real independent living skills.

Recommendation 6:

DCF administration must ensure that management at CJTS is on site and accessible to all staff at all times and that such management fully understands all aspects of the facility and its programs.

2002-2003

The Child Advocate and the Attorney General found that management staff at CJTS was not available on-site during critical periods to assist staff through supervision and oversight of decision-making.  Further, we concluded that the lack of top management presence on the unit had led to a disconnect between the demands and expectations placed on line staff and the capabilities and actual needs of youth, staff, and the organization.

Current

Since the supplementary report of 2003, CJTS has undergone yet one more change in its administrative officers (the third in its short history), and by the beginning of 2004, 2 and ½ years after opening, most, but not all, top management posts had been filled. Currently, the facility lacks a permanent Assistant Superintendent for Residential Services and a Director of Agency Safety and Security who would head the Agency Police Officers.  The rapid turnover in administrative positions and the inability of DCF to staff the management of the facility fully was not helpful in establishing a clear vision for CJTS or in implementing high-quality programming.

In the plans developed for the new facility, a key concept was that CJTS would employ an organizational arrangement known as “unit management”.  As stated in the planning documentation,

Unit management is a team approach ...It incorporates the notion that cooperation is most likely in small groups that have lengthy interaction….[It] relies upon continuous communication among all staff and between staff and inmates.

The approach depends upon interaction of staff across levels as well as across functions.  Each management wave, however, has shown little inclination to be active on the living units and grounds to complete the management part of the unit team.  This continues to mean that managers have little share in the difficulties experienced by line staff, and line staff have little opportunity to learn from the supervision and larger perspective that management can provide.  Without physical interaction among all levels of staff and residents, unit management has become an empty concept.

Until the recent publicized conditions in CJTS, administrative staff was "on duty" only by telephone on nights, weekends, and holidays.  In reviewing CJTS daily logs for August through December 2003, we noted that, even in critical situations, it frequently took Superintendent-level staff between 20 and 60 minutes to respond to pages at night or on weekends.  In several incidents for which the policies in use clearly called for supervisory or administrative sign-off, line staff were left on their own to make critical decisions about the treatment of youth because neither managers nor clinicians responded to their requests for consultation.

Up until May 2004, there had been little managerial presence on the grounds of the facility.  Superintendent-level offices are in a separate building from those housing the residents, and without a specific purpose, top-level administrators rarely spent time in the housing or educational units.  There are frequent meetings of various arrangements of staff and managers in the facility (Management Meetings, Clinical Team Meetings, Residential Meetings, etc.), but very little interaction between managers and line staff took place on a day-to-day basis.  Even at the middle management level, we have found several supervisory personnel who appear to spend inordinate amounts of time enclosed in private offices off the units.  This practice makes it difficult to plan workable procedures within a particular team, to supervise practice, or to manage the implementation of change.  Absentee management simply is not management and does not work.

Lack of administrative and management familiarity with the operations of the facility has been at the root of the failure of the institution to implement authentic change in an efficient, humane, and timely manner.  Many plans hatched at the top of the organization have died immediately when brought to the units because the new policy, procedure, or program failed to take into account operational constraints in the facility.  After three years, CJTS still does not have in place routine processes for supervising and managing such basic issues as cleanliness or safety.  New programs introduced have not been correctly or thoroughly implemented, because there has been no regular supervisory presence to support or demand change.  Attitudes antithetical to the mission of the facility have been allowed to flourish without the presence of leadership in the units to encourage the development of a unified sense of purpose.

Recommendation 7:

The Connecticut Juvenile Training School administration must define, develop and implement protocols for tracking and following up on “critical incidents.”

2002-2003

The Child Advocate and the Attorney General were concerned that, as of their second report, CJTS Quality Assurance Division did not have in place even a rudimentary system for tracking and reporting critical incidents in the facility.

Current

In May 2003, the Quality Assurance Director instituted a monthly data report that includes numbers of suicide attempts, assaults by youth, seclusion incidents, physical restraint incidents, and posey restraint impositions.  The intent of these reports was to provide information for administrators, managers, and supervisors to use to monitor the frequency of restrictive measure utilization.

Despite the best efforts of the Quality Assurance division to collect complete data, we still have serious doubts that all incidents in which seclusion or restraint is used are reported.  While the administrators have informed staff that all incidents are to be entered into the electronic data collection system before shifts’ end, staff members who are uncomfortable with the technology or with such rigorous reporting requirements can easily sabotage the effort.  There are no back-up systems in place to insure that critical incidents are completely reported in a timely manner, and no formal sanctions for failure to report critical incidents.

The tracking of critical incidents in a facility serves two purposes:

1.     It allows managers to review operations in order to identify and manage systemic issues that affect the occurrence of activities at odds with the mission and philosophy of the facility; and

2.     It forces staff to focus on such activities, and recognize the frequency with which they occur.  It makes an issue out of what too often become routine occurrences in the daily life of the facility.

Haphazard implementation of critical incident tracking, however, meets neither of these goals and only creates one more set of paperwork that conscientious staff must fill-out.

In certain instances, physical restraint impositions are not specifically recorded.  We have seen multiple critical incident reports for seclusion or posey restraints, which include notes that the youth was handcuffed or physically held by police or youth officers in order to move youth to rooms or special areas.  Staff usually do not complete multiple separate incident reports for each phase of the process of implementing poseys or seclusion, resulting in serious undercounting of the number of such incidents.

The current incident tracking system still does not track critical incidents involving accusations against staff.  On occasion, the CJTS Ombudsman has presented data concerning Child Abuse/Neglect reports and grievances filed by youth, but maintenance, evaluation, and public presentation of such information has been very infrequent.  In addition, this minimal tracking and reporting has never included information concerning outcomes of reports and complaints, and the results of investigations of potential staff misconduct are not publicly tracked.

The technology installed at CJTS provides a videotaped record of the daily events in the living units.  We are concerned that, having invested substantial funds in such a system, the administrators at CJTS and in DCF have failed to take advantage of the technology at their disposal.  The Child Advocate investigators have uncovered a number of critical incidents by conducting both targeted and random reviews of these videos; we see no such consistent effort by facility staff to make routine use of this system to monitor events.  Given the absence of any other mechanisms for insuring recording compliance, the video system should be used in regular reviews of critical incident reporting accuracy.

Recommendation 8:

The Connecticut Juvenile Training School administration must improve the process of imposing and reviewing sanctions on children at the facility.

2002-2003

Interviews with staff and youth at CJTS led the Child Advocate and the Attorney General to be concerned about inconsistent sanctions for similar behavior as well as a lack of a clear understanding by staff and children as to what all of the rules of the facility were.

Current:

By Spring 2003, CJTS administrators had added a group behavioral therapy program, Aggression Replacement Therapy (ART), to the school curriculum in the facility.  Training all staff on this approach to assisting youth with behavioral control continued through the remainder of 2003.  During Summer 2003, consultants at the facility prepared and began training staff on a Behavior Management System.  The events of the last few weeks and our observations lead us to believe that the implementation of both initiatives has been incomplete and highly flawed.

The introduction to the behavior management protocols states

The system is designed …to engage the youths at CJTS in an understanding of the benefits of positive behavior as well as the consequences of negative behavior.

In fact, the behavior management program is a very poorly structured system of sanctions and punishment, and has little of a positive system of rewards.  In theory, youth move through four levels while in CJTS, each based upon “earning points” each day for good behavior.  Each level carries certain privileges and leads directly to certain decisions in the progress of a child’s plan.  The only concrete benefit, tokens for the facility store, allows boys to occasionally purchase such prizes as hygiene products of a somewhat higher quality than issued by CJTS.  Through Fall 2003, we saw little consistent upward movement of youth through the various levels, and youth interviewed appeared little motivated by the token rewards received.  Until recently, residents rightly perceived that they had little chance of admission to the living unit — nicknamed “Tahiti” — reserved for those youth who attained the highest behavioral level.

The rights gained as boys progress through the levels of the program actually raise concern; participation in necessary educational, vocational, and supportive clinical programs, as well as in recreational activities, is frequently contingent upon a youth having reached a particular level in the Behavior Management progression.  This makes receipt of necessary services contingent upon good behavior and is tantamount to denying appropriate education or mental health treatment as a punishment for rule infractions.

We are concerned that among the sanctions available for treating infractions, “seclusion” continues to be listed as an option.  State and Federal law both clearly outlaw the use of seclusion for disciplinary purposes.  We believe that this blending of restrictive responses to situations that are immediate threats to community or youth safety with disciplinary sanctions gives clear insight to the role seclusion and restraint have come to play in punishing the youth in CJTS.

The activities for which youth are charged (given particular sanctions) are of some concern.  First, among one of the most serious charges is that a youth “engages staff in a restraint.”  Given that most restraints happen to youth on the Mental Health Unit, youth with diagnosed serious emotional disturbance, it is most unfortunate that loss of control not only leads to restraint, but results in loss of status as well.  Clinical and residential staffs do need to deal with such behavior, but punishment at this point seems highly inappropriate.  Second, the language of charges is freely adapted from language far more suited to the adult facilities from which it is borrowed.  While we agree that staff must invoke sanctions for youth who are not where they are supposed to be, or who use crude and demeaning language, the use of terms such as AWOL or Sexual Harassment for these actions is highly inflammatory.

Recommendation 9:

The actions of officials and employees of the Department of Children and Families should be reviewed to determine whether or not disciplinary action is warranted.

2002-2003

The Child Advocate and the Attorney General argued that the failure of DCF officials and employees, and personnel at the Connecticut Juvenile Training School to take timely and appropriate action to protect the children in their care suggested incompetence, mismanagement or misconduct.  We recommended the actions of officials and employees of the Department of Children and Families should be reviewed to determine whether disciplinary action against them is warranted.

Current

Some managers and supervisors were reassigned after our first report, and the top administration of the facility is not made up of the same personnel.  Unfortunately, given that some of the earlier problems continue, the minor disciplinary actions taken seem not to have impressed those now in the facility.

It is clear that no matter what actions were taken regarding those who were involved in abusive or fraudulent behavior in the past, DCF and CJTS administrators have been uninterested or impotent to take action against current employee malfeasance.  The Child Advocate has brought to the attention of DCF and CJTS three instances of employees who in the past have been perpetrators of both physical and sexual abuse against Long Lane School residents, who are, nonetheless, still working at CJTS.  In recent months, the Child Advocate also has brought to the attention of both the DCF Hotline and the Commissioner of DCF, video footage of at least 4 individuals seriously abusing and endangering boys in their care.  We have been informed that union progressive discipline rules prevent DCF from permanently removing or reassigning employees from the units for such offenses.  If such is the case, we urge DCF administrators and human resources staff to work more closely with the state Office of Labor Relations to determine what specific rights the department has in such instances.  If, as we suspect is more likely the case, abusive staff remains protected because of poor DCF personnel management procedures, we again urge DCF seek outside assistance to improve its human resources management and documentation so that clearly inappropriate employees no longer put youth in the facility at risk.  Abuse and neglect of children in the care of the Department cannot be tolerated.

Fundamental management principles make it clear that the conduct of good staff need to be supported and reinforced while the conduct of poor staff need to be corrected.  It is clear to us that the majority of the workers at CJTS are hardworking and caring individuals who sincerely want to see the children succeed.  These staff have also been failed by the systemic problems at CJTS.  On the other hand, the few “bad apples” put both youth and staff at risk.

Recommendation 10:

Oversight of state operated facilities serving children, such as the Connecticut Juvenile Training School, should be truly independent from DCF functions associated with program development and program administration in order to ensure that DCF decision-making is objective.

2002-2003

The Child Advocate and the Attorney General found that DCF had failed to provide proper oversight at CJTS.  We found it unacceptable to have a situation where a state operated facility was unable to meet the licensing standards that are applied to privately operated facilities.  Based upon this finding, we recommended that responsibility for oversight of CJTS be independent of the chain of command for the facility.

Current

Currently, there is no outside oversight of CJTS.  For one year, the Child Advocate maintained a monitor on site to oversee activities within the school.  The Child Advocate was notified in December 2003 that DCF would no longer fund such an observer.  We find it disheartening that most of the progress noted in this report began with the presence of those Monitors on the CJTS campus.  Further deterioration at CJTS, including the events of May 2004, occurred after the monitor was gone from CJTS.  Internal oversight of CJTS remains ineffective at best, and seriously tainted at worst.

The DCF Bureau of Quality Assurance conducted a thorough review of the facility that came to many of the same conclusions as the Child Advocate and the Attorney General.  The report called for the development of a Corrective Action Plan, and for regular reports on the implementation of this plan.  Neither of these processes were ever put into place.  The internal review division has never been given power in this kind of situation to effect any meaningful change in the operations of its collateral divisions.

Of particular concern is the ability of DCF to police individual abuses within its own system.  A Special Investigations Unit investigates reports to the Child Abuse and Neglect Hotline concerning actions of CJTS employees.  The Child Advocate and the Attorney General have serious concerns about the objectivity of these investigations and, therefore, about the safety the process affords for boys incarcerated in a facility so totally removed from the community.  We are becoming increasingly alarmed by the number of clearly actionable reports deemed unsubstantiated by the Special Investigations Unit of the Department.  Of 126 reports made to the DCF Hotline since CJTS opened, 8 have been substantiated.  Yet, on at least 4 occasions in the last six months, the OCA has reviewed tapes that show tripping, kicking, and punching of youths, but even with this video evidence, SIU has refused to classify the incidents as abusive.

In reviewing SIU reports several DCF practices have come to concern us:

1.      Routinely, even reports that in other contexts would be deemed accusations of assault, are identified as reports of “institutional neglect” rather than abuse;

2.      The burden of proof rests with the child.  Youths’ statements are regularly dismissed unless corroborated by staff; 

3.      Inappropriate, unduly harsh application of restraint methods is not substantiated as abusive, despite claims by management and the rank-and-file that all staff are trained and competent to impose restraint; and

4.      Youths’ behavior prior to the incident is frequently treated in reports as provocation to abuse, and is used to excuse staff actions.

The willingness of DCF staff to minimize, excuse, or overlook the actions of their colleagues at CJTS leads the Child Advocate and the Attorney General to have great concern that the SIU is incapable of protecting children in DCF facilities.

Recommendation 11:

An effective internal quality assurance program is necessary at the Connecticut Juvenile Training School.

2002-2003

The Quality Assurance function was added to the CJTS organization well after the facility opened.  By the time of their second report on the facility, the Child Advocate and the Attorney General found that an effective internal quality assurance program still needed to be defined and implemented.

Current

In 2003, the Quality Assurance Manager for Quality Assurance put into place a monthly Quality Assurance report largely to meet requirements for accreditation by the American Correctional Association (ACA).  While initially, the report tracked only critical incidents, it has over the last year come to include a wider range of statistical descriptions of specific occurrences.  Since January 2003, the CJTS Quality Assurance Division has also conducted some in-depth reviews of specific restraint occurrences.  This does represent some progress from the lack of any critical incident tracking which we found in prior investigations but the facility still lacks a fully operating, effective quality assurance function.

The CJTS management team have available some very sophisticated tools for operations evaluation and management- e.g., a twenty-four hour video system, an internally designed information system, and high-level personnel specifically charged with quality assurance functions.  However, they have made only haphazard use of these tools to create a quality facility.

For instance, by the beginning of 2004, the institution’s Critical Incident Reporting was to have expanded to a full critical incident review of all restraints in the facility using written reports and video of the actual incident.  However, as of April 2004, notwithstanding that CJTS staff had imposed over 290 physical and mechanical restraints, the Quality Assurance division could provide records of only 14 such reviews.  Most of the written records of these reviews did not include thorough staff de-briefing and instruction, nor did they result in any significant personnel or process improvement recommendations beyond how to impose such restrictive measures properly.  This limited effort has little hope of bringing about systemic change within the facility.

The essence of quality assurance is the systematic improvement of an organization’s ability to meet the goals it has set for itself.  Building a quality organization goes far beyond data collection, statistical manipulation, and haphazard responses to surface issues.  It is a management process, not a statistics-gathering mission.  CJTS has not taken this next step to build its information gathering capacity into a true system for quality improvement.  Such a system must contain an ongoing mechanism for defining issues, procedures for collecting data that allows accurate description of all facets of the process under study, a forum and process for synthesizing the information available from all participants in an area of concern to draw conclusions about necessary corrections, and routine mechanisms for tying the solutions uncovered into policy, planning, training, and supervisory functions of the facility.  Finally, each improvement process must be continuous, in that implemented changes must be routinely subjected to re-evaluation and adjustment.

Recommendation 12:

The management structure and protocols for internal communication at the Department of Children and Families must be revamped so timely and accurate information is presented to responsible managers.

2002-2003

Poor communication and lack of accountability plagued CJTS and DCF Administration during both previous investigations.  Despite the available technology, neither information, feedback, management nor supervision flowed between CJTS and DCF.  Instead, CJTS functioned in isolation.

Current

At CJTS, DCF has available to it information and communications technology that far outstrips that in most similar facilities.  Yet, three years after its opening, it is outside agents, like Child Advocate Monitors and Investigators and attorneys for youth at CJTS, who continue to be the key transmitters of critical information between DCF Central Administration and CJTS, and between levels of personnel in the facility.  It is these outside individuals who regularly analyze data and point out trends, who review records and videos to identify situations in need of attention.  DCF and CJTS have not developed systematic ways of insuring that needed information is transferred to individuals charged with managing the facility.

At the casework level, CJTS finally has put in place the basic features of CONDOIT, its internal information system.  In this system, the facility has for the first time a compilation of intra-facility information about each of the boys in residence.  Our review of that system leaves us concerned, however, because

1. There remain various pieces of information that appear to be kept in disparate records in the facility, as we frequently note references to other records or notations that we cannot locate in CONDOIT; and
2. The system still has not been fully integrated with LINK, the information system used by other services within DCF.

2002-2003

The Child Advocate and the Attorney General recommended that DCF undertake a comprehensive analysis of the needs of youth under its supervision through its juvenile justice function.  We recommended that the planning function should be separate and independent from those divisions of DCF responsible for program administration.

Current

DCF and the Court Support Services Division (CSSD) of the Judicial Branch have entered discussions to institute joint planning for youth who come before the Superior Court.  Those discussions have only recently resulted in the issuance of a Request for Proposal to launch an integrated assessment and placement system in Hartford.  Planning has not reached even this beginning point in any other city or region.

Based upon the events of the past several weeks and these findings, the Child Advocate and the Attorney General reiterate their past findings and recommendations and further urge DCF administration to develop a formal corrective action plan to address the issues of safety, security, programming, educational services, treatment planning and services, human resources, and personnel management which have been present through the three years since the program’s founding.  Such a plan should contain stringent implementation deadlines with management incentives and sanctions tied to each. 

Specifically, we recommend that such a plan should include the following.

1. DCF should immediately redraft, complete, and promulgate policies for CJTS that reflect the accepted mission of the facility.

2. DCF and CJTS staff must establish within the facility an adequate program of recreation, skill development, and community involvement.

3. The Quality Assurance Division of CJTS, in cooperation with DCF’s agency-wide Quality Assurance Division, must immediately institute the basic pieces of a genuine internal and external quality assurance, planning, and staff development program.

4. The processes of assessment, intervention planning and delivery, and aftercare must be improved to reflect the facility’s role in treating juvenile offenders with mental and behavioral health issues.

5. DCF and CJTS must review the system for serving juvenile offenders in the State of Connecticut.