A preliminary investigation by the California Department of Education has found the El Dorado Hills private school where a child with autism stopped breathing and later died last week violated several state regulations when they put the teen in a face-down restraint position for an extended period.
The boy, identified by the Sacramento County Coroner’s Office as Max Benson, 13, became unresponsive while in the restraint hold and died a day later at UC Davis Medical Center.
The incident took place Nov. 28 at Guiding Hands School on Windplay Drive, according to the El Dorado County Sheriff’s Office. Benson became unresponsive while being held in a ‘prone restraint’ for nearly an hour, according to a source familiar with the investigation.
In a letter sent to the school’s site administrator, Cindy Keller, on Dec. 5 from the California Department of Education and released to The Sacramento Bee through a California Public Records Act request, state regulators found “sufficient evidence” that the facility had violated multiple state rules governing how and when physical restraints can be used on students.
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Those violations included using an emergency intervention — the prone restraint — for “predictable behavior,” using an emergency intervention as a substitute for the student’s personally-designed behavior intervention plan and using the restraint for longer than necessary.
The state also found in applying the restraint, school staff used “an amount of force which is not reasonable and necessary under the circumstances.”
Current evidence supports a finding that the staff’s actions were harmful to the health, welfare or safety of the student, the inspection stated.
The state suspended the private facility’s certification as a result of Benson’s death, meaning it cannot accept new students. The school remains open, however.
Benson’s mother, Stacia Langley, declined through a family friend to comment, but referred questions to attorney Seth Goldstein.
“Whenever a disciplinary matter or an action is taken to correct behavior, it has to be reasonable under the circumstances,” Goldstein said. “If it’s unreasonable or unwarranted, it’s an offense.”
Goldstein said contrary to initial reports, Benson was 5-foot-4 and weighed at most 230 pounds. The sheriff’s office said Thursday an emergency call placed by the school during the incident described Benson as 6 feet and 280 pounds.
“He was not an unmanageable child in any sense of that term in terms of that size,” Goldstein said.
Benson was from Davis and had only been attending the school for a few months, Goldstein said.
Attorney Arlene Mayerson at advocacy group Disability Rights Education and Defense Fund in Berkeley called the state findings “extremely serious.”
“Schools using restraints should be closely monitored,” Mayerson said. “Many children in the state are at risk of bodily harm by these practices. They are used far too widely.”
Cherilyn Caler of Jackson removed her son from Guiding Hands Thursday after learning that Benson died.
In an interview Friday with The Bee, Caler said her 13-year-old son witnessed the incident that resulted in Benson’s death.
Caler said her son is in Benson’s class and said he witnessed the teacher and teacher’s aid physically restrain Benson. Her son, who is on the autism spectrum, told her that Benson was restrained for a period he described as lasting for hours.
According to the account Calder received from her son, Benson was disciplined for kicking a wall. A second parent of a Guiding Hands student, who asked not be identified, said her child also reported Benson was disciplined for kicking a wall.
Caler said her son told her after Benson stopped moving, the staff told Benson to stop pretending he was sleeping. After about thirty minutes of Benson not moving, the classmate said staff realized Benson was unresponsive and called for medical assistance.
Caler said her son has been put in a restraint before at Guiding Hands, and the boy has told her students sometimes pretend to be asleep so staff would release them.
Caler previously complained to the school about the use of restraints, because her son received a rug burn on the left side of his face once after being put in one.
Elk Grove resident Melanie Stark, who pulled her 9-year-old son from the school Thursday, said she had a three-hour meeting with Guiding Hands school administration and an Elk Grove Unified representative on Wednesday to discuss how the school handles her child’s behavior. She has a pending complaint with the DOE about the use of restraints at the school, she said.
The DOE was not immediately able to provide all complaints against the school, though The Bee has filed a Public Records Act request for them.
Stark said she was concerned that her son was restrained on his first day at the school in September, and disagreed with the school’s method and definition of restraint.
According to Stark, a female teacher’s aid often wrapped her arms and legs around her son so he couldn’t get up from his desk. Stark said the school defined the method as a physical prompt, where a teacher uses physical contact to guide a learner through an activity.
“That was too aggressive, and it was happening about four times a week,” Stark said.
Josh Greenfield, 23, was a student at Guiding Hands until 2013. He said he was restrained twice during his time at Guiding Hands and was frightened by the experiences. Greenfield said he thought the restraints were excessive. Once, he said he was placed in a prone restraint because he ignored a teacher calling his name in a hallway.
Rebecca St. Clair of Folsom, another parent with a child at Guiding Hands, said after hearing that Benson was restrained, she recalled an incident where her son was put in a prone restraint two years ago. She said staff placed him inside a thick gym mat and multiple staff put their weight onto the mat to keep the boy still. She said she was upset by the incident.
“He was on edge and it was digging into his bone,” St. Clair said of her son. “He was crying from the pain, but because he was able to calm down he was released.”
It wasn’t until St. Clair personally witnessed a child being rolled into a gym mat and restrained the week before Benson’s death that she said she realized how “alarming and unsettling” it is, she said.
“I tried to assure myself that this was based on trust. I really trusted the teachers,” St. Clair said. “That trust has been broken. I thought they were so careful. I feel so wrong about that now.”
Prone restraints are banned for use in schools in several states and are controversial.
Advocacy group Disability Rights California determined that prone restraints are hazardous and potentially lethal in a recent report that includes fatal case studies. In its report, it recommends that restraint and containment be “viewed as the result of a treatment failure, not a treatment intervention.”
According to the report, prone containment should never be used for people at risk for positional asphyxiation, including those with obesity and those in an agitated, excited state.
In 2016, the U.S. Department of Education found school restraint and seclusion to be discriminatory in an Oakland case where a boy with autism was restrained 92 times over a period of 11 months. According to a Disability Rights California press release, the nine-year-old student at Anova Center for Education in Concord was held face down by two to three adults for up to an hour and a half at a time. Since then, Oakland Unified School District stopped restraining students with disabilities.
Districts around the region contract with Guiding Hands to provide special education and related services to children with special needs, according to its website.
The number of students enrolled in special education programs for autistic students has skyrocketed over the last decade, according to the latest data from the California Department of Education. There were about 8,300 autistic students in public special education programs in the Sacramento region during the 2017-18 school year. That’s roughly triple the number enrolled in special education programs in the 2008-09 school year.
Put another way, about one in 45 of the region’s public school students were enrolled in special education programs for autistic children last school year, compared to one in 135 a decade ago.
Davis Joint Unified, where Benson was enrolled, said Benson was its only student attending Guiding Hands.
“No other district students currently attend or have ever attended this school, and we will not be placing students there in the future,” the district said in a statement to The Bee.
Stark said she called Elk Grove Unified to remove her son from the school, and was told the district was already working on the paperwork.
A spokeswoman for the Elk Grove Unified School District said late Friday that 56 of its students attend Guiding Hands. She also said that the district had informed parents of the incident.
Folsom Cordova Unified School District confirmed seven of its students attend Guiding Hands. District spokesperson Daniel Thigpen confirmed that its special education and administration staff visited the school on Thursday after learning of Benson’s death.
Folsom Cordova Unified officials have been in contact with district’s families that have children at Guiding Hands, and are meeting with them to discuss alternative schools, Thigpen said. Thigpen said the district is not making recommendations about whether to keep or remove children from Guiding Hands.
“This is a conversation that any parent would expect in this situation,” Thigpen said. “We owe it to our parents to open up the dialogue and explore other options.”
Sacramento City Unified spokesman Alex Barrios said that the district does have a contract with Guiding Hands, and said early Friday afternoon the district was beginning the process of reaching out to families of the 29 students in SCUSD’s region who are enrolled at Guiding Hands.
St. Clair, Caler and Stark said they were not informed of Benson’s death by the school prior to media reports.
“It was pretty obvious that it was becoming public,” St. Clair said. “They were scrambling.”
This article was updated Dec. 7 at 9 p.m. to clarify where Max Benson died.