The adults gathered in a hotel ballroom in Peoria — school employees, caregivers, health care workers — fell silent as their instructor, a muscled and tattooed mixed martial arts fighter, stared at them to demand attention.

Over five days of training, the participants would learn how to physically control children who pose a danger to themselves or others. But first, Zac Barry focused on what he views as the most important lesson.

“Choosing to use a restraint should be an extremely difficult decision,” he told the class. “Kids die in restraints.”

To Barry, a social worker who teaches a system called Therapeutic Crisis Intervention, the message is clear: Physically restraining a child is a deadly serious matter. It should be used in an emergency and at no other time.

“We do not do it to force compliance,” he told the class. “We’re not doing it to inflict pain or harm. We’re definitely not using it as punishment or discipline in any way, shape or form.”

But a Chicago Tribune and ProPublica Illinois investigation shows that message often is lost.

An analysis of more than 15,000 physical restraints in 100 Illinois school districts from August 2017 to early December 2018 found that about a quarter of the interventions began without any documented safety reason. Instead, they often happened after a student was disrespectful, profane or not following rules. These instances violate a 20-year-old state law that allows children to be restrained at school only for safety reasons.

Records show that most of the children restrained had behavioral or intellectual disabilities.

The law defines physical restraint as holding a student or otherwise restricting the child’s movement. The student can be standing, seated or lying down. A brief hold intended to keep students safe or to escort them from one place to another is not considered a restraint. Illinois law prohibits the use of mechanical restraints, such as straps or handcuffs, in schools.

One girl in the Chicago suburbs who had spent five hours in a seclusion room was “taken to floor” after she refused to return to isolation after a bathroom break, according to records from the elementary school run by Proviso Area for Exceptional Children in Maywood.

“My back hurt,” she said, kicking her legs. “Y’all got me smashed to the floor.” She was restrained for 32 minutes as school workers waited for her to stop moving.

In 50,000 pages of school records reviewed by reporters, aides and teachers documented numerous injuries to the children they had restrained: Cuts on the students’ hands, scratches on necks and noses. Collarbones that hurt to touch. Knots on their heads and split lips. Sore ankles and wrists.

In at least two dozen incidents, schools called an ambulance for a child.

School employees got hurt, too, as they wrestled with flailing children who sometimes bit, hit or kicked while trying to get free.

On Nov. 19, ProPublica Illinois and the Tribune published “The Quiet Rooms,” an investigation into the practice of secluding students in small spaces. The next day, the Illinois State Board of Education took emergency action to prohibit the locked “isolated timeouts” previously allowed under state law.

Reporters also had begun to tell state officials about their findings on restraint, which schools often use in tandem with seclusion. Among those findings: Schools across the state were using prone restraints, in which students are held facedown on the floor, and some districts used them frequently.

Restraints in a prone position are particularly dangerous because they can cut off a child’s ability to breathe. Officials from the state Board of Education, which was not monitoring schools’ use of seclusion or restraint, said in an interview they did not know the extent to which Illinois children were being put in prone restraints. A board official noted it was not required by law to keep track.

The board, which put emergency restrictions in place on all restraints in the wake of “The Quiet Rooms,” is moving to ban prone restraints permanently.

“Under my watch, I cannot — I will not — allow it to continue,” state schools Superintendent Carmen Ayala said in an interview. Ayala, appointed in February, said she was “taken aback” to learn about the behavioral interventions schools were using, including seclusion and prone restraint. New rules require schools to report their use of seclusion or restraint within two days.

Many districts, including the Proviso special education cooperative, declined to discuss individual incidents but told reporters they follow the state law and strive to keep children safe.

The schools examined as part of this investigation likely represent a fraction of the number that actually used physical restraint in Illinois. The 100 school districts and special-education cooperatives included in the analysis were selected because they previously reported using seclusion to the federal government or because they exclusively served students with disabilities.

Many more districts — more than 280 — reported to the U.S. Department of Education that they had used physical restraint in the 2015-16 school year, the most recent data available. Even that number is likely an undercount, as the federal database relies on self-reporting from districts and is known to omit information.

For 11-year-old Austin Kelly, being restrained or secluded has been a routine part of his time at school, his family told reporters.

The school he attends, the Kansas Treatment and Learning Center in east-central Illinois, restrained students at least 171 times from August 2017 to early December of last year, records show. Officials from the Eastern Illinois Area Special Education district did not respond to requests for comment.

At his grandmother’s home in Ashmore this year, Austin and his brother were playfully chasing each other when, as they fell to the floor, Austin cried out: “I’m restraining you!”

“It’s just he thinks normal is … restraints,” said Austin’s mother, Spring Andrews. “His brother will do something to make him mad, and he’ll restrain him!”

Andrews said Austin, who has attention deficit hyperactivity disorder, does not need to be restrained to calm down.

“They showed him that violence is OK. They showed him that putting hands on someone is OK,” she said. “It is not OK.”

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Escalating Encounters

When school employees learn the techniques of physical restraint, they practice on other adults, moving in slow motion as they grip their arms from behind or take them to the ground. Everyone is a willing participant.

In reality, physically restraining a child can be an ugly encounter.

That becomes evident in reading the records that state law requires school workers to keep when they restrain a child. The documents often detail these incidents moment by moment, including what was said.

One incident last year in the Valley View School District southwest of Chicago began with employees taking away pencils that a boy had been using as drumsticks in class. He got upset, threw books and was taken to a seclusion room, where he stomped on a staff member’s foot. He then was restrained for 15 minutes as school workers tried to hold him still, and he complained he couldn’t breathe.

“You’re gonna get me dead,” he said as he begged to be let go. Valley View district officials did not respond to a request for comment.

At the Kansas Treatment and Learning Center, records show that workers scoffed when a boy told them his father had forbidden employees to restrain him. They then performed what’s known as a “takedown” and restrained him flat on his back on the floor. Workers also held him in a standing position and put him in seclusion.

The incident lasted five hours; workers took 14 pages of notes.

“Are we going to do this all day?” an aide asked the boy. “Are you ready to get up? Yes or no. You ready to sit against (the) back wall? Yes or no. Good choices.”

The same boy was restrained three times that day in November 2018, the last time so forcefully that school employees documented his cries of pain and noted that they gave him ice packs and used a wheelchair to take him to the bathroom because his knee was injured during the incident.

Students sometimes lash out — swearing, spitting, head-butting — during the encounters. One student at the A.E.R.O. Special Education Cooperative in Burbank, southwest of Chicago, was restrained last year after he dropped to the floor and began flailing his legs while being escorted to a timeout room.

Taken to the floor in a prone position, he yelled and swore at a staff member, saying, “I wanna punch you in the face you … bitch.”

Marks Left on Students, Staff

Records kept by school workers document how both students and staff can be injured during physical restraints. Children often said they couldn’t breathe or were being hurt as adults gripped their limbs and applied body pressure.

Records also documented numerous incidents when school employees used physical restraint to address a serious safety concern: to stop children from harming themselves, keep them from running into busy parking lots or prevent them from punching classmates during an argument. School workers restrained one boy who tried to bite an employee; he then tried to choke another worker with her own sweatshirt strings during the restraint.

In interviews and records, aides, teachers and workers noted their multiple attempts to calm students and avoid restraint.

To disability advocacy groups, frequent physical restraint at school reflects a failure on the part of the staff. If educators regularly resort to an intervention meant for emergencies, they aren’t addressing the cause of students’ behavior, advocates argue.

“There are children who are restrained and/or secluded frequently, and then they go to a different school environment where it rarely happens at all. The only thing that’s changed is philosophy, the thinking, the awareness,” said Annie Acosta, director of fiscal and family support policy at The Arc, a Washington, D.C.-based disability rights organization. “When you think about it from (the staff’s) perspective, too, restraining kids is not a good day at work.”

About three dozen districts examined for this investigation had restrained children at least 100 times between August 2017 and December 2018. For some, it was many more.

In Mount Prospect, the Northwest Suburban Special Education Organization, or NSSEO, reported 2,078 incidents of physical restraint. The total for the Southern Will County Cooperative for Special Education in Joliet was 1,424. For the Northern Suburban Special Education District in Highland Park, or NSSED, 1,175.

State records show each of those entities enrolls fewer than 425 children.

None of them would provide detailed records that show what types of restraint were used, for how long or for what reasons. They released data only. An NSSED official declined to comment about the district’s large number of restraints, and the other two districts did not respond to requests for comment.

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Unacceptable Reasons

The 1999 law governing restraint and seclusion in schools spelled out that safety was the only acceptable reason to restrain a child.

But over the 15-month period reporters analyzed, schools regularly did not document safety concerns before restraining students. On a single day in September 2018, for example, about two dozen restraints at schools throughout the state began for reasons other than safety.

At a program run by the School Association for Special Education in DuPage County, or SASED, employees used a seated restraint on a child who had run from staff in the hallway. He didn’t start kicking until school workers held his arms, documents show.

A student who refused to stay in one place was restrained in a La Grange Area Department of Special Education program. Staff noted the child yelled and screamed during the restraint.

And at Moye Elementary in the O’Fallon district near St. Louis, staff restrained a girl who was “being unsafe” doing handstands in the timeout room. The restraint lasted 10 minutes.

The SASED executive director declined to be interviewed for this story. The La Grange and O’Fallon districts did not respond to requests for comment.

The proposed update to the law announced this month specifies that restraint may be used only while there’s a “threat of imminent serious physical harm.” It also explicitly states reasons when restraint can’t be used: as discipline, punishment or retaliation, out of convenience for staff or to prevent property damage.

The new rules also say restraint must end immediately when the emergency ends or when students indicate they cannot breathe. Reporters found at least 30 incidents in which students said they could not breathe yet the restraint continued.

Of the 15,000 restraints analyzed by reporters, roughly 1,300 lasted 15 minutes or longer. About 260 went on for more than 30 minutes — with more than a quarter of those involving children being held faceup or facedown on the floor.

Some children had medical conditions that made restraint unsafe for them, but school staff physically restrained them anyway in apparent violation of state law, the investigation found.

In Urbana, workers held a boy facedown on the floor after he threatened to punch them. When they remembered he had asthma, they flipped him over on his back. He was restrained for 18 minutes. In the A.E.R.O. cooperative, the school nurse was called to monitor a boy for seizures while staff restrained him for 29 minutes after he tried to walk out of class.

An Urbana school district spokesman declined to comment on the prone restraint incident but wrote in a statement that the district previously complied with all state rules and will continue to do so as the rules change.

James Gunnell, executive director of A.E.R.O., declined to talk about the district or its approach to restraint. The district did provide a statement saying it was “committed to complying with all laws and regulations relating to time out and physical restraint, and the safety of our students is paramount.”

Three other districts — Proviso special education, SASED and NSSED — provided statements that echoed A.E.R.O.’s almost word for word.

The new rules would ban the use of prone restraint entirely and strictly limit the use of supine restraint, in which the student is restrained faceup.

Superintendent Ayala and other top state education officials said prone restraint was too dangerous to continue to use in schools in part because of the impulse to “pin” kids to the floor.

Restraints that can obstruct breathing, including prone restraints, are prohibited in 31 states for all children and in a handful more just for students with disabilities. Last month, three California school workers were charged with involuntary manslaughter after the death of a student with autism who had been restrained prone.

Reporters’ analysis of school records found that “floor restraints” — both prone and supine — were used in about two dozen of the 100 districts analyzed. Together, districts used these restraints nearly 1,800 times in the 15-month period examined.

Thirteen-hundred of those floor restraints were in the prone position, and three districts accounted for the majority of those incidents. A.E.R.O. used prone restraint 530 times in 15 months; the Southwest Cook County Cooperative Association for Special Education, more than 300 times. Plainfield Community Consolidated School District 202 logged more than 200 prone restraints.

Plainfield school officials said they have stopped using prone and seated restraints since ISBE announced its proposed changes. They said students are restrained only when there is an “imminent danger of harming themselves or someone else.” Southwest Cook officials declined to comment.

In May, 9-year-old Isaiah Knipe was put in a prone restraint on a carpeted floor for throwing a chair soon after he arrived at Middlefork School in Danville, according to records and his family. When he came home on the school bus, his mother saw a rug burn on his left cheekbone.

A reporter asked Isaiah what happened. He said he got the mark because “the floor was hairy.”

“It been hurting for a while but not now,” he said.

The district restrained students 138 times during the 15 months reporters analyzed.

Kristin Dunker, director of the Vermilion Association for Special Education, which includes Middlefork, said she looked into the incident involving Isaiah and did not find the staff member at fault.

“Unfortunately, it just happened,” Dunker said. “When you put your hands on a student, there is a chance for injury. … It is dangerous, and that is why we try not to put our hands on kids.”

Pleas for Relief

Notes kept by school workers describe children struggling with adults while being restrained. Many of the students swear, cry out and beg to be let up.

Training Lessons Lost

In its five-day training course in Peoria, Therapeutic Crisis Intervention didn’t teach restraint until day three.

For two full days, attendees practiced what to say to angry students, how to give them space instead of moving closer, how to demonstrate calm and support without placing a hand on the child.

TCI, which was originally developed at Cornell University for use in residential child care facilities, allowed a reporter to participate in the March session.

Barry, the trainer, knows what it’s like to have to decide quickly whether to restrain a child. He worked with challenging kids in residential facilities.

The goal of crisis training, he told his class, is not to arm adults with weapons but to help children. Too often, he said, “totally unnecessary” restraints are used because adults insist on forcing children to comply with instructions.

“The price of tranquility should never be death,” he said.

Current Illinois law requires that school workers who use physical restraint be trained at least once every two years; it also mandates that they be taught alternatives to restraint, including de-escalation techniques.

The proposed new rules would require at least eight hours of training each year. They also would expand the training to include trauma-informed and restorative practices, behavior management and ways to spot students in distress during a restraint or timeout.

Most schools send delegates to formal training; these workers then return to teach the material to their colleagues.

Records and interviews show the training sometimes is condensed and key points are lost. Five days of training might be reduced to a two- or three-day session when taught back in schools, according to training records obtained from districts through the Freedom of Information Act.

That means employees often know how to restrain children but may not be fully equipped to manage situations so restraint isn’t needed.

At the Special Education District of Lake County, records show, staff members initially get eight hours of training from the Crisis Prevention Institute, or CPI. Refresher training in subsequent years lasts four hours.

In describing the training, a teacher at one of the SEDOL schools, Gages Lake, told a reporter that “more is focused on how to hold a kid and less about de-escalation.”

CPI instruction is used in clinical settings and correctional facilities as well as schools. A typical school training includes learning how to calm an upset child verbally, how to safely break free from a child who is biting or pulling hair and how to perform standing and sitting restraints.

CPI, based in Milwaukee, teaches the restraint method used by many Illinois schools.

Executives from the firm are aware the company’s name has become synonymous with restraint; school workers often refer to restraining children as having “CPI’d” them.

The executives say they want trainees to focus on how to ease tense situations without physical intervention. Seven of the 10 units that make up CPI teaching are about prevention and de-escalation.

“Schools that focus on restraint are ignoring the core of CPI, which is de-escalation,” said CPI Vice President AlGene P. Caraulia.

The CPI and TCI systems typically do not teach prone restraint for schools. Records from school districts that use those systems show they sometimes mix in other training methods that do.

The Menta Method, used in some Illinois schools, teaches that staff should take children from a standing position to seated to facedown, or prone, if necessary. But if the state bans prone restraint, teaching that “descent” to the floor wouldn’t be acceptable anymore.

“Since ISBE originally adopted emergency rules, Menta has suspended all use of floor restraints,” a public relations firm said in a statement on behalf of Menta. “Menta will develop a new, comprehensive staff training program to align with ISBE’s final rules that are expected sometime in April.”

No training is ultimately effective if it isn’t applied, though.

Pat Tingley, a former aide at the Kansas Treatment and Learning Center, said he went through in-depth TCI training on de-escalation and restraint. But back at school, he said, staff members got impatient with children and turned quickly to restraint.

“It went straight from 1 to 100,” he said.

“I was given the tools to do things correctly in training, but once the school bell rang that was out the door,” Tingley said. Then, he clarified. “It is not that the training went out the door. The restraint training was still in use.”

Tingley said he resigned last fall after working at the school for two months. The “last straw,” he said, was seeing a young child being restrained on the ground by five adults as the boy cried and gasped for air in one of the school’s seclusion rooms.

“I couldn’t handle seeing that,” Tingley said. “He was a very good kid always. He had a bad day.”

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Bear Hugs

For years, Jacob Lopez’s family worried that his school was restraining him too often, instead of trying other ways to manage his behavior.

Jacob, who has autism and ADHD, had transferred as a first grader to a special education program run by SPEED Special Education Joint Agreement District 802 in Chicago Heights, south of Chicago. For the next five years, Jacob was repeatedly restrained by workers in different SPEED programs, according to records provided by his family.

His mother, Kristina Soczyk, didn’t understand it.

“If I don’t have to restrain him, why do you have to restrain him?” Soczyk said she asked the school. “I don’t have to put my hands on him. He’s tiny.”

In all, records show, the cooperative restrained children more than 400 times, including in the prone position, over the 15-month period reporters examined.

When Jacob was 6 years old, in 2013, SPEED staff documented restraining him after he kicked his desk and kicked over a chair.

Jacob’s restraint that day and others were described in the documents as putting him in a “bear hug.” His family said he was restrained on the floor and would come home with marks on his arms.

In October 2016, records show, Jacob’s grandmother called the school with concerns about “another injury” to Jacob and asked to revoke the family’s consent to restrain him. She said she worried about the staff’s ability to “safely manage students.”

Soon afterward, Jacob’s mother and grandmother met with school officials, records show.

School notes from the meeting state that “Ms. Soczyk feels that Jacob is having panic attacks because the restraint is being completed in a painful way.” The notes also say “Jacob is blind in his (left) eye and he feels blindsided if he cannot see how he is being restrained.”

SPEED Superintendent Tina Halliman declined to comment about Jacob, citing student confidentiality, but wrote in a statement that the district “complies with all state and federal laws, rules and regulations.”

In spring 2017, an updated behavior plan for Jacob, agreed to by his family, allowed him to be restrained when there were safety concerns and other methods didn’t work.

When his family thought Jacob still was being restrained too often, they moved to Will County. But that didn’t help either. His mother learned that the school district there also sent children with special needs to SPEED programs.

In the end, the family’s solution was to leave Illinois. Soczyk said Jacob, who is now 12, is doing “amazing” in a school in Dyer, Indiana, where he attended his first school dance. His mother said she feels his behavior is being managed appropriately.

They live not more than a mile across the Illinois-Indiana border.

“It is the only reason we moved,” Soczyk said.