Once again, a student has died at the hands of his teachers. Murdered on the front lawn of his school… all because he had thrown a sandwich.
At 1:10 PM on April 29th, first responders from Kalamazoo, Michigan, arrived at Lakeside Academy, a boarding school for teens with a history of anti-social behaviors, to find 16-year-old Cornelius Frederick lying dead on the lawn.
They were able to re-start the boy’s heart, but it would stop again at the hospital, and this time they would be unable to revive him. They learned from the staff that the boy had collapsed while being restrained. The reason for his restraint was allegedly that he had thrown a sandwich.
How the throwing of a soft, harmless lunch item escalated into cardiac arrest on the front lawn, we don’t know. But we can imagine.
It has happened so very many times before.
Despite many laws and studies proving the danger of physical restraint, it is still used commonly in schools across America. It is most commonly used on disabled and etnic minority children.
It should not be lost on us that Cornelius was Black – like many other victims of restraint. Black and other ethnic minorities are more likely to have force used on them by authority figures, more likely to be institutionalized and arrested, and more likely to die in police custody.
The young, the marginalized, the disabled – these are the ones most likely to be considered so dangerous that they must be tied, smothered, and beaten.
The stories are numerous and horrifying.
There was Khadaan Christians, an autistic 8-year-old who, in 2013, was repeatedly handcuffed to a chair with cloth over his face to prevent him from spitting at his teachers. His mother was not informed.
“I had a meltdown and stuff, and I didn’t want to go to timeout and I made a bad decision,” he told NPR.
His meltdowns were usually a result of him resisting changing activities from reading or doing art to something else, something that autistic people are known to struggle with.
There was Christopher Baker in Kentucky who was repeatedly stuffed in a green sack as a punishment for “acting up” in class.
There was the teacher in Pennsylvania who, for years, routinely used bungee cord and duct tape to tie disabled children to chairs while she kicked and hit them. It took two years for her aides to speak out, and the biggest change that occurred in that school was that teachers in that school refused to have teacher’s aides any more.
In 2014, a report to the US Senate entitled Dangerous Use of Seclusion and Restraints in Schools Remains Widespread and Difficult to Remedy: A Review of Ten Cases covered incident after incident in which an angry child was brutally treated by the very people entrusted with their care.
The aforementioned report to the senate pointed out that there is “no evidence” that there is any kind of therapeutic benefit to the physical restraint or isolation of children.
Furthermore, there is no such thing as a “safe” technique, only more- or less-safe techniques.
Children like Khadaan Christians are the lucky ones, because those victims of restraint only suffer physical injuries or emotional trauma.
Every now and then, during the kind of restraint a staff member has used on others many times before, a heart stops forever.
There was Michael Renner-Lewis III, a 15-year-old autistic student who, like Cornelius Frederick, lived in Kalamazoo Michigan. In 2003 he had a seizure and his parents were called. He recovered from the seizure but “became agitated” and was restrained. By the time his caregiver arrived to pick him up, he was dead.
There was 7-year-old Angellika Arndt, who in 2006 was restrained after she became giddy at lunch and couldn’t stop giggling and blowing bubbles in her milk. She was asked to “cool down,” which required sitting still for 15 minutes– a difficult task for any 7 year old, let alone one with the number of diagnoses she had. When she was unable to sit still, according to the Minnesota report,
“Several staff members had held Angie’s arms and legs while an adult male staff person lay across her back, forcing her head down and immobilizing her 67-pound body until she lay still, no longer breathing. Angie was finally released when they thought she had fallen asleep. Staff were unaware that Angie had stopped breathing until they rolled her limp body over to discover she had begun to turn blue.”
Then there was 16-year-old Corey Foster. On April 12, 2012, Corey was playing basketball with the other students in the gym. When Corey resisted leaving the gym– transitions being difficult for him– he was pressed up against the wall and then pinned to the floor by four staff members. He would never rise again.
There was nine-year-old Randy Steele, who didn’t want to take a bath, and eleven-year-old Andrew McClain, who didn’t want to move to another table at breakfast.
There was 15 year old Gareth Myatt, who didn’t want to clean a toaster, and 15 year old Edith Campos, who wouldn’t give up a family photograph.
There was 12 year old Robert Rollins. He couldn’t find his teddy bear.
In many of these cases, the holds used were found to be routine– something the staff had used before, often many times, and in many cases, exactly as they had been trained to do.
A nurse at Andrew McClain’s facility– who was not there on the day he died– wrote,
This technique – which Elmcrest had used for two years – was taught to every Elmcrest employee. We used the holds believing they were safe. The two mental health workers involved in Andrew’s restraint were both current on their training, with one of them having completed his annual update just days before Andrew’s restraint. It is difficult to realize and accept, that we placed our patients and ourselves in jeopardy every time we used this restraint.
– “After We Lost Andrew.”
When these children died, their killers thought they were doing their job. They thought they were doing it to make their students safer. They thought what they were doing was necessary.
They never should be led to believe any such thing.
The danger of restraint — particularly of the young — has been known for a long time. A paper in 2000 covered 21 cases of people dying under prone restraint. Police incidents have also shone a spotlight on the risks of restraint, particularly prone restraint, and the popular show Orange is the New Black shocked audiences with the death of a popular character due to restraint.
They suffocate when they are placed in positions which prevent them from inflating their rib cage, or which bends their neck in such a way that their airways are cut off.
They die of catecholamine rush – essentially dying of fright.
They die of Rhabdomyolisis, the breakdown of the muscles due to extreme exertion or trauma.
They die because this particular time, this particular hold, this particular incident, was more than their bodies and minds could handle.
Beyond the physical risks, there is plenty of evidence that restraint is emotionally traumatic for the person being restrained and can actually increase emotional volatility — the person is more likely to need to be restrained again, and again, as small incidents escalate into fight-or-flight scenarios.
Even studies in rats show that restraint results in an increase in anxiety behaviors and a decrease in ability to learn.
Studies show that up to 47% of people develop PTSD from episodes of restraint and seclusion.
Those who insist that restraint is a “necessary tool” to deal with emotionally dysregulated kids are belied by schools like Centennial in Bethlehem, PA which has banned restraint and specializes in dealing with kids who have been removed from other facilities after multiple episodes of brutal restraint.
All of these reasons and more led to the state of Michigan — where this most recent death occurred — to create strict laws around restraint and seclusion of students.
According to the Michigan Department of Education, schools may only use restraint under the most dire circumstances — when they can clearly demonstrate that all other avenues were closed and that it was an “emergency” situation necessary to protect the physical safety of others. When restraint is used, it must not persist beyond ten minutes.
Despite a proliferation of such laws these incidents continue to occur with infuriating regularity.
We at Neuroclastic have repeatedly tried to shine the light of Max Benson’s life on the catastrophic consequence of violent restraint. Max was an autistic 13-year-old who, in 2018, spat in frustration and was pinned to the floor for nearly two hours, where he slowly suffocated to death under the weight of the people whose job it was to support him.
Perhaps the most aggravating and frustrating aspect of these horrific deaths is the fact that they so often occur at specialized facilities which boast of being specially equipped to handle students with behavioral difficulties.
Often using terms like “positive behavioral support” or “behavioral health,” these schools claim to have highly-trained staff who are skilled in serving students with behavioral difficulties. They list restraint as a method of “last resort” to protect the safety of other staff and students.
And yet, every time this occurs, the description of the incident never remotely seems to justify the level of force being used. A 13-year-old spitting does not appear to be a “last resort” type of incident. Nor does an autistic teen who wants to keep playing basketball. Or a hyperactive seven-year-old unable to hold herself still.
…Or a troubled teen who threw a sandwich.
In none of these incidents were the staff or other students in clear danger. The only injuries belonged to the murdered child.
Why? Why does this keep happening?
Why do educators kill their students over a kick, or a basketball, or a sandwich? Why do they do it despite research, despite training, despite evidence, despite warnings, and despite laws?
To our knowledge, Cornelius was not autistic. But he could have been. He was at Lakeside for a reason. He was in need of help and care. His death is no more or less tragic with or without a diagnosis of disability.
No human should ever die at the hands of those who have been charged with his care and education.
So let’s shine a light on this incident now.
Let’s ask ourselves – why did this happen?
The school is called Lakeside Academy.
Lakeside admits only students age 12-18, without intellectual disability, who meet the following criteria:
|• Impulsivity, irresponsibility and/or lack of self-discipline
• Denial and/or justification of behavior
• History of anger and aggression
• Demonstration of a low degree of empathy
• Exhibition of poor coping skills
• Non-compliance with authority
• Amenable to treatment in a normative culture
Lakeside says that it runs three programs — all residential — one for boys and one for girls who are “in need of out-of-home placement” and a third for boys with “sexually aggressive” behavior.
Because it is residential, Lakeside falls outside of the Michigan Department of Education, which means it is exempt from Michigan’s strict anti-restraint laws governing schools.
In Michigan schools, teachers are forbidden to restrain or isolate any child unless it is a true and verifiable “emergency.” Any use of restraint must be reported and justified with proof that someone was either being injured or very definitely about to be injured.
Instead, Lakeside falls under the regulation of the Department of Health and Human Services, which primarily governs hospitals and other medical settings. They also forbid certain kinds of restraint — such as anything that involves the person being pinned to the ground — and insist that restraint can only be used if verbal non-confrontational methods have been tried first, and the person is “visibly at the point of striking” or putting themselves in potential danger.
Which means that it was illegal for them to pin Cornelius to the ground on the front lawn. The laws certainly don’t suggest that the throwing of a sandwich justifies any kind of restraint at all.
So why did this happen?
According to their website, Lakeside focuses “on the confrontation and redirection of negative behavior while recognizing desired, positive behavior.”
The Lakeside program places an emphasis on the responsibilities and choices each
individual student makes and helps them to recognize that all choices have results of some sort, whether they are positive or negative. Through this process, the Lakeside program helps the student focus, first, on their present behaviors, then on the underlying motivation or precursors to such behaviors. – LakesideAcademy.net
Why do they take this approach?
We aren’t sure.
Child psychologists keep telling us that reward-based programs do not help children with emotional development. In fact, they often backfire and can lead to greater emotional turmoil.
For example, Vancouver-based Dr. Vanessa Lapoint, a child psychologist and author of Discipline Without Damage, has advised against using reward systems in helping children manage their behaviour. Increasing the consequences of behaviour that they might not be able to control can result in the loss of hoped-for rewards, which is, in itself, punishing.
“It has at its core what we call a relational disconnection which will cause some deregulation to the child,” she told CBC in 2016.
Her advice is in line with most child psychologists, who emphasize in their books and studies that the key to behavioral regulation is emotional regulation, and that means you need flexible role models who understand the child’s abilities and focus on soothing the emotions, not controlling the behaviors. They insist that you need to build emotional intelligence and emotional management skills… not reward and punish outward behaviours over which the child often has no control.
Studies show that a flexible parenting style, rather than rigid rules, result in children who are less likely to act out.
Rigid authority figures, psychologists have found, leads to rigid, inflexible kids who are more emotionally volatile. When a rigid authority figure meets an inflexible kid, clashes are going to happen.
Nor does it help to confront negative behavior and point out why it is bad. According to Scientific American:
Studies indicate that highly confrontational therapeutic approaches are rarely effective in the long term. For example, in a 1993 controlled trial psychologist William Miller of the University of New Mexico and his colleagues found that counselors who used confrontational styles with problem drinkers—for example, by taking them to task for minimizing the extent of their drinking problem—had significantly less success in helping their clients overcome their addictions than did counselors who used supportive styles that relied on empathy.
Finally, the National Academy of Science’s report on effective parent training programs notes the importance of ensuring that training is “trauma-informed.”
“Trauma has a particularly damaging effect on children’s development.
Children exposed to trauma often experience problems with regulation of
affect and impulses, constricted emotions, and an inability to express or
experience feelings (Armsworth and Holaday, 1993; van der Kolk, 2005).”
Parenting Matters: Supporting Parents of Children Age 0-8
A 2013 paper published in the Journal of Family Violence describes what trauma-informed care in a place like Lakeside should look like.
Staff members and families are taught to understand that what is often referred to as a youth demonstrating “bad”, “difficult”, or “conduct disordered” behavior is actually a youth in a dysregulated state who is reacting either to reminders of traumatic events or significant environmental stressors. – “Trauma Systems Therapy in Residential Settings.” Journal of Family Violence, 2013.
Lakeside’s website makes no mention of emotional intelligence or modeling flexibility. Its focus seems very much to be on outward behaviour: confrontation of negative behaviors, reward of positive ones, and building a “normative” peer culture.
This is the most common type of verbiage we find in schools like this, where incidents such as this one occur.
Behaviorally-focused care is ultimately damaging to such kids, because often they can’t control their reactions. Imagine being given “consequences” for behaviour that is a result of trauma and beyond your control.
Furthermore, a behaviorally-focused approach is bound to lead to rigid authority figures who feel the need to provide “consequences.”
A mentality that tells students “do what I say or there will be consequences” is bound to send an emotionally-fragile, traumatized teen into a rage occasionally.
The escalation of minor incidents– such as Max spitting or Corey refusing to leave the basketball court– into a full-blown meltdown which demands death-inducing levels of restraint suggests an inflexibility on the staff’s behalf which came up against the inflexibility of the dysregulated child.
Just like little Angellika squirming in her chair, many of the students at Lakeside must struggle to contain their emotional outbursts, and may often be pushed off the edge by an insistent staff member who is not sensitive to their emotional state.
It isn’t reward and punishment they need but emotional regulation, a safe environment, and caregivers they can trust.
Cornelius probably threw that sandwich because he was upset. Why was he upset? How did the staff members react to that? How does Lakeside train their staff to deal with these volatile and psychologically volatile youth when they throw sandwiches?
Well, first of all, they don’t.
Lakeside is “partnered with” and “operated by” a company called Sequel Youth and Family Services. Sequel trains and places staff in a large number of schools across the country, one of which is Lakeside.
Their arrangement resembles that of a property-management company for a homeowner’s association. Sequel is essentially employed by Lakeside to hire and train the staff.
This kind of set-up spreads out responsibility beautifully.
Sequel does not own the school or sit on the non-profit’s board. It isn’t even based in the state of Michigan. But the local administration can point fingers at Sequel, saying that the staff were provided and trained by them, so it is Sequel’s fault if the staff screw up.
And they do screw up.
On a monthly basis, it seems.
The state of Michigan lists the last two years of code violation investigations online. There are 21 reports in all, many of them containing multiple investigations and verdicts.
You can read them yourself here if you feel like crying for a while.
Cornelius was there for two years, so these reports span the length of time he was at Lakeside before his death.
I read all of them.
Some of them were minor and understandable– a staff’s brief distraction resulting in unwanted touching between two sexually aggressive teens, or a misunderstanding regarding who was supposed to book a gynecology appointment.
The staff are human beings, and they’re going to mess up occasionally. We all mess up occasionally. Accidents definitely happen.
But some others are… really upsetting.
Here are some of the things I learned about Lakeside during the time of Cornelius’s residency there:
Many of the kids were sleeping on green “prison mats” instead of proper mattresses.
Sometimes feces would belch up through the shower drains, and the students were still expected to shower when this was happening.
Restraint is a common occurrence at Lakeside, usually due to violent behavior or self-harm, but sometimes due to yelling threats/inability to de-escalate.
Before restraint happens, the teens are “put in a verbal.” According to Lakeside’s policy description, this simply means trying to de-escalate the situation by calmly and sympathetically finding out what is bothering them and basically gently talking them down.
Based on the “verbals” viewed on video by investigators, the reality sounds much more formal — other students are sometimes sent out of the room, and the student in the “verbal” is sometimes confronted by multiple staff members. The staff describe them as holding the kid “accountable” and getting them to confront and address their own behavior.
Sounds like a difficult thing to do when you’re in the middle of a meltdown. Sounds more like a confrontation than a de-escalation. None of the kids interviewed in the reports seem to like being “put in a verbal.”
In the incidents reviewed by investigators, at least some “verbals” involved yelling at the student or intimidating approaches, which the investigators ruled as “inappropriate.”
It was not uncommon for some of the staff to yell at the kids or even swear at them.
“The campus has changed because you never used to get bullied or made fun of by staff. Now they look in our file and tell us we are worth nothing.”
“Staff 9 called me a whore and a bitch, and she even told me ‘to go fuck myself.’ That same staff even told me to kill myself a few times.”
“Staff 5 puts everyone on blast which puts their business out there for everyone and this causes us to cry. She does this a lot.”
“They want us to be these perfect little kids and they can’t even show us how.”
“Staff 14 told me that the boys were going to a men’s prison when I asked him where the boys were going.”
I learned that Lakeside has many dorms, all named after Greek mythological figures for some reason, and that if staff cause problems in one dorm they just transfer them to another.
I learned that students at Lakeside have chores and responsibilities which they are expected to complete regardless of their emotional or physical situation, and they have “levels” which presumably relate to privileges or amount of responsibility they are given.
I learned that in at least three incidents, students who were very sick, or had broken bones were only given basic nursing care and not taken to hospital until several days later.
In one case this meant that a girl who was vomiting and severely dehydrated by a stomach virus was forced to participate in activities and play kickball, accused of faking her illness by staff despite nurses confirming that she was indeed ill, until she eventually collapsed from dehydration and was taken to a hospital.
In another case, a girl broke her foot and was not taken for X-rays until several days later. In a third, a boy broke his ankle in two places – badly enough to require surgery – but was only given tylenol and wrapped in an ace bandage until 5 days later when he was finally taken to hospital.
These incidents were not considered violations because nurses had examined the injuries each time and made their best guess.
I learned that licensing inspections reported “continued non-compliance” when it came to confirming education and training of hires prior to or even after hire. A dozen employees who had histories of criminal convictions did not have the requisite paperwork filled out to address these convictions and whether they would be safe to work with kids.
My personal favourite horror was when they hired a woman without noticing that she was on the child abuse registry and let her work there for 5 months before DHHS found out.
I learned that the one-man seater position, which is considered unsafe because it folds the patient, is “only allowed on the kids from California.”
I read about several incidents where staff entered student bedrooms where there are no cameras– where they allegedly choked or slapped the students during a confrontation. Because there were no cameras, these incidents were not ruled violations because they were he said/she said situations, sometimes despite multiple student witnesses.
In one case, a boy had an upsetting phone call from his mother. He returned from the call very dysregulated and got into verbal confrontations with a staff member. The student tried to leave the situation by going to his room. The staff member pursued him, entered his room, and swore at him.
All of that being said, I did get the feeling that the general staff culture was to try and do their best for their kids. Most kids, when asked, reported feeling safe at Lakeside.
There were many incidents of staff being written up, suspended, or fired for negative interactions with students, which suggests that staff were held accountable if management got wind of what was going on.
I had my back to them when I heard her raise her voice. Then I heard him say, “I said shut up.” The next thing I heard was a loud slapping sound to which I turned and asked her if she hit him. She said, “Yea I hit him.” I told her “leave the room right now because you have lost your job”.
That particular quote is from one of the therapists, not one of the care staff, but it shows that she felt confident management would back her up.
But then again, there were many incidents of staff being written up, suspended, or fired for negative interactions with students.
Enough incidents to result in 21 reports over a period of 29 months, each report often containing two, three, or four allegations and at least one verified violation.
This suggests to me that something was wrong either in the hiring process, the training process, the protocols in place, or all three.
One incident in particular really struck home with me, in light of Cornelius’s death.
In 2018, a girl wanted to go for a walk outside to let off steam when she was upset over something. She ended up with severe rug burn on her face.
When the girl said she needed to go outside and walk her emotions off, a staff member who was her “group leader” and had worked there for two years told her to “hold on” and said she “wasn’t being patient.”
She went outside without him.
The incident escalated to her being pinned supine on the grass, then dragged inside by two staff members. There were no cameras on the lawn, but there was a camera to record what happened after two staff dragged her back inside.
“Resident A appears to be compliant with the transport and is not struggling against the hold. Once she is released, she appears to remain standing calmly with multiple staff standing around her. She leans down to untie one shoe then stands upright at which time she appears to be talking with staff. Shortly thereafter, she is pushed backward slightly by Staff 1 and Staff 2, which causes her to stumble a couple of steps. She continues to stand upright with her arms down by her sides. Staff 1 and Staff 2 then grabbed Resident A and Staff 1 quickly moves forward and places Resident A in a single person standing hold. Her arms are observed to be high above her back. Other staff in the room attempt to remove her shoes. Resident A eventually falls or is moved to the ground with Staff 1 on top of her with her face close to a wall. The staff move her body more to the center of the small hallway. She is face down at this point and Staff 1 is holding her arms high above her back. Staff 2 is holding her midsection/legs and Staff 3 is removing Resident A’s shoes.”
She was restrained, on her face, all because she was upset and wanted to go outside and walk it off.
If they had let her go, just followed her and monitored her location, she probably would have returned on her own.
Instead, they chose to escalate it to the point where she could have been killed.
Luckily, this time, she only got a case of rugburn on her face.
“…a large abrasion to Resident A’s left upper cheek area extending from just beneath the outside corner of her eye to her hairline. The abrasion was roughly the shape of an oval and was various shades of red, pink, and brown. The area also appeared to be slightly swollen.”
She was angry and upset. She chose a nonviolent, doctor-recommended method of dealing with emotional turmoil: Exercise!
She ended up pinned on the lawn where, two years later, Cornelius would take his last breaths.
I doubt if, when more details emerge about his death, there will be much to differentiate the two incidents, except that the girl lived, and Cornelius did not.
According to the report from 2018:
Staff 3 stated that Resident A was being aggressive all evening and was refusing expectations, which warranted the restraint.
She wouldn’t do what she was told, they mean.
I bet Cornelius didn’t either. I bet that is what “warranted” the restraint which would lead to his death.
We NEED. TO. TAKE. THE. EMPHASIS. OFF. OF. BEHAVIOR.
Perfect obedience is not the route to “behavioral health.”
A troubled, traumatized teen is not going to do what they are told all of the time.
NO teen is going to do what they are told all of the time.
In fact, sometimes it is GOOD for them to refuse doing what they are told. Sometimes they may not be emotionally capable of doing what they are told. Sometimes they are stating their own personal limits, trying to set boundaries which keep them feeling safe.
None of that is worth dying for.
Maybe they recognized that, because at the time of Cornelius’s death, things were changing at Lakeside.
In the beginning of 2019, Sequel announced that it would be adopting the Ukeru system for training staff at their facilities.
Ukeru is the brain child of the Grafton Health Network – an interstate “behavioral health” 501(c) and a major residential care provider. They recognized the problem with restraint and decided to do something about it.
Their system, Ukeru, has been proven to reduce restraints in an institution by as much as 99%. In other words, it basically eliminates the need for restraint my training staff how to actually support traumatized people properly.
The Ukeru system emphasizes Comfort vs Control. In other words, stop trying to control behavior and instead help the people feel comfortable.
“We realized we had a culture that was highly controlling. We wanted to flip that.” – Kim Sanders, President of Ukuru.
Ukuru emphasizes the importance of changing staff culture to get rid of controlling attitudes and replace them with comforting ones. It pushes the staff to be good role models for emotion management and to treat the students with compassion.
This ideology, this prioritization of keeping people feeling comfortable instead of trying to control their behavior, not only nearly eliminates the need for restraint, it also vastly increases the success of the people in their care.
Notice the dates.
This type of methodology has been proven to work since 2007.
TWO THOUSAND AND SEVEN.
It is 2020, folks.
Grafton Integrated Health launched Ukeru training for other facilities in 2015, but their system was based off of psychology research which other companies, like Sequel, could have used to develop their own, similar programs long ago.
Ukeru is by no means the only system dedicated to eliminating restraint. There is Low Arousal Approach, for example, which focuses on helping people stay connected and calm, and avoid getting over-excited, which leads to the kind of loss-of-control that puts people in danger.
The common thread in all of these systems is reducing the amount of controlling behavior from staff, which leads to a missing teddy bear escalating into a death.
Jeff Newman, a Case Manager and a Critical Incident Investigator in the State of Colorado for people with intellectual and developmental disabilities said, in response to Cornelius’s death,
“The missing ingredient is an atmosphere of power and control being something vested all in the hands of the staff and none in the hands of the people. Our abuse findings went from a regular occurrence (typical for the industry) down to way less, and the biggest shift was getting way better and drilling in the rights the person had to autonomy and the worker’s job to help the person plan to accomplish what they want SAFELY rather than dictate what they can and cannot do..
The Safe to Learn Initiative focuses on trying to get these basic principles across to lawmakers and school systems across the world.
We have the information. We know how to avoid and reduce these deaths. But most schools ignore that information. That is a LOT of people whose lives could have been saved by prioritizing comfort and safety over “accountability” and “consequences.”
But I’m glad that more and more training systems are dedicated to trying to teach staff the importance of connecting and understanding, instead of controlling behavior. But it came too late for Cornelius.
It seemed strange to me that Sequel announced that it would adopt Ukeru one year ago, and yet still a young man just died on the front lawn at a Sequel facility. So I emailed Ukeru to ask them if Sequel had started their training at Lakeside yet.
What I learned made me incredibly sad.
“In January 2020, Ukeru trained a cohort of Lakeside Academy staff to become trainers of our approach. We subsequently provided support as Lakeside trained its first group of employees to become Ukeru users. We were, in fact, scheduled to return for a follow-up consult today.”
– Kim Sanders, President of Ukeru Systems, in an email dated May 3, 2020
“From our own experience, we also know that implementation and culture change require considerable effort, which Lakeside has and continues to demonstrate. But it also takes time to take hold.”
In other words, people can’t give up control quickly or easily. Staff who are used to saying “do this, or else” aren’t going to give that up all at once.
The culture of “do what you are told, or else” is a dominant one throughout much of the special needs industry. Billions of dollars of ABA therapy promote the idea of providing consequences for behavior, rather than recognizing the emotional roots underneath it.
By focusing on outward behavior, rather than the emotions underneath, we create this I-have-given-a-mand-and-now-must-provide-consequences culture which lead to Cornelius’s death.
The change in culture didn’t come soon enough for Cornelius.
Maybe the staff who killed Cornelius hadn’t been trained yet.
Maybe the Lakeside staff doing the training hadn’t gotten the message across properly.
Maybe staff thought the new training was garbage, that they had been doing things their way for years, and it worked fine.
Maybe they genuinely wanted to do better, but fell into old habits in the heat of the moment.
None of that matters to Cornelius, who perished under the weight of the people who were supposed to be providing comfort, not control.