CONCORD (AP) – Children were restrained or secluded in New Hampshire’s residential treatment facilities more than 20,000 times in five years, according to a state watchdog office’s report released Thursday.

The Office of the Child Advocate issued its report citing a lack of state oversight eight months after it opened a system review of the use and reporting of restraint and seclusion. The state has about two dozen residential treatment facilities, including the state-run youth detention center for children who are placed by school districts, the child protection system or juvenile courts.

Many of the children have been abused, and being restrained or secluded can cause further physical and psychological harm, said Moira O’Neill, director of the child advocate office.

“It’s dangerous, and it doesn’t help,” she said in an interview.

While many states ban the use of face-down restraints, also called prone restraints, New Hampshire law instead prohibits physical restraints that obstruct a child’s airway, impairs breathing, places pressure on the upper body or obstructs blood circulation. According to the report, at least five facilities use prone restraints, “suggesting either a refusal to comply with the law or different interpretations in terms of its use.”

Facilities are collecting detailed information about each incident and providing monthly tallies to the Department of Health and Human Services as required under state law, O’Neill said. But the department is not performing the required analysis or providing it to the Legislature, she said.

Monitoring is important because without analyzing trends, there’s no way to identify and solve the problems that lead to restraint and seclusion, O’Neill said.

“Behavior that rises to the level of restraint or seclusion is a signal that something is wrong. Maybe something is wrong with the child, maybe something is wrong with the treatment, it may be staff doesn’t know what they’re doing,” she said. “Is it a staff person who needs some training? Or a certain time of day so we could say ‘What’s going on at that certain time?’ Or is there a particular clinical program that isn’t working?”

Jake Leon, spokesman for the Department of Health and Human Services, responded by highlighting that overall, the use of restraints and seclusion is dropping. The number of incidents has fallen by 37% since 2015 and 14% from 2017 to 2018. He also said the department has been establishing a “culture of safety and system of care to expand access to community-based services and increase clinical care at community residential programs.” Strategies are being implemented to reduce restraints and seclusion, and new and renewed contracts will include requirements to monitor and reduce the use of those approaches.

In 2018, the Disability Rights Center issued a report saying staff at the youth detention center routinely violated state law in using dangerous face-down restraint methods, including in the case of a 14-year-old boy with emotional and behavioral disabilities who ended up with a broken shoulder blade. Attorney General Gordon MacDonald and the state health commissioner responded by calling the report unfounded and irresponsible and accusing the center of cherry-picking information about the incident.

O’Neill said small improvements have been made in recent months but there is a long way to go to better document and eventually eliminate restraints and seclusion. Since last month, the department has created a new system to collect the detailed reports from facilities, she said, and many of the facilities themselves are establishing more therapeutic approaches.

In one incident described in the report, a boy was restrained on the floor face down and then handcuffed after he spoke disrespectfully to staff, refused to follow orders and swung his head back, hitting a staffer in the eye, when they took hold of his arms to make him stand up. Staff later said the boy may have been upset about having a personal family memento removed from his room.

“We certainly hear, ‘Well, those are difficult, aggressive kids.’ I would say, ‘Those are kids without their needs being met,'” O’Neill said. “These are not monsters. These are kids who really need our help.”

Newsletter