Angellika Arndt died May 26, 2006 after being physically restrained. Earlier in the day, Angellika was put in a "control hold" for gargling with her milk.

The death of the 7-year-old Wisconsin girl who lost consciousness after being held down at a Rice Lake, Wis., day treatment center has fanned the flames of an ongoing local and national debate about the use of physical restraints.

Angellika Arndt, who was living with foster parents in Ladysmith, Wis., was held face-down by two clinic workers on nine different occasions in the month she attended the weekday treatment program, according to a report by state officials who investigated her death. After being restrained on May 25, Angellika passed out, and died the next day at a Minneapolis hospital. The coroner determined the cause of death to be chest asphyxia.

A Northwest Counseling and Guidance Clinic official has said its staff acted appropriately.

But Angellika's case highlights a question that professionals in treatment and corrections facilities, as well as public and private schools, must ask every day: How do you handle out-of-control kids?

Clinic officials and their defenders say the staff obeyed current laws, and that such restraints are sometimes necessary to protect the child and others.

But critics say Angellika should never have been placed on her stomach in restraint holds that could endanger her breathing. Some of those holds lasted one to two hours, according to the state report.

"She should have never been on her stomach, she should have been upright," said Mary Beth Kelley, a former special education teacher now on the faculty of the special education program at the University of Minnesota.

"There's been enough research out there, enough deaths, that I'm surprised anyone would still use that as a practice," she said.

The fact that Angellika was held in the face-down position, and for periods of between one and two hours each time, is "totally unacceptable," agreed Anne Gearity, a clinical social worker with the Washburn Child Guidance Center in Minneapolis who specializes in high-risk children.

"Whatever happened, they lost control," Gearity said.

No one agency compiles statistics on children who die after being restrained. But a Cornell University study found 45 child or adolescent fatalities between 1993 and 2003 that involved physical or mechanical restraints. And many professionals believe the number is much higher.

Northwest Counseling and Guidance Clinic runs 12 outpatient day treatment programs throughout Wisconsin. Children who go there are the ones whose illnesses have made them incapable of succeeding in a regular or specialized classroom, said Denison Tucker, clinic president.

"We're the stage before institutionalization," Tucker said.

To help its staff learn how to deal with children whose behavior can be so challenging, the clinic brought in a Milwaukee-area company called Crisis Prevention Institute, a prominent provider of training for schools and other facilities across the country.

The company trains professionals who then go back to their place of work and teach others. The training focuses on how to keep situations from escalating to the point where they become dangerous, said Judith Schubert, the company's president.

"We always try to say in our training that any time we put our hands on someone, we're introducing risk," Schubert said. "There is no safe physical restraint."

A company brochure called "Risks of Restraints" cautions that death can result from restraint-related asphyxia, and that "especially dangerous positions" include face-down floor restraints.

So why did the staff at the Rice Lake clinic use that position with Angellika?

"Because there is no uniform standard on that," said Tucker, the clinic president. "That really is the difficulty in this. There's quite a range of opinion."

Schubert said that her company has a record of one Northwest Counseling staff member attending its training six years ago but no evidence that they did any of the required follow-up, such as regular refresher courses. And no Crisis Prevention Institute materials, such as booklets the trainer gives to staff, have been sent to the clinic since then, she said.

Charlie Kyte, executive director of Minnesota Association of School Administrators, said that kids with behavioral problems present a huge challenge to staff, whether in school or in other types of programs.

"I'd have a hard, hard time imagining that any adults were restraining this child for that amount of time unless the child was really out of control," he said, referring to Angellika. "My guess is they were doing their best to calm this child when this tragedy happened."

Parents in the Twin Cities area said they worry the same thing could happen to their children.

For Brenda McCoy of Andover, it nearly did.

McCoy's autistic son, John, was 8 years old when he was forcibly restrained in a special education class in the Anoka-Hennepin School District in 2003.

John had been refusing to participate in a game that involved orange goal markers. Instead, he was picking up the markers and sitting on them. When a worker moved to retrieve them, he lunged at her, McCoy said, recounting the incident from the school's written report.

According to the report, he was scratching and grabbing at staff. They then put him face down under a large 6-foot-long gym mat, weighted down with a heavy blanket, pillows — and a male staff member's foot, McCoy said.

When McCoy arrived to pick him up, she said, her son was shaking and his face was almost purple.

"I will never forget his little face looking up at me — it was like, 'Rescue me!'" McCoy said.

School officials investigated the incident and determined that "there was an improper use of restraint," said district spokesman Brett Johnson. "It shouldn't have happened."

Anoka-Hennepin also uses the Crisis Prevention Institute training, Johnson said. Restraint is used only when a student is a danger to himself or others, he said.

Minnesota and Wisconsin have somewhat differing laws about restraint, but neither state forbids its use altogether.

Wisconsin's Mental Health Act requires that clients in public and private treatment centers not be restrained "except for emergency situations" or when the restraint is part of a treatment program.

In Minnesota, the use of restraint in inpatient programs is strictly regulated, with each program required to be certified in its use. "Most programs have worked really hard to create an environment where holds are very rare," said Mary Regan, executive director of the Minnesota Council of Child-Caring Agencies, an association of children's treatment providers.

But day treatment programs are not covered by the law. And schools in both states may use restraints in emergencies.

The problem is, one staff person's "emergency" may be another's lack of training, said Barbara J. Harrison, a licensed social worker and registered nurse from Shoreview whose own 8-year-old daughter was restrained at a Twin Cities day treatment center.

"Sometimes the staff in these programs are not very experienced, and I think they can fuel the fire," Harrison said. "(Our daughter) was power-struggling with them. In this program they were clearly into control."

She and fellow mom Carolie Collins of Woodbury are active in the Minnesota Parent Leadership Network, a group advocating for change in the children's mental health system. Both were outraged at the story of Angellika.

Collins said she doesn't believe restraint should ever be used unless help is on the way.

"If it's that dangerous a situation where you have to protect people, then where was the ambulance (for Angellika)?" she asked. "Where were the police?"

Emily Gurnon can be reached at egurnon@pioneerpress.com or 651-228-5522.