Youth Athletes: Sports Programs' Guidance, Practices, and Policies to Help Prevent and Respond to Sexual Abuse
Published: 2015-05-29T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Media reports of the sexual abuse of youth athletes by their coaches have raised questions about how athletic organizations protect against such abuse. Research shows that the power dynamic between coaches and athletes aiming for high performance makes those athletes uniquely vulnerable to abuse. Although states are primarily responsible for addressing abuse, federal laws may apply, such as those that prohibit sex discrimination, including sexual abuse, in federally-funded education programs, require reports of campus crimes, and set minimum standards for state child abuse reporting laws. GAO was asked to review efforts to prevent and respond to the sexual abuse of youth athletes under age 18.
GAO examined (1) the role of federal agencies in preventing and responding to sexual abuse of youth athletes, and (2) steps selected athletic programs aimed at high performance take to prevent and respond to such abuse. GAO reviewed relevant federal laws, regulations, guidance, and literature; visited a nongeneralizable sample of 11 athletic programs in three states selected on factors including sport popularity, gender participation, and geographic diversity; and interviewed federal agencies, relevant associations, and experts.
section_title: What GAO Found
paragraphs: Several federal agencies have roles in preventing and responding to the sexual abuse of a broad population of youth under age 18, which may include youth athletes. For example, the Department of Health and Human Services (HHS) and the National Center for Missing and Exploited Children, a nonprofit organization that receives Department of Justice (Justice) funding, published suggested practices for preventing child sexual abuse in youth-serving organizations. These suggested practices include defining and prohibiting misconduct; screening staff using fingerprint-based criminal background checks and other tools; and training staff on how to recognize, report, and respond to abuse. The National Center for Missing and Exploited Children also makes available information on child protection policies in youth sports settings, such as defining appropriate coach-athlete relationships. In addition, Justice may investigate alleged youth athlete abuse if there is a possibility the case constitutes a federal crime. These efforts may apply to youth in a range of settings. In addition, the Departments of Education (Education) and Justice oversee compliance with a civil rights law that protects individuals from sex discrimination, including sexual abuse, at schools that receive federal funding, which would generally include youth participating in sports camps on university campuses. Education also oversees postsecondary school compliance with a federal law requiring reporting of crimes, including sex offenses, that occur on or near campus. To ensure schools are meeting their obligations under these laws, Education and Justice conduct compliance reviews and investigations, and Justice participates in federal litigation involving claims of sex discrimination. Education also provides guidance and training to schools in areas such as developing codes of conduct, offering prevention and awareness training, and establishing reporting procedures.
The 11 athletic programs GAO reviewed all reported using methods, such as screening and training staff, to help prevent and respond to the sexual abuse of youth athletes. For example, the selected athletic programs, which included 8 private athletic clubs and 3 universities operating youth sports camps, all reported using name-based background checks to screen staff members for a criminal history. Two universities that operated sports camps reported they sometimes used fingerprint-based checks, while officials from other athletic programs cited the high cost of fingerprint checks as a barrier. Training for athletic staff in the programs GAO visited included how to identify signs of, respond to, and report suspected incidents of sexual abuse. Policies for all of these athletic programs also require staff to report suspected abuse to law enforcement. Further, the selected programs had response policies that generally included removing the suspected offender from the program and conducting their own investigations, which could result in lifetime bans from the program. Athletic programs' policies also included a variety of possible disciplinary actions, such as warning letters or required leave, for addressing inappropriate behavior that falls short of sexual abuse. Some of these policies have been created or revised in recent years, including the policies that private athletic clubs are implementing based on the United States Olympic Committee's athlete safety program, SafeSport, which prohibits various forms of misconduct, including child sexual abuse. GAO did not assess the effectiveness of any of the selected athletic programs' policies.
section_title: What GAO Recommends
paragraphs: GAO makes no recommendations in this report. Education, HHS, and Justice provided technical comments, which we incorporated as appropriate.

section_title: Letter
paragraphs: Media coverage on and academic research of the sexual abuse of youth  athletes by their coaches has raised questions about the type of  approaches and policies youth-focused athletic organizations use to  protect children from potential abuse. In many cases, youth athletes have  positive interactions with their coaches and gain important leadership  skills and self-confidence through their participation in sports. However,  reports of sexual abuse, misconduct, and inappropriate relationships  between coaches and athletes have occurred across a variety of sports,  gender interactions, and settings, with some resulting in convictions of  coaches of one or more sexual offenses. As research has shown, child  sexual abuse often has significant detrimental consequences to children’s  physical, psychological, academic, and behavioral development.
Little is known about the prevalence of sexual abuse of youth athletes in  the United States However, research has highlighted the specific ways in  which athletes have been “groomed” by coaches—a set of behaviors that  perpetrators carry out to establish trust and later facilitate sexual activity  with a child. Research also indicates that the power dynamics between  coaches and athletes aiming for high performance make those athletes  uniquely vulnerable to abuse due, in part, to the high risk, high reward  environment in which they compete and the position of power held by  coaches who play critical roles in ensuring their success. Among the  different settings where such incidents can occur are youth sports camps  held on college and university campuses and private athletic clubs  targeting high athletic performance, such as Olympic-level training clubs  for athletes who display competitive excellence in their sport.
States have the primary role in ensuring the safety of their citizens;  however, federal law establishes minimum standards for state mandatory  reporting laws regarding suspected child abuse and neglect, including  sexual abuse. Athletic programs must comply with any applicable state  requirements regarding mandatory reporting, which can vary from state to  state, and programs may be subject to other requirements, depending on  their setting. For example, postsecondary schools are required to comply  with Title IX of the Education Amendments of 1972 (Title IX), which  prohibits sex discrimination, including sexual harassment and abuse, in  federally-funded education programs and activities, and the Jeanne  Clery Disclosure of Campus Security Policy and Campus Crime Statistics  Act (Clery Act), which requires postsecondary schools that receive federal  student aid funding to report certain crimes that occur on and around their  campuses. You and former Representative George Miller, in his role as  Ranking Member of the House Committee on Education and the  Workforce, expressed interest in learning more about efforts made by  federal agencies and athletic programs to prevent and respond to the  sexual abuse of youth athletes under the age of 18.
Our review addresses the following questions for athletic programs aimed  at developing high performing athletes:  1.  What role do federal agencies play in preventing and responding to  the sexual abuse of youth participating in these programs?  2.  What steps do selected athletic programs take to prevent and respond  to the sexual abuse of youth athletes?
To perform this work, we used a variety of approaches. To understand  what role federal agencies play in preventing and responding to the  sexual abuse of youth athletes under age 18, we reviewed relevant  federal laws and regulations as well as relevant agency documents, such  as guidance and procedures for conducting compliance reviews. We  interviewed officials from the Departments of Education (Education),  Health and Human Services (HHS), and Justice (Justice). We also  interviewed relevant experts on coaching, athletics administration, and  sexual abuse, and officials from a range of relevant organizations,  including youth sport and education associations; victim advocacy  groups; the National Collegiate Athletic Association (NCAA); the United  States Olympic Committee (USOC); and the USOC’s national governing  bodies (NGB) for the selected private athletic programs of figure skating,  hockey, and swimming, and four of their regional affiliates. We also  reviewed relevant literature from these groups. To gather information on  how selected athletic programs address the sexual abuse of youth  athletes, we conducted site visits to a nongeneralizable sample of athletic  programs in three states—California, Florida, and Texas. We  interviewed representatives of and reviewed documentation for a total of  11 athletic programs, which included 3 universities that operate youth  sports camps and 8 local private athletic clubs. States and athletic  programs were selected based on criteria including popularity of sport  among youth, college rankings in selected sports, gender participation,  and geographic diversity. We gathered information about the relevant  policies and procedures selected athletic programs have designed for  screening staff and volunteers, education and awareness training,  monitoring and supervision, reporting of complaints, responding to  complaints, and imposing sanctions. We also reviewed training  materials on the subject of youth protection. For more information on our  scope and methodology, see appendix I.
We conducted this performance audit from February 2014 to May 2015 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on the audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: Youth Athletic Programs Aimed at Developing High Performance
subsections: section_title: Private Athletic Programs
paragraphs: Youth aiming to develop advanced skills, compete at a high performance  level, and achieve competitive excellence in a sport have a variety of  options for honing their skills. Youth can participate through private  athletic clubs—local sport-specific organizations that serve athletes who  compete, or may be interested in competing, at the highest performance  level. Generally, these clubs are part of a larger sport network under the  umbrella of the USOC.
The Amateur Sports Act of 1978 established the USOC as a federally  chartered nonprofit corporation that serves as the centralized body for  U.S. Olympic sports. In 1998, the Amateur Sports Act was revised by  the Ted Stevens Olympic and Amateur Sports Act. Under the act, the  USOC is authorized to recognize NGBs, which govern their respective  sports and recommend athletes to the USOC for participation in the  Olympic Games. Currently, the USOC recognizes 47 NGBs. The act  sets forth a number of purposes for the USOC, including to exercise  jurisdiction over U.S. participation in the Olympic Games and the  organization of the Olympic Games when held in the United States. Other  purposes include to provide swift resolution of conflicts and disputes  involving athletes and NGBs; to coordinate and provide information on  training, coaching, and performance; and to encourage and support  research, development, and dissemination of information in the areas of  sports medicine and sports safety. The USOC may provide financial  support and other resources to the NGBs, as needed and as the USOC  considers appropriate.
All members of the USOC are organizations, such as NGBs; the USOC  has no individual members. Members of the NGBs may include youth  and adult athletes, coaches, and other staff, although some NGBs may  only have organizational members. The USOC and NGBs can impose  various requirements as a condition of membership, but do not govern  employment practices of clubs. Clubs may also be members of regional  affiliates or associations of their sport, which generally serve as  intermediaries between the NGB and the local clubs, and as the  governing body for the local club within their region. (See fig. 1.)
The USOC established the SafeSport program, an athlete safety program  that addresses misconduct in sports through information, training, and  resources. The program was born out of a working group convened by  the USOC in 2010 to develop a set of recommendations for promoting  safe training environments in sports. To deliver its recommendations, the  working group sought input from a range of stakeholders. The  subsequent creation of the SafeSport program included one-on-one  discussions and a review of relevant research and best practice  documents, including a resource document on child sexual abuse  prevention from the Centers for Disease Control and Prevention (CDC)  within HHS.  The USOC’s minimum standards policy for the program  required each NGB to adopt an athlete safety program by December 31,  2013, that included the following minimum components: a policy that prohibits and defines six forms of misconduct: bullying,  hazing, harassment (including sexual harassment), emotional  misconduct, physical misconduct, and sexual misconduct (including  child sexual abuse);  criminal background checks for individuals who are in a position of  authority over or have frequent contact with athletes; an education and training program covering key components of their  athlete safety program by January 1, 2014; a procedure for reporting misconduct; and a grievance process to address allegations of misconduct following a  report or complaint.
section_title: Youth Sports Camps on College and University Campuses
paragraphs: Youth seeking to compete at a high performance level and achieve  competitive excellence in a sport can also participate in sports camps  held on college and university campuses. For example, some colleges  and universities offer sport-specific skill building through youth sports  camps and instructional clinics held on their campuses. While the  offerings vary by campus, such camps and clinics are available for a  variety of sports, may be offered as day or overnight camps, and may  range in duration from a few days to several weeks. In addition, the  degree to which colleges and universities operate and oversee the camps  can vary. For example, youth sports camps may be operated by the  college or university’s athletic department, by a private entity that  contracts with the college or university to use its facilities, or by a  combination of the two.
section_title: Behaviors of Perpetrators of Child Sexual Abuse
paragraphs: While child sexual abuse—the act of forcing a child to engage in sexual  activity with a perpetrator—is criminal in nature, according to research,  perpetrators of such abuse typically exhibit other inappropriate, and  sometimes noncriminal, behaviors. These behaviors may be displayed on  a continuum and may include grooming, sexual misconduct, and child  sexual abuse. (See fig. 2.)
section_title: Federal Efforts to Address Child Sexual Abuse in a Broader Context May Apply to Youth Athletes
subsections: section_title: Federal Agencies Engage in Some Activities to Prevent and Respond to Child Sexual Abuse that May Apply to Youth Athletes
paragraphs: Federal agencies engage in various efforts to prevent and respond to the  sexual abuse of a broad population of youth, and these efforts may apply  to youth athletes, depending on the circumstances. Some of these  federal efforts may help prevent or respond to the sexual abuse of youth  athletes in both private athletic clubs and university sports camps. For  example, HHS and Justice provide resources in the areas of sexual  violence prevention, reporting, and response practices, and the Federal  Bureau of Investigation (FBI) has a role in investigating incidents of child  sexual abuse that may constitute federal crimes. Other federal activities  may influence postsecondary schools’ efforts to prevent and respond to  the sexual abuse of youth athletes at sports camps held on their  campuses. Specifically, Education and Justice oversee school  compliance with Title IX, which prohibits sex discrimination, including  sexual harassment and abuse, in any education program or activity that  receives federal funds. In addition, Education oversees compliance with  the Clery Act, which requires schools that participate in federal student  aid programs to annually disclose statistics on certain crimes, including  sex offenses, that occur on or near their campuses. (See table 1.)
section_title: HHS and Justice Provide Resources and Justice Conducts Criminal Investigations to Address Child Sexual Abuse in a Variety of Settings, Including Youth Athletics
paragraphs: CDC and the National Center for Missing and Exploited Children  (NCMEC), a nonprofit organization that receives Justice funding, each  developed suggested practices for preventing and responding to sexual  abuse within youth-serving organizations, which may include youth  athletes in private athletic clubs and college and university sports  camps. Both CDC and NCMEC’s resources emphasize similar  categories of suggested practices: conducting an organizational self- assessment; screening staff for risk factors; defining behavioral guidelines  and creating safe environments; training staff on sexual abuse and  misconduct; monitoring behavior; and developing reporting and response  strategies when complaints or allegations are made (see table 2).
The NCMEC resource, in particular, includes information on how to  address the unique interactions that occur between coaches and youth  athletes. For example, NCMEC’s resource provides references to sexual  abuse prevention and response programs, online training available  through selected athletic organizations, and an article on developing  appropriate relationships between coaches and athletes. NCMEC’s  resource also offers youth-serving organizations some considerations  regarding background checks to screen applicants. NCMEC suggests  organizations use name-based and fingerprint-based criminal history  checks in addition to other screening tools, such as interviews and  reference checks. According to NCMEC, name-based checks typically  offer greater accessibility and more timely results. However, based on a  federal pilot program through which NCMEC assisted certain youth- serving organizations in conducting nationwide fingerprint-based criminal  history checks, NCMEC officials concluded fingerprint-based checks were  the most reliable way to identify those with disqualifying criminal histories  in other states, under a different name, or under a different date of birth.
Further, they concluded that fingerprint checks provide the greatest  potential in confirming an individual’s identity.
HHS and Justice also provide funding for sexual violence awareness and  prevention programs. Although these efforts do not focus on athletic  programs, funding has been used in some instances to address sexual  abuse in athletics. For example, an official from the Pennsylvania  Coalition against Rape told us that the organization, in part using funding  from the CDC’s Rape Prevention and Education Program, has  partnered with Pennsylvania State University (Penn State) to help the  university strengthen its sexual abuse prevention and response activities  in response to high-profile incidents of sexual abuse involving youth  athletes on campus. Justice’s Office on Violence Against Women also  provides funding to colleges and universities to help prevent sexual  violence through its campus grant program, and officials from this office  indicated that some college grantees have included athletic departments  in their efforts to increase awareness of sexual violence.
In addition to the suggested practices and prevention resources offered  by HHS and Justice, the FBI has a role in investigating crimes against  children that fall under federal jurisdiction, which may involve youth  athletes who participate in private athletic clubs or college and university  sports camps. For example, if a youth athlete is transported across state  lines and sexually abused by a coach or other athletic personnel, the FBI  may investigate the incident for possible violations of federal law. As  researchers and experts on athlete abuse have noted, travel can be an  area of significant risk for sexual abuse and misconduct, particularly if  coaches travel alone with or share hotel rooms with athletes. FBI officials  told us they are alerted to these crimes through various means, including  direct reports from victims and families, witnesses, state and local law  enforcement agencies, university and youth group officials, mandatory  reporters, such as medical professionals and legal practitioners, and  other federal law enforcement partner agencies. The FBI relies on a  network of 71 Child Exploitation Task Forces that partner with 400 state  and local law enforcement entities to help bridge federal, state, and local  resources to address the challenges of child exploitation investigations,  which may include those involving youth athletes. Still, according to the  FBI, child sexual abuse offenses, such as those involving youth athletes,  are inherently challenging, as children or their parents may be reluctant to  report them, especially when their abuser is in a position of trust, as is  often the case with sports coaches.
section_title: Education and Justice Oversee Postsecondary School Compliance with Federal Requirements to Address Sexual Abuse, Which May Include Youth at Sports Camps on Campus
paragraphs: Education oversees school compliance with Title IX and Clery Act  requirements, which may apply to incidents of sexual abuse of youth  athletes on college and university campuses. In general, Title IX and  Education’s regulations implementing Title IX require schools to take  steps to respond to sexual violence, including abuse, while the Clery Act  requires schools to annually report statistics on sex offenses that occur  on or near their campus to Education and in a security report for students  and employees. However, these requirements would generally not apply  in cases of sexual abuse of youth participating in sports at private athletic  clubs unrelated to a postsecondary school. According to Education  officials, determining a school’s obligations under either law would  depend on the circumstances of each incident, which may be affected by  the structure of sports camp operations, as well as where the abuse is  alleged to have occurred.
Title IX: Education officials said that Title IX would generally apply to  cases of sexual abuse committed by school employees, and a school  would be obligated to take steps to prevent and respond to such  abuse, if the school knew or reasonably should have known about the  abuse. By contrast, if alleged sexual abuse occurs in a program held  on campus, but operated by an entity independent of the school,  Education first determines whether Title IX applies and, if so, whether  the school met its obligations under the law. One factor Education  considers when making these determinations is whether the camp  receives significant assistance from the school, such as use of a  school’s facilities. As with cases of abuse committed by school  employees, in cases of abuse committed by third parties, such as  coaches at sports camps who are not employed by the university,  Education also considers whether the school knew of or should  reasonably have known of the alleged abuse to determine whether  the school is obligated under Title IX to address the abuse.
Clery Act: With respect to reporting campus crimes under the Clery  Act, Education officials stated that a school’s reporting obligations  would be triggered if sexual abuse occurs on or near a campus and is  reported to a campus official responsible for Clery Act reporting.  They explained that this would be true regardless of whether the  school is involved with the daily operations of a sports camp.
subsections: section_title: Federal Oversight and Enforcement Activities
paragraphs: Education conducts reviews of and investigations into schools’  compliance with Title IX and Clery Act requirements to ensure schools  are meeting their obligations under these laws.  Justice may also review  and investigate allegations of Title IX violations. Because Title IX  protections cover a broad population and Clery Act requirements apply to  a range of incidents, Education officials stated that they do not target their  activities toward youth athletes specifically. Officials from Education and  Justice told us they initiate Title IX investigations, and Education officials  told us they initiate Clery Act investigations, both in response to  complaints received alleging suspected violations and on their own  initiative. Although Education officials told us of investigations into  possible Title IX and Clery Act violations at Penn State, as of February  2015, both investigations were ongoing and determinations had not yet  been reached, according to officials. Education and Justice officials said  they were not aware of any other cases or complaints in recent years  specifically alleging sexual abuse of youth athletes participating in sports  camps on school campuses. However, given the purposes for which their  data collection systems were established, neither Education nor Justice’s  systems allow officials to conduct automated searches for cases involving  the sexual abuse of youth athletes by coaches or other athletic personnel.
Title IX: Education and Justice officials said their complaint intake  systems do not track information about the relationship between the  victim and the perpetrator or the age of the victim, given the broad  focus of their enforcement activities.
Clery Act: Education officials explained that crime statistics required  by the Clery Act contain high-level information about incidents, which  do not include information about the relationship between victims and  perpetrators in sex offense cases.
Federal agencies may take certain actions if a school is found to be out of  compliance with either Title IX or the Clery Act. If Education’s OCR finds  that a school has violated Title IX, it first seeks to establish voluntary  compliance through a resolution agreement, which describes changes the  school agrees to make to ensure its procedures for preventing and  responding to sexual abuse comply with Title IX. If Education is unable to  achieve voluntary compliance in a Title IX case, it may initiate  proceedings to terminate the school’s federal funding, or refer the case  to Justice for possible litigation. Additionally, Education’s FSA can  impose fines on colleges for Clery Act violations.
section_title: Education’s Efforts to Assist Schools in Their Obligations to Prevent and Respond to Sexual Abuse
paragraphs: Education has published several guidance documents to assist schools in  complying with Title IX and the Clery Act, which include information that  may apply to the sexual abuse of youth participating in university sports  camps.
Guidance on Protected Individuals and Covered Settings  Title IX: OCR guidance emphasizes that Title IX protects students from  sexual harassment and sexual abuse carried out by a school employee.  OCR guidance further specifies that any sexual activity between an adult  employee and a student below the legal age of consent in his or her state  is viewed as unwelcome and nonconsensual, and therefore sexual  harassment under Title IX. Although the guidance focuses on school  employees and students, according to a senior OCR official, the same  principles would apply in cases of sexual activity between adult coaches  and youth athletes participating in sports camps held on campus.
Clery Act: OPE guidance specifies that all crimes covered by the Clery  Act should be counted in schools’ crime statistics for their annual security  reports and reports to Education, even if they involve individuals not  associated with the school. According to officials from OPE and FSA, the  sexual abuse of youth athletes participating in sports camps held on  campus are covered by the Clery Act.
Guidance on Training and Education  Title IX: OCR’s Title IX guidance states that schools should provide  training about how to identify and prevent sexual abuse to all employees  likely to witness or receive reports of sexual abuse, including athletic  coaches. OCR also explained in guidance that schools are responsible  for developing policies that prohibit inappropriate conduct by school  personnel and procedures for identifying and responding to such  conduct. Such policies, OCR guidance states, could include a code of  conduct that addresses grooming—behavior intended to establish trust  with a minor to facilitate future sexual activity. In our prior work on sexual  abuse by K-12 school personnel, experts cited behavioral codes of  conduct and awareness and prevention training on sexual abuse as key  tools for preventing abuse. Furthermore, experts said identifying and  addressing violations of conduct, including those that fall short of abuse,  as they occur could help prevent future abuse.
Clery Act: In October 2014, Education issued final regulations  implementing recent amendments to the Clery Act which, among other  things, define requirements for schools to offer sexual violence prevention  and awareness programs to employees, including athletic personnel.   OPE and FSA officials stated that they instructed schools to provide  training and education on sexual violence, which may include populations  involved in youth sports programs on campus. Officials from OPE and  FSA also confirmed that schools should offer training to temporary hires  for youth sports camps. According to OPE officials, while schools are  strongly encouraged to mandate training, such a requirement was not  included in the final Clery Act regulations because it was not required by  the statute. Officials said that concerns were raised during the negotiated  rulemaking process that mandating training would be burdensome for  schools with large numbers of students and employees.
Guidance on Reporting and Response  Title IX: In its Title IX guidance, OCR recommends that schools working  with minors incorporate relevant state and local mandatory requirements  for reporting child abuse and neglect into their policies, as schools may  have reporting obligations to local child protective services and law  enforcement agencies. OCR guidance also states that individuals  designated as responsible employees are obligated to report alleged  incidents of sexual abuse to school officials. To assist schools in  appropriately responding to reported cases of sexual abuse, which may  include youth athletes, OCR guidance states that schools should consider  potential conflicts of interest when investigating reports of alleged sexual  abuse. OCR officials confirmed that employees from a college’s athletic  department should not be responsible for conducting investigations of  suspected sexual abuse of youth athletes.
Clery Act: OPE guidance outlines schools’ Clery Act obligations, which  include reporting the number of certain crimes, including sex offenses,  occurring on or near their campuses in an annual security report,  submitting those statistics to Education, and maintaining a daily crime log  to record information about all reported campus crimes. FSA officials  also reported providing training that instructed schools to inform those  employees with significant responsibility for campus activities, such as  athletic directors and coaches, of their duty to report any crimes on  campus under the Clery Act. FSA officials said they have also responded  to inquiries from schools about how to set up procedures to ensure  reports are made in light of a recent high profile case at Penn State where  questions were raised about reporting suspected sexual abuse of youth  athletes. In response to these inquiries, FSA officials told us they  explained to colleges that designating a Clery compliance officer—an  individual responsible for coordinating a college’s Clery Act activities— can help colleges ensure they have an individual on campus who is  aware of and can enforce Clery Act requirements across different campus  departments.
section_title: Selected Athletic Programs Use Screening and Training of Staff, Among Other Actions, to Prevent and Address the Sexual Abuse of Youth Athletes
subsections: section_title: All Selected Athletic Programs Reported Using Name-Based Criminal Background Checks to Screen Staff, but Vary in Use of Other Screening Tools
subsections: section_title: Criminal Background Checks
paragraphs: Each of the 11 athletic programs we visited reported conducting some  type of screening to determine if applicants are suitable to work with  children. For the eight private athletic clubs we visited, determining  minimum standards for who receives background checks and what type  of check is used is the responsibility of the NGBs of their sport or their  regional affiliates. At sports camps operated by the three universities we  visited, the school determines who gets checked and in what ways.   Annual or bi-annual screenings of staff were the most frequently used  method among the selected athletic programs we visited. The most  commonly used screening method of all the athletic programs we visited  was the name-based criminal background check, which involves  comparing the names, dates of birth, and Social Security numbers of  individuals to information collected by private vendors from state and local  court and criminal records. These background checks involve scanning  national or federal criminal databases and sex offender registries. While  relying on name-based checks, sports camps at two universities we  visited also used fingerprint checks in certain instances, such as when  employees work at camps for multiple years, and for volunteers.
Officials acknowledged the benefits and challenges of using name-based  and fingerprint-based checks. Although NCMEC officials cited some  advantages to using name-based criminal history checks from private  screening vendors, such as availability and timeliness, athletic program  officials we spoke with raised concerns about the completeness and  accuracy of those checks, and some told us of their preference for  fingerprint-based checks. For example, NGB officials told us that due to  the number of background check vendors in the marketplace and the  various databases they use, it can be difficult for consumers to know the  quality of the vendors and of the information in their databases.  Information compiled by vendors is typically drawn from a variety of state  and county law enforcement databases which may not be frequently  updated to ensure criminal histories are complete and accurate,  according to an official from one child sexual abuse prevention  organization. Officials from two of the three NGBs we talked with told us  they would prefer to use fingerprint-based background checks, with one  citing NCMEC’s conclusions from the pilot program that fingerprint-based  checks provide greater accuracy in identifying an individual than name- based checks.
Officials at both private athletic clubs and university sports camps told us,  however, that the cost of fingerprint-based background checks was a  concern. GAO previously conducted work on FBI criminal history checks  for non-criminal justice purposes and found that state law enforcement  authorities often charge fees for fingerprint-based checks. One official  from an organization that uses sports programs to engage at-risk youth  explained that these fees can range from $25 to $100 per check and can  be cost prohibitive for organizations that rely on large numbers of athletic  personnel.
section_title: Interviews and Reference Checks
paragraphs: In addition to background checks, four youth athletic programs whose  officials we met with reported having screening policies that called for  applicant interviews, and reference checks of applicants were generally  not required among the 11 athletic programs, according to program  officials. According to officials at both private athletic clubs and university  sports camps, because sports communities are often small and well  acquainted, applicants are typically referred by coaches and other athletic  personnel, and formal screening practices such as targeted interview  questions and reference checks are not commonly used. Officials at one  of the private athletic clubs that reported conducting applicant interviews  told us there is no need for specific interview questions to weed out  perpetrators of sexual abuse because they could detect such offenders  based on appearance or demeanor. However, as noted by one national  child advocacy center, many perpetrators of child sexual abuse are well  educated and respected members of the community and look like anyone  else. Further, research has pointed out that the belief that offenders fit  certain stereotypes can hinder child sexual abuse prevention. One NGB  official explained that in local programs, there is a feeling that “everybody  knows everybody,” and that it is unnecessary to ask for references.  Though the NGB requires private athletic clubs to check references, this  official expressed doubt that clubs are following through. The official told  us the NGB is developing an enhanced tool for clubs that will offer sample  questions for interviews and reference checks to address findings from a  study which evaluated their SafeSport program against the CDC resource  and identified weaknesses in screening policies, including the lack of  personal interviews and reference checks in which youth protection is  discussed.
section_title: Selected Athletic Programs Establish Policies Governing Behavioral Standards and Require Staff Training to Prevent and Address the Sexual Abuse of Youth Athletes
subsections: section_title: Policies Governing Behavior between Coaches and Athletes
paragraphs: The policies of selected athletic programs whose officials we met with set  basic standards of behavior between coaches and youth athletes. Private  athletic clubs we visited generally had athlete safety policies that were  based on guidance provided by their respective NGBs. Officials from  each of the eight private clubs explained that in response to the recent  creation of SafeSport policies by the USOC and their NGB, clubs either  defer to their NGB’s policies or look to their NGB or regional affiliates for  implementation guidance. For example, NGB SafeSport guidelines detail  a variety of behavioral boundaries, prohibitions, and expectations for  coach-athlete relationships, covering topics such as physical contact and  social media use, among others. The SafeSport policies of all three NGBs  whose officials we met with also provide guidelines local clubs may want  to consider to ensure their SafeSport policies reflect and account for the  particular setting of the club and facility. For example:
One NGB’s social media guidance prohibits coaches from connecting  to any athletes through a personal social media page or application,  and suggests that any contact via social media should only take place  through an official team page that parents are able to join.
An official at one local hockey club we met with told us their policy is  to lock all locker room doors when youth players are on the ice. In  addition, this official explained that youth and adult hockey players  sometimes use the locker rooms simultaneously at the club’s facility,  and when this occurs, the club has two individuals serve as monitors  in the locker room, one more than their NGB recommends.
Policies of the three selected universities that operate sports camps also  addressed issues of child protection, with some reflecting changes made  to enhance youth safety in light of sexual abuse incidents at Penn State  University. They covered practices to prevent sexual misconduct and  monitoring and supervision of campers, among other topics. For example:
One university swim camp developed a code of conduct for its staff  that states any inappropriate interaction or relationship with a camper  will result in immediate termination and, depending on the  circumstance, notification of law enforcement authorities.
Officials at all three universities we visited stressed the importance of  preventing one-on-one interactions between staff and campers  through a practice known as two-deep leadership, as a way to limit  opportunities for misconduct. For example, in one camp’s counselor  handbook, private one-on-one interactions were listed as a violation.
One university recently changed its policies on access to campus  facilities following a report evaluating another university’s response to  a high profile case of sexual abuse of youth athletes on its campus.  Using the report’s recommendations as a benchmark against its own  policies, the university we visited changed access to its facilities so  that electronic keycards previously used to enter a building would be  deactivated once an individual no longer needed access.
Over the last 2 years, another university created an office focused on  youth on campus. This office developed a central registration system  to maintain information about all university camps. In addition, they  created a system of spot checks in which staff from this office conduct  in-person visits to camps to ensure staff-to-camper ratios are followed  and those present at the camp are on the central registration list,  among other safety measures.
section_title: Training
paragraphs: All 11 of the youth athletic programs included in our study had policies  requiring training of staff on youth athlete safety. The eight private athletic  clubs required training of staff and volunteers with regular, routine, or  frequent access to youth athletes, while the three universities we visited  required all sports camp staff and volunteers to complete training.
Training participation in both private clubs and university sports camps  was generally monitored using a roster, according to program officials.  Child sexual abuse prevention was a topic included in the required  training for the selected athletic programs, and training generally covered  topics such as how to identify the warning signs of, respond to, and report  suspected abuse, including sexual abuse involving an athlete and athletic  personnel. (See table 3.) All of the athletic programs we reviewed offered  online training, and one program also offered training led by an instructor.  Training is generally required at least every other year, and participants  must complete one or more quizzes before receiving credit for completing  the course.
Some athletic programs we visited offer child sexual abuse prevention  training and education resources to parents and athletes, though none  require training of these groups. Further, officials from both types of  athletic programs cited some challenges in implementing mandatory  parent and athlete training. For example, officials from the eight private  athletic clubs said they cannot require parents to take the training unless  they are members of the NGB of their sport.
One NGB official noted that some Canadian provinces require parents  to take child abuse prevention training before their child can  participate in athletic programs, but he believed that policy would be  unlikely to be accepted in American sports. An official from the  organization that spearheaded the effort to require training explained  that it took the Canadian sports community years to embrace child  sexual abuse prevention training. He told us that while organizations  had background checks and other policies in place, education on the  need for such policies and a greater understanding of the issue of  abuse was also necessary. He explained that, in his view,  perpetrators of sexual abuse are able to operate, in part, because of  ignorance and indifference in the community. Eventually, through a  survey, the organization found that the Canadian sports community  supported the training and considered it a good recruitment and  retention tool.
Another NGB official told us that in its commissioned report to assess  its SafeSport program against abuse prevention and response  standards, parent training was cited as a weak area that needed  improvement. Specifically, the author of the report recommended  the NGB require parents to take SafeSport training, noting that few  parents discuss sexual abuse prevention with their children and those  who do often give inaccurate information. In response, the task force  charged with addressing the report’s recommendations suggested the  NGB strongly recommend parents take the training and encourage  participation through an incentive program that would tie parent  training on SafeSport with clubs’ SafeSport recognition status and  funding. Regarding athlete training, this NGB’s task force  recommended that its SafeSport committee and staff work with the  training vendor to develop material appropriate for parents to use to  discuss abuse prevention with children under age 12.
At one university we visited, officials cited the short duration of camp  programs, which generally last between 4 days and 1 week, as a barrier  to expanding training to both parents and campers. Officials told us that  camps do provide parents with general safety information such as  emergency contact numbers and, in the case of one university camp, an  overview of hiring practices. However, as one campus official explained,  information on the Clery Act, sexual abuse prevention, or requirements to  report is not currently provided to camp parents, although the university’s  Clery statistics are available online.
section_title: Monitoring for Compliance with Policies
paragraphs: Athletic programs we visited developed some internal practices and  policies to monitor compliance with athlete safety policies. Each of the  three NGBs whose officials we talked with required the appointment of  staff at the regional and, in some cases, local level to monitor SafeSport  program implementation and oversee each private athletic club’s efforts  to meet SafeSport requirements. In addition, one official explained that  the NGB she represents is considering a recommendation made in the  report that assessed its SafeSport program to conduct a baseline study to  determine the extent of child abuse and the effectiveness of various  prevention and response policies.
University staff responsible for overseeing youth on campus also help  monitor camp operations, according to officials from the universities we  visited. For example, officials at one university we visited told us they  developed a central registration system that tracked all of its camps, and  included information on the program name, schedules, and the staff and  athletes to assist with monitoring. This tracking system allows campus  officials to identify who works with each camper, making it easier to  investigate allegations of inappropriate interactions between staff and  campers, according to one campus security official at the university.  University officials also explained that staff overseeing youth programs on  campus will periodically observe athlete interactions with camp staff to  ensure that child protection policies, such as never having a camper  alone with one adult, are being followed. An official from another  university told us that while the coaches are in charge of day-to-day  operations of the camps, the administrative oversight duties are primarily  handled centrally by the university’s camp coordinator and human  resources. For the more heavily enrolled sports, coaches have the  support of the university’s director of operations who assists with the  administration of the camp.
An official from one private athletic club also explained how the wider  sports community can help alert them to potential problems with  interactions between athletic personnel or other adults and youth athletes.  For example, the official told us a parent notified the head coach that a  registered sex offender, who had inadvertently been let into the building,  was observing youth hockey practice. The club responded by developing  a policy of escorting all visitors at the rink.
section_title: Reporting and Response Policies of Selected Athletic Programs Vary Based on the Type of Incident and Program
subsections: section_title: Reporting
paragraphs: In cases where the sexual abuse of a youth athlete is observed or  suspected, all 11 athletic programs we visited have policies that require  contacting the appropriate law enforcement or child protection officials.  According to athletic program officials we spoke with, their programs’  policies reflected their state’s requirements for reporting child sexual  abuse, including how to report, which child welfare or law enforcement  agencies are designated to receive reports, and who is responsible for  reporting. In some cases, officials at universities we visited told us they  changed policies to reflect recent changes in state law that address child  abuse, including sexual abuse. Additionally, athletic programs may  choose to designate additional staff as mandatory reporters beyond those  persons designated by state child abuse and neglect reporting laws. For  example, officials from one university we visited told us the university  decided to designate all staff on campus as mandatory reporters of child  abuse and neglect after their state identified university administrators as  mandatory reporters. University officials explained that while designating  all staff as mandatory reporters could lead to over-reporting of the same  issues, it would be better than incidents not being reported.
In addition to contacting the appropriate law enforcement authorities, the  policies for each of the programs we visited included reporting observed  or suspected abuse to internal officials. The policies of local private  athletic clubs we visited provided options for reporting incidents to the  club or regional affiliate’s SafeSport staff or NGB by phone, email, or  letter, or anonymously through an online reporting system. At university  sports camps, internal reporting structures varied, but could include  university police, general counsel, the Clery compliance office, and in  some cases, the university’s Title IX coordinator.
section_title: Response
paragraphs: Following reports of suspected sexual abuse to law enforcement, which  may lead to criminal investigations, all of the selected athletic programs  we met with reported having response policies that generally include  separating the alleged perpetrator from athletes, and which may also  bring immediate suspension. Policies also include conducting an internal  investigation that could result in a range of sanctions, including bans from  the athletic program if there are findings of wrongdoing. Under these  policies, the accused is provided the right to receive a written notice of the  complaint, present information during the investigation, and appeal the  final decision. However, these reporting and response policies have not  been put into action and tested because officials from each of the 11  athletic programs told us they were not aware of cases of alleged sexual  abuse involving athletes and athletic personnel affiliated with their  program.
In addition to criminal investigations handled by law enforcement, any  allegations of sexual abuse or misconduct occurring at the private athletic  clubs we visited would generally be handled by their respective NGB,  which would also be responsible for determining any violations of policy  and resulting sanctions for cases in which violations are found. In some  cases, NGB officials lead investigations of abuse complaints at private  athletic clubs and, in the case of two NGBs, contract with private  investigators to carry out the investigation once the NGBs have  completed initial work to ascertain basic information about the complaint  and seek cooperation from the alleged victim. At the university sports  camps we visited, after making reports to law enforcement, multiple  departments and offices, including the Title IX compliance and the Clery  Act compliance offices, the university police, the general counsel’s office,  and others may be involved in responding to such allegations internally.  At one school we visited, an official explained that the Title IX coordinator  and the human resources department would work together to either  conduct an investigation of any incident involving a youth athlete  participating in campus programs, or engage an outside investigator to  conduct the investigation.
According to the response policies of athletic programs we visited, athletic  personnel found to have committed sexual abuse against a youth athlete  can face penalties including bans from the sport or campus.
Officials at all three NGBs we spoke with told us they can recommend  imposing a lifetime ban from their sport on those found to have  sexually abused youth athletes.
Two of the three NGBs we reviewed also publish a list of banned  coaches and other athletic personnel. However, officials from one  NGB told us that they knew of multiple coaches that were banned  from their sport only to find them moving on to coach in other sports.
At the university sports camps we visited, if there are findings of  wrongdoing the universities can terminate the university employee  involved. One school told us they would ban perpetrators of sexual  violence from campus for three years and if the perpetrator is an  employee, the human resources department can impose a variety of  sanctions, from mandatory counseling to suspension or termination.
As with allegations of sexual abuse, in cases of inappropriate behavior  that falls short of abuse, the policies of selected athletic programs we  visited included a variety of disciplinary actions. For example, officials  from one NGB explained that although sharing a hotel room with an  athlete while traveling for competition was formerly a common cost-saving  measure, SafeSport policies now strictly forbid it. However, they said  some coaches have continued to share rooms, and in response the NGB  issued formal warning letters to coaches who violated the policy. In  addition, according to this official, more severe measures would be taken  in the event of subsequent violations or if the shared room violation is  combined with other violations. Officials from university camps told us  they also have a variety of disciplinary actions to choose from when staff  members are found to have acted inappropriately with campers, such as  verbal or written reprimands or requiring staff to take leave.
According to one USOC official, responding to allegations of sexual  misconduct requires significant expertise. To address this, the official told  us the USOC is working to create a United States Center for SafeSport  that will establish an administrative proceeding for handling allegations of  sexual misconduct as defined in a standardized safe sport code. This  centralized approach to investigating and resolving allegations at the  center would aim to deliver expert and consistent results across sports  and sports organizations, as well as provide the ability to effectively share  information about individuals who have been suspended or banned for  policy violations. This official explained that all NGBs have adopted  definitions for sexual misconduct established by the SafeSport program.  According to this official, plans for the center, once created, include  developing a national code to help individuals further distinguish between  appropriate and inappropriate behavior, which can enhance people’s  ability and willingness to report misconduct, and the ability of the center to  ensure fair and equitable responses to incidents. According to this official:
There are plans for the center to include a board of directors that  would have no material conflicts or relationships with the USOC or  any NGB to ensure independent review of all SafeSport cases.
The center may compile and maintain a centralized list of those who  are banned from USOC and NGB membership.
The center is expected to be launched sometime during 2015. As of  February 2015, work to secure insurance within budget and  sustainable financial support for five years for the center was ongoing.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to the Departments of Education, HHS,  and Justice for review and comment. Education, HHS, and Justice  provided technical comments, which we incorporated as appropriate.
As agreed with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the Secretary of  Education, HHS, and the Attorney General and interested congressional  committees. The report will also be available at no charge on the GAO  Web site at www.gao.gov.
If you or your staff members have any questions about this report, please  contact me at (202) 512-7215 or brownke@gao.gov. Contact points for  our Offices of Congressional Relations and Public Affairs may be found   on the last page of this report. GAO staff who made key contributions to  this report are listed in appendix II.
section_title: Appendix I: Objectives, Scope and Methodology
paragraphs: This appendix discusses in detail our methodology for addressing two  research questions for athletic programs aimed at developing high  performing athletes:  (1) What role do federal agencies play in preventing  and responding to the sexual abuse of youth participating in these  programs? and (2) What steps do selected athletic programs take to  prevent and respond to the sexual abuse of youth athletes?
To address these questions, we reviewed relevant federal laws,  regulations, and guidance. We conducted interviews with officials from  the Departments of Education, Health and Human Services, and Justice,  representatives of youth sports and education associations, and experts.  We also conducted site visits to a nongeneralizable sample of youth  sports camps on university campuses and private athletic programs in  three states, which were selected based on the popularity of sports  among youth, gender participation, college rankings in selected sports,  and geographic diversity. We conducted this performance audit from  February 2014 through May 2015 in accordance with generally accepted  government auditing standards. Those standards require that we plan  and perform the audit to obtain sufficient, appropriate evidence to provide  a reasonable basis for our findings and conclusions based on our audit  objectives. We believe that the evidence obtained provides a reasonable  basis for our findings and conclusions based on our audit objectives.
subsections: section_title: Review of Federal Laws, Regulations and Guidance
paragraphs: To determine the federal role in preventing and responding to the sexual  abuse of youth athletes in these programs, we reviewed relevant federal  laws, including the Child Abuse Prevention and Treatment Act (CAPTA);  Title IX of the Education Amendments of 1972 (Title IX); and the Jeanne  Clery Disclosure of Campus Security Policy and Campus Crime Statistics  Act (Clery Act), among others. In addition, we reviewed Education’s  regulations and guidance on Title IX and Clery Act requirements, and the  agency’s policies and procedures for ensuring compliance with these  requirements. However, we did not evaluate the effectiveness of  Education’s policies and procedures to assess compliance with Title IX or  the Clery Act. We also reviewed documents on suggested practices for  preventing and responding to child sexual abuse in youth-serving  organizations from the Centers for Disease Control and Prevention and  the National Center for Missing and Exploited Children, an organization  that receives grant funding from Justice.
section_title: Interviews with Federal Officials and Experts
paragraphs: To examine the federal role in addressing the sexual abuse of these  youth athletes, we also interviewed officials from Education, HHS and  Justice, as well as experts on coaching, athletics administration, and  sexual abuse. At Education, we spoke with officials in the Office for Civil  Rights, the Office of Postsecondary Education, and the Federal Student  Aid office. At HHS, we spoke with officials at the Administration for  Children and Families and the Centers for Disease Control and  Prevention. At Justice, we interviewed officials from the Office on  Violence Against Women, the Office of Justice Programs, the Civil Rights  Division, and the Federal Bureau of Investigation. Additionally, we  interviewed officials from a range of relevant organizations, including the  National Collegiate Athletic Association (NCAA), the Association of Title  IX Administrators, the National Center for Missing and Exploited Children,  the National Sexual Violence Resource Center, and the Pennsylvania  Coalition Against Rape.
section_title: Site Visits
paragraphs: To gather more in-depth information on the policies and practices  selected private athletic clubs and university sports camps use to protect  youth athletes from sexual abuse, we conducted site visits to a total of 11  athletic programs located in three states: California, Florida, and Texas.  University sports camps were selected based on a sequence of steps,  which included identifying the most popular sports among youth,  identifying universities that offered youth camps and clinics and that had  NCAA division I rankings in these sports, and geographic diversity. First,  we identified the 10 most popular athletic programs for high school  students during the 2012-2013 school year. We then identified  universities that offered youth sports camps in five sports: basketball,  football, gymnastics, swimming and diving, and volleyball. Our final  selection took into account sport popularity, Division I rankings in these  sports during the 2013-2014 school year, gender participation, camp and  clinic operations, camp type (overnight, day, and commuter camps), and  geographic diversity. We selected a total of three universities with youth  sports camps and clinics in the above five sports. The university sports  camps we selected were all run directly by the university. However, some  sports camps on campuses may have a different operational structure; for  example, they may be run by a private entity that is simply renting space  on the campus.
In addition to university sports camps, we visited a total of eight local  private athletic clubs implementing an athlete safety program based on  the SafeSport program established by the U.S. Olympic Committee  (USOC). To select the private athletic programs, we considered gender  diversity, recommendations by experts and those who conduct research  on the intersection of sports and athlete sexual abuse, and sport  diversity. We selected eight local private athletic clubs in the sports of  figure skating, hockey, and swimming, and located in proximity to the  universities we visited. In addition, we met with four of their regional  affiliates.
We also interviewed officials from the USOC, and the three NGBs of the  Olympic sports we selected. At the local private athletic clubs we visited,  we spoke with board members, athlete safety coordinators, and coaches;  at the university campuses we visited we spoke with university  compliance officials, university administrators, legal counsel, and camp  directors. During each of these interviews, we collected information on  policies, training materials, and other relevant documentation for  preventing and responding to the sexual abuse of, and misconduct  against, youth athletes by athletic personnel. We did not assess the  sufficiency of these policies or how selected athletic programs  implemented these policies. We also did not evaluate how selected  athletic programs’ policies were applied to past cases of child sexual  abuse as it was beyond the scope of this report. In addition, we did not  evaluate whether any particular athletic program was in compliance with  any state or federal requirements.
Information we gathered on our site visits represents the conditions  present at the time of our visit. We cannot comment on any changes that  may have occurred after our fieldwork was completed. Our site visit  findings cannot be generalized to the larger youth athletics population.
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Sara Kelly and Debra Prescott  (Assistant Directors), Claudine Pauselli (Analyst-in-Charge), Christina  Cantor, and Aimee Elivert made key contributions to this report. Also  contributing to this report were James Bennett, Rachel Beers, Sarah  Cornetto, Helen Desaulniers, Holly Dye, Nisha Hazra, Kristen Jones,  Kathy Leslie, Kristy Love, Sheila McCoy, and Andrew Stavisky.
section_title: Related GAO Products
paragraphs: Child Welfare: Federal Agencies Can Better Support State Efforts to  Prevent and Respond to Sexual Abuse by School Personnel. GAO-14-42.  Washington, D.C.: January 30, 2014.
Child Care: Overview of Relevant Employment Laws and Cases of Sex  Offenders at Child Care Facilities. GAO-11-757. Washington, D.C.:  August 19, 2011.
Child Maltreatment: Strengthening National Data on Child Fatalities Could  Aid in Prevention. GAO-11-599. Washington, D.C.: July 7, 2011.
K-12 Education: Selected Cases of Public and Private Schools That Hired  or Retained Individuals with Histories of Sexual Misconduct. GAO-11-200.  Washington, D.C.: December 8, 2010.
Seclusions and Restraints: Selected Cases of Death and Abuse at Public  and Private Schools and Treatment Centers. GAO-09-719T. Washington,  D.C.: May 19, 2009.
Residential Facilities: Improved Data and Enhanced Oversight Would  Help Safeguard the Well-Being of Youth with Behavioral and Emotional  Challenges. GAO-08-346. Washington, D.C.: May 13, 2008.
Residential Treatment Programs: Concerns Regarding Abuse and Death  in Certain Programs for Troubled Youth. GAO-08-146T. Washington,  D.C.: October 10, 2007.