Residential Treatment Programs: Concerns Regarding Abuse and Death in Certain Programs for Troubled Youth
Published: 2007-10-10T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Residential treatment programs provide a range of services, including drug and alcohol treatment, confidence building, military-style discipline, and psychological counseling for troubled boys and girls with a variety of addiction, behavioral, and emotional problems. This testimony concerns programs across the country referring to themselves as wilderness therapy programs, boot camps, and academies, among other names. Many cite positive outcomes associated with specific types of residential treatment. There are also allegations regarding the abuse and death of youth enrolled in residential treatment programs. Given concerns about these allegations, particularly in reference to private programs, the Committee asked the General Accountability Office (GAO) to (1) verify whether allegations of abuse and death at residential treatment programs are widespread and (2) examine the facts and circumstances surrounding selected closed cases where a teenager died while enrolled in a private program. To achieve these objectives, GAO conducted numerous interviews and examined documents from closed cases dating as far back as 1990, including police reports, autopsy reports, and state agency oversight reviews and investigations. GAO did not attempt to evaluate the benefits of residential treatment programs or verify the facts regarding the thousands of allegations it reviewed.
section_title: What GAO Found
paragraphs: GAO found thousands of allegations of abuse, some of which involved death, at residential treatment programs across the country and in American-owned and American-operated facilities abroad between the years 1990 and 2007. Allegations included reports of abuse and death recorded by state agencies and the Department of Health and Human Services, allegations detailed in pending civil and criminal trials with hundreds of plaintiffs, and claims of abuse and death that were posted on the Internet. For example, during 2005 alone, 33 states reported 1,619 staff members involved in incidents of abuse in residential programs. GAO could not identify a more concrete number of allegations because it could not locate a single Web site, federal agency, or other entity that collects comprehensive nationwide data. GAO also examined, in greater detail, 10 closed civil or criminal cases from 1990 through 2004 where a teenager died while enrolled in a private program. GAO found significant evidence of ineffective management in most of the 10 cases, with program leaders neglecting the needs of program participants and staff. This ineffective management compounded the negative consequences of (and sometimes directly resulted in) the hiring of untrained staff; a lack of adequate nourishment; and reckless or negligent operating practices, including a lack of adequate equipment. These factors played a significant role in the deaths GAO examined.

section_title: Letter
paragraphs: Thank you for the opportunity to discuss residential treatment programs  for troubled youth. In the context of this testimony, we are using the term  residential treatment program to refer to entities across the country and  abroad calling themselves wilderness therapy programs, boarding schools,  academies, behavioral modification facilities, and boot camps, among  other names. While some of these programs are funded publicly by state  and local government agencies, others are privately owned and operated.  Private residential treatment programs typically market their services to  the parents of troubled teenagers—boys and girls with a variety of  addiction, behavioral, and emotional problems—and provide a range of  services, including drug and alcohol treatment, confidence building,  military-style discipline, and psychological counseling for illnesses such as  depression and attention deficit disorder.
Many cite positive outcomes associated with specific types of residential  treatment. There are also allegations regarding the abuse and death of  youth enrolled in residential treatment programs. Given concerns about  these allegations, particularly in reference to private programs, you asked  us to (1) verify whether allegations of abuse and death at residential  treatment programs are widespread and (2) examine the facts and  circumstances surrounding selected closed cases where a teenager died  while enrolled in a private program.
To verify whether allegations of abuse and death at residential treatment  programs are widespread, we gathered available information about  allegations made over the last 17 years by performing interviews with  relevant experts, reviewing relevant studies and documents, conducting  Internet searches for Web sites making allegations, reviewing data from  the National Child Abuse and Neglect Data System (NCANDS), and  reviewing relevant state and federal court documents. We were unable to  disaggregate information on public and private programs; consequently,  the information we present includes allegations against both types.
To select our case studies, we identified numerous closed civil and  criminal cases in which a court was asked to decide whether a private  residential treatment program was responsible for the death of an enrolled  teenager. When identifying our cases, we specifically excluded teenager  deaths at public programs such as state-sponsored foster programs,  juvenile justice programs for delinquent youth, or programs that  exclusively treat psychological disorders or substance abuse in a hospital  setting. We focused on deaths between the years 1990 and 2004 to  illustrate the long-standing issues presented by private residential  treatment programs. We limited our cases to closed cases and, thus,  ongoing cases from the last several years were not included in our work.  We selected these 10 cases based on several factors including victim age,  program location, type of program the victim attended, and date of death.
We then examined, in more detail, the facts and circumstances of the  death and any related abuse of the victim. To validate the facts and  circumstances of each case, and to the extent possible, we conducted  interviews with related parties, including current and former program staff  and officials, attorneys and law enforcement officials involved in the  cases, and the parents of the victims. Further, we reviewed available  documentation to support the facts of each case including (but not limited  to) marketing materials, police reports, autopsy reports, and state agency  oversight reviews and investigations. In addition, we conducted site visits  at nine residential treatment programs to obtain a firsthand perspective on  how residential treatment programs operate. Five of these nine programs  were related to the still-operational programs discussed in our cases— either because they were the same program or represented a permutation  of the original program operating under a different name or in a new  location.  Where we obtained financial information about the programs,  we converted this information to 2007 dollars so that the information was  comparable.
It is important to emphasize that residential treatment programs are  intended to help youth with serious problems—in some cases, these  problems constitute life-threatening addictions and diseases. We did not  attempt to evaluate the benefits of residential treatment programs in  dealing with these serious problems. Moreover, it is not possible to  generalize the results of our investigation as applying to all residential  treatment programs, whether privately or publicly funded. We found it  difficult to obtain an overall picture of the extent of the residential  treatment program industry. For example, while states often regulate  publicly funded programs, a number of states do not license or otherwise  regulate private programs. Because programs determine how to describe  themselves, especially in their marketing materials, there is no standard  definition for “wilderness therapy program,” “boot camp,” or other terms  used to describe the types of programs and facilities considered to be part  of this industry. GAO is completing a comprehensive review of state and  federal oversight of residential treatment programs for youth with  behavioral and emotional challenges and expects to report next year.
We performed our work from June through September of 2007 in  accordance with the quality standards for investigations set forth by the  President’s Council on Integrity and Efficiency.
subsections: section_title: Background
paragraphs: Since the early 1990s, hundreds of residential treatment programs and  facilities have been established in the United States by state agencies and  private companies. Many of these programs are intended to provide a less- restrictive alternative to incarceration or hospitalization for youth who  may require intervention to address emotional or behavioral challenges.  As mentioned earlier, it is difficult to obtain an overall picture of the  extent of this industry. According to a 2006 report by the Substance Abuse  and Mental Health Services Administration, state officials identified 71  different types of residential treatment programs for youth with mental  illness across the country. A wide range of government or private entities,  including government agencies and faith-based organizations, can operate  these programs. Each residential treatment program may focus on a  specific client type, such as those with substance abuse disorders or  suicidal tendencies. In addition, the programs provide a range of services,  either on-site or through links with community programs, including  educational, medical, psychiatric, and clinical/mental health services.
Regarding oversight of residential treatment programs, states have taken a  variety of approaches ranging from statutory regulations that require  licensing to no oversight. States differ in how they license and monitor the  various types of programs in terms of both the agencies involved and the  types of requirements. For example, some states have centralized licensing  and monitoring within a single agency, while other states have  decentralized these functions among three or more different agencies.  There are currently no federal laws that define and regulate residential  treatment programs. However, three federal agencies—the Departments of  Health and Human Services, Justice, and Education—administer programs  that can provide funds to states to support eligible youth who have been  placed in some residential treatment programs. For example, the  Department of Health and Human Services, through its Administration for  Children and Families, administers programs that provide funding to states  for a wide range of child welfare services, including foster care, as well as  improved handling, investigation, and prosecution of youth maltreatment  cases.
In addition to the lack of a standard, commonly recognized definition for  residential treatment programs, there are no standard definitions for  specific types of programs—wilderness therapy programs, boot camps,  and boarding schools, for instance. For our purposes, we define these  programs based on the characteristics we identified during our review of  the 10 case studies. For example, in the context of our report, we defined  wilderness therapy program to mean a program that places youth in  different natural environments, including forests, mountains, and deserts.  Figure 1 shows images we took near the wilderness therapy programs we  visited.
According to wilderness therapy program material, these settings are  intended to remove the “distractions” and “temptations” of modern life  from teens, forcing them to focus on themselves and their relationships.  Included as part of a wilderness training program, participants keep  journals that often include entries related to why they are in the program  and their experiences and goals while in the wilderness. These journals,  which program staff read, are part of the individual and group therapy  provided in the field. As part of the wilderness experience, these programs  also teach basic survival skills, such as setting up a tent and camp, starting  a fire, and cooking food. Figure 2 is photo montage of living arrangements  for youth enrolled in the wilderness programs we visited.
Some wilderness therapy programs may include a boot camp element.  However, many boot camps (which can also be called behavioral  modification facilities) exist independently of wilderness training. In the  context of our report, a boot camp is a residential treatment program in  which strict discipline and regime are dominant principles. Some military- style boot camp programs also emphasize uniformity and austere living  conditions. Figure 3 is a photo montage illustrating a boot camp which  minimizes creature comfort and emphasizes organization and discipline.
A third type of residential treatment program is known as a boarding  school. Although these programs may combine wilderness or boot camp  elements, boarding schools (also called academies) are generally  advertised as providing academic education beyond the survival skills a  wilderness therapy program might teach. This academic education is  sometimes approved by the state in which the program operates and may  also be transferable as elective credits toward high school. These  programs often enroll youth whose parents force them to attend against  their will. The schools can include fences and other security measures to  ensure that youth do not leave without permission. Figure 4 shows some  of the features boarding schools may employ to keep youth in the  facilities.
A variety of ancillary services related to residential treatment programs  are available for an additional fee in some programs. These services  include:    Referral services and educational consultants to assist parents in  selecting a program.
Transport services to pick up a youth and bring him or her to the  program. Parents frequently use a transport service if their child is  unwilling to attend the program.
Additional individual, group, or family counseling or therapy sessions  as part of treatment. These services may be located on the premises or  nearby.
Financial services, such as loans, to assist parents in covering the  expense of residential treatment programs.
These services are marketed toward parents and, with the exception of  financial services, are not regulated by the federal government.
section_title: Widespread Allegations of Abuse and Death at Residential Treatment Programs
paragraphs: We found thousands of allegations of abuse, some of which involved  death, at public and private residential treatment programs across the  country between the years 1990 and 2007. We are unable to identify a more  concrete number of allegations because we could not locate a single Web  site, federal agency, or other entity that collects comprehensive  nationwide data related to this issue. Although the NCANDS database,  operated by the Department of Health and Human Services, collects some  data from states, data submission is voluntary and not all states with  residential treatment programs contribute information. According to the  most recent NCANDS data, during 2005 alone 33 states reported 1,619 staff  members involved in incidents of abuse in residential programs. Because  of limited data collection and reporting, we could not determine the  numbers of incidents of abuse and death associated with private  programs.
It is important to emphasize that allegations should not be confused with  proof of actual abuse. However, in terms of meeting our objective, the  thousands of allegations we found came from a number of sources besides  NCANDS. For example:    We identified claims of abuse and death in pending and closed civil or  criminal proceedings with dozens of plaintiffs alleging abuse. For  instance, according to one pending civil lawsuit filed as recently as July  2007, dozens of parents allege that their children were subjected to  over 30 separate types of abuse.
We found attorneys around the country who represent youth and  groups of youth who allege that abuse took place while these youth  were enrolled in residential treatment programs. For example, an  attorney based in New Jersey with whom we spoke has counseled  dozens of youth who alleged they were abused in residential treatment  programs in past cases, as has another attorney, a retired prosecutor,  who advocates for abuse victims.
We found that allegations are posted on various Web sites advocating  for the shutdown of certain programs. Past participants in wilderness  programs and other youth residential treatment programs have  individually or collectively set up sites claiming abuse and death. The  Internet contains an unknown number of such Web sites. One site on  the Internet, for example, identifies over 100 youth who it claims died  in various programs. In other instances, parents of victims who have  died or were abused in these programs have similarly set up an  unknown number of Web sites. Conversely, there are also an unknown  number of sites that promote and advocate the benefits of various  programs.
Because there are no specific reporting requirements or definitions for  private programs in particular, we could not determine what percentage of  the thousands of allegations we found are related to such programs. There  is likely a small percentage of overlapping allegations given our inability to  reconcile information from the sources we used.
section_title: Cases of Death at Selected Residential Treatment Programs
paragraphs: We selected 10 closed cases from private programs to examine in greater  detail. Specifically, these cases were focused on the death of a teenager in  a private residential treatment program that occurred between 1990 and  2004. We found significant evidence of ineffective management in most of  these 10 cases, with many examples of how program leaders neglected the  needs of program participants and staff. In some cases, program leaders  gave their staff bad advice when they were alerted to the health problems  of a teen. In other cases, program leaders appeared to be so concerned  with boosting enrollment that they told parents their programs could  provide services that they were not qualified to offer and could not  provide. Several cases reveal program leaders who claimed to have  credentials in therapy or medicine that they did not have, leading parents  to trust them with teens who had serious mental or physical disabilities  requiring proper treatment. These ineffective management techniques  compounded the negative consequences of (and sometimes directly  resulted in) the hiring of untrained staff; a lack of adequate nourishment;  and reckless or negligent operating practices, including a lack of adequate  equipment. These specific factors played a significant role in most of the  deaths we examined.
Untrained staff. A common theme of many of the cases we examined  is that staff misinterpreted legitimate medical emergencies. Rather than  recognizing the signs of dehydration, heat stroke, or illness, staff  assumed that a dying teen was in fact attempting to use trickery to get  out of the program. This resulted in the death of teenagers from  common, treatable illnesses. In some cases, teens who fell ill from less- common ailments exhibited their symptoms for many days, dying  slowly while untrained staff continued to believe the teen was “faking  it.” Unfortunately, in almost all of our cases, staff only realized that a  teen was in distress when it was already too late.
Lack of adequate nourishment. In many cases, program philosophy  (e.g., “tough love”) was taken to such an extreme that teenagers were  undernourished. One program fed teenagers an apple for breakfast, a  carrot for lunch, and a bowl of beans for dinner while requiring  extensive physical activity in harsh conditions. Another program forced  teenagers to fast for 2 days. Teenagers were also given equal rations of  food regardless of their height, weight, or other dietary needs. In this  program, an ill teenager lost 20 percent of his body weight over the  course of about a month.  Unbeknownst to staff, the teenager was  simultaneously suffering from a perforated ulcer.
Reckless or negligent operating practices. In at least two cases,  program staff set out to lead hikes in unfamiliar territory that they had  not scouted in advance. Important items such as radios and first aid  kits were left behind. In another case, program operators did not take  into account the need for an adjustment period between a teenager’s  comfortable home life and the wilderness; this endangered the safety of  one teenager, who suddenly found herself in an unfamiliar  environment. State licensing initiatives attempt, in part, to minimize the  risk that some programs may endanger teenagers through reckless and  negligent practices; however, not all programs we examined were  covered by operating licenses. Furthermore, some licensed programs  deviated from the terms of their licenses, leading states, after the death  of a teen, to take action against programs that had flouted health and  safety guidelines.
See table 1 for a summary of the cases we examined.
subsections: section_title: Case One
paragraphs: The victim was a 15-year-old female. Her parents told us that she was a  date-rape victim who suffered from depression, and that in 1990 she  enrolled in a 9-week wilderness program in Utah to build confidence and  improve her self-esteem. The victim and her parents found out about the  program through a friend who claimed to know the owner. The parents of  the victim spoke with the owner of the program several times and  reviewed brochures from the owner. The brochure stated that the  program’s counselors were “highly trained survival experts” and that “the  professional experience and expertise” of its staff was “unparalleled.” The  fees and tuition for the program cost a little over $20,600 (or about $327  per day). The victim and her parents ultimately decided that this program  would meet their needs and pursued enrollment.
The victim’s parents said they trusted the brochures, the program owner,  and the program staff. However, the parents were not informed that the  program was completely new and that their daughter would be going on  the program’s first wilderness trek. Program staff were not familiar with  the area, relied upon maps and a compass to navigate the difficult terrain,  and became lost. As a result, they crossed into the state of Arizona and  wandered onto Bureau of Land Management (BLM) land. According to a  lawsuit filed by her parents, the victim complained of general nausea, was  not eating, and began vomiting water on about the third day of the 5-day  hike. Staff ignored her complaints and thought she was “faking it” to get  out of the program. Police documents indicate that the two staff members  leading the hike stated that they did not realize the victim was slowly  dehydrating, despite the fact that she was vomiting water and had not  eaten any food.
On the fifth day of the hike, the victim fell several times and was described  by the other hikers as being “in distress.” It does not appear that staff took  any action to help her. At about 5:45 p.m. on the fifth day, the victim  collapsed in the road and stopped breathing. According to police records,  staff did not call for help because they were not equipped with radios— instead, they performed CPR and attempted to signal for help using a  signal fire. CPR did not revive the victim; she died by the side of the road  and her body was covered with a tarp. The following afternoon, a BLM  helicopter airlifted her body to a nearby city for autopsy. The death  certificate for the victim states that she died of dehydration due to  exposure. Although local police investigated the death, no charges were  filed. Utah officials wanted to pursue the case, but they did not have  grounds to do so because the victim died in Arizona. The parents of the  victim filed a civil suit and settled out of court for an undisclosed sum.
Soon after the victim’s death and 6 months after opening, the founder  closed the program and moved to Nevada, where she operated in that state  until her program was ordered to close by authorities there. In a hearing  granting a preliminary judgment that enjoined the operator of the program,  the judge said that he would not shelter this program, which was in effect  hiding from the controls of the adjoining state. He chastised the program  owner for running a money-making operation while trying to escape the  oversight of the state, writing, “ wishes to conduct a  wilderness survival program for children for profit, without state  regulation” and she “hide the children from the investigating state  authorities and appear uncooperative towards them.” He expressed  further concerns, including a statement that participants in the program  did not appear to be receiving “adequate care and protection” and that  qualified and competent counselors were not in charge of the program.  The judge also noted that one of the adult counselors was “an ex-felon and  a fugitive.” After this program closed, the program founder returned to  Utah and joined yet another program where another death occurred 5  years later (this death is detailed in case seven). We found that the founder  of this residential treatment program had a history in the industry—prior  to opening the program discussed in this case, she worked as an  administrator in the program covered in another case (case two). Today,  the program founder is still working in the industry as a consultant,  providing advice to parents who may not know of her history.
section_title: Case Two
paragraphs: The victim was a 16-year-old female who had just celebrated her birthday.  According to her mother, in 1990 the victim was enrolled in a 9-week  wilderness therapy program because she suffered from depression and  struggled with drug abuse. The victim’s mother obtained brochures from  the program owner and discussed the program with him and other  program staff. According to the mother, the program owner answered all  her questions and “really sold the program.” She told us:  “I understood there would be highly trained  and qualified people with  who  could handle any emergency… they boasted  of a 13-year flawless safety record,  I  thought to myself ‘why should I worry? Why  would anything happen to her?’”
Believing that the program would help her daughter, the victim’s mother  and stepfather secured a personal loan to pay the $25,600 in tuition for the  program (or about $400 per day). She also paid about $4,415 to have a  transport service come to the family home and take her daughter to the  program. The victim’s mother and stepfather hired the service because  they were afraid their daughter would run away when told that she was  being enrolled in the program. According to the victim’s mother, two  people came to the family home at 4 a.m. to take her daughter to the  program’s location in the Utah desert, where a group hike was already  under way.
Three days into the program, the victim collapsed and died while hiking.  According to the program brochure, the first 5 days of the program are  “days and nights of physical and mental stress with forced march, night  hikes, and limited food and water. Youth are stripped mentally and  physically of material facades and all manipulatory tools.” After the victim  collapsed, one of the counselors on the hike administered CPR until an  emergency helicopter and nurse arrived to take the victim to a hospital,  where she was pronounced dead. According to the victim’s mother, her  daughter died of “exertional heatstroke.” The program had not made any  accommodation or allowed for any adjustment for the fact that her  daughter had traveled from a coastal, sea-level residence in Florida to the  high desert wilderness of Utah. The mother of the victim also said that  program staff did not have salt tablets or other supplies that are commonly  used to offset the affects of heat.
Shortly after the victim died, the 9-week wilderness program closed. A  state hearing brought to light complaints of child abuse in the program and  the owner of the program was charged with negligent homicide. He was  acquitted of criminal charges. However, the state child protective services  agency concluded that child abuse had occurred and placed the owner on  Utah’s registry of child abusers, preventing him from working in the state  at a licensed child treatment facility. Two other program staff agreed to  cooperate with the prosecution to avoid standing trial; these staff were  given probation and prohibited from being involved with similar programs  for up to 5 years. In 1994, the divorced parents of the victim split a  $260,000 settlement resulting from a civil suit against the owner.
After this program closed, its owner opened and operated a number of  domestic and foreign residential treatment programs over the next several  years. Although he was listed on the Utah registry of suspected child  abusers, the program owner opened and operated these programs  elsewhere—many of which were ultimately shut down by state officials  and foreign governments because of alleged and proven child abuse. At  least one of these programs is still operating abroad and is marketed on  the Internet, along with 10 other programs considered to be part of the  same network. As discussed above, the program owner in our first case  originally worked in this program as an administrator before it closed.
section_title: Case Three
paragraphs: The victim was a 16-year-old male. According to his parents, in 1994 they  enrolled him in a 9-week wilderness therapy program in Utah because of  minor drug use, academic underachievement, and association with a new  peer group that was having a negative impact on him. The parents learned  of the program from an acquaintance and got a program brochure that  “looked great” in their opinion. They thought the program was well-suited  for their son because it was an outdoor program focusing on small groups  of youth who were about the same age. They spoke with the program  owner and his wife, who flew to Phoenix, Arizona, to talk with them. To be  able to afford the program’s cost of about $18,500 (or $263 per day), the  victim’s parents told us they took out a second mortgage on their house.  They also paid nearly $2,000 to have their son transported to the campsite  in the program owner’s private plane. At the time they enrolled their son,  the parents were unaware that this program was started by two former  employees of a program where a teenager had died (this program is  discussed in our second case).
According to the victim’s father, his son became sick around the 11th day  of the program. According to court and other documents, the victim began  exhibiting signs of physical distress and suffered from severe abdominal  pain, weakness, weight loss, and loss of bodily functions. Although the  victim collapsed several times during daily hikes, accounts we reviewed  indicate that staff ignored the victim’s pleas for help. He was forced to  continue on for 20 days in this condition. After his final collapse 31 days  into the program, staff could not detect any respiration or pulse. Only at  this time did staff radio program headquarters and request help, although  they were expected to report any illnesses or disciplinary incidents and  had signed an agreement when employed stating that they were  responsible for “the safety and welfare of fellow staff members and  students.” The victim was airlifted to a nearby hospital and was  pronounced dead upon arrival. The 5-foot 10-inch victim, already a thin  boy, had dropped from 131 to 108 pounds—a loss of nearly 20 percent of  his body weight during his month-long enrollment.
The victim’s father told us that when he was notified of his son’s death, he  could only think that “some terrible accident” had occurred. But according  to the autopsy report, the victim died of acute peritonitis—an infection  related to a perforated ulcer. This condition would have been treatable  provided there had been early medical attention. The father told us that  the mortician, against his usual policy, showed him the condition of his  son’s body because it was “something that needed to be investigated.” The  victim’s father told us he “buckled at the knees” when he saw the body of  his son—emaciated and covered with cuts, bruises, abrasions, blisters, and  a full-body rash; what he saw was unrecognizable as his son except for a  childhood scar above the eye.
In the wake of the death, the state revoked the program’s operating  license. According to the state’s licensing director, the program closed 3  months later because the attorney general’s office had initiated an  investigation into child abuse in the program, although no abuse was  found after examining the 30 to 40 youth who were also enrolled in the  program when the victim died. The state attorney general’s office and a  local county prosecutor filed criminal charges against the program owners  and several staff members. After a change of venue, one defendant went to  trial and was convicted of “abuse or neglect of a disabled child” in this  case. Five other defendants pleaded guilty to a number of other charges— five guilty pleas on negligent homicide and two on failure to comply with a  license. The defendants in the case were sentenced to probation and  community service. The parents of the victim subsequently filed a civil suit  that was settled out of court for an undisclosed amount.
section_title: Case Four
paragraphs: The victim was a 15-year-old male. According to the victim’s mother, in  2000 she enrolled her son in a wilderness program in Oregon to build his  confidence and develop self-esteem in the wake of a childhood car  accident. The accident had resulted in her son sustaining a severe head  injury, among other injuries. After an extensive Internet search and  discussions with representatives of various wilderness programs and  camps for head-injury victims, the mother told us she selected a program  that she believed would meet her son’s needs. What “sold me on the  program,” she said, was the program owner’s repeated assurances over the  telephone that the program was “a perfect fit” for her son. She told us that  to pay for the $27,500 program, she withdrew money from her retirement  account. The program was between 60 to 90 days (about $305 to $450 per  day) depending on a youth’s progression through the program.
The victim’s mother said that she became suspicious about the program  when she dropped her son off. She said that the program director and  another staff person disregarded her statements about her son’s “likes and  dislikes,” despite believing that the program would take into account the  personal needs of her son. Later, she filed a lawsuit alleging that the staff  had no experience dealing with brain-injured children and others with  certain handicaps who were in the program. What she also did not know  was that the founder of the program was himself a former employee of  two other wilderness programs in another state where deaths had  occurred (we discuss these programs in cases two and three). The  program founder also employed staff who had been charged with child  abuse while employed at other wilderness programs.
According to her lawsuit, her son left the program headquarters on a group  hike with three counselors and three other students. Several days into the  multiday hike, while camping under permit on BLM land, the victim  refused to return to the campsite after being escorted by a counselor about  200 yards to relieve himself. Two counselors then attempted to lead him  back to the campsite. According to an account of the incident, when he  continued to refuse, they tried to force him to return and they all fell to the  ground together. The two counselors subsequently held the victim face  down in the dirt until he stopped struggling; by one account a counselor  sat on the victim for almost 45 minutes. When the counselors realized the  victim was no longer breathing, they telephoned for help and requested a  9-1-1 operator’s advice on administering CPR. The victim’s mother told us  that she found out about the situation when program staff called to tell her  that her son was being airlifted to a medical center. Shortly afterwards, a  nurse called and urged her to come to the hospital with her husband. They  were not able to make it in time—on the drive to the hospital, her son’s  doctor called, advised her to pull to the side of the road, and informed her  that her son had died. The victim’s mother told us that she was informed,  after the autopsy, that the main artery in her son’s neck had been torn. The  cause of death was listed as a homicide.
In September 2000, after the boy’s death, one of the counselors was  charged with criminally negligent homicide. A grand jury subsequently  declined to indict him. The victim’s mother told us that at the grand jury  hearing, she found out from parents of other youth in the program that  they had been charged different amounts of money for the same program,  and that program officials had told them what they wanted to hear about  the program’s ability to meet each of their children’s special needs. In  early 2001, the mother of the victim filed a $1.5 million wrongful death  lawsuit against the program, its parent company, and its president. The  lawsuit was settled in 2002 for an undisclosed amount.
Due in part to the victim’s death, in early 2002, Oregon implemented its  outdoor licensing requirements. The state’s Department of Justice  subsequently filed a complaint alleging numerous violations of the state’s  Unlawful Trade Practices Act and civil racketeering laws, including  charges that the program misrepresented its safety procedures and  criminally mistreated enrolled youth. In an incident unconnected to this  case, the program was also charged with child abuse related to frostbite.  As a result of these complaints, in February of 2002, the program entered  into agreement with the state’s attorney general to modify program  operations and pay a $5,000 fee. The program continued to work with the  State of Oregon throughout 2002 to comply with the agreement. In the  summer of 2002, BLM revoked the camping permit for the program due, in  part, to the victim’s death. The program closed in December of 2002.
section_title: Case Five
paragraphs: The victim was a 14-year-old male. According to his father, in 2001 the  victim was enrolled in a private West Virginia residential treatment center  and boarding school. He told us that his son had been diagnosed with  clinical depression, had attempted suicide twice, was on medication, and  was being treated by a psychiatrist. Because their son was having  difficulties in his school, the parents—in consultation with their son’s  psychiatrist—decided their son would benefit by attending a school that  was more sensitive to their son’s problems. To identify a suitable school,  the family hired an education consultant who said he was a member of an  educational consultants’ association and that he specialized in matching  troubled teens with appropriate treatment programs. The parents  discussed their son’s personality, medical history (including his previous  suicide attempts), and treatment needs with the consultant. According to  the father, the consultant “quickly” recommended the West Virginia  school. The program was licensed by the state and cost almost $23,000 (or  about $255 per day).
According to the parents and court documents, the victim committed  suicide 6 days into the program. On the day before he killed himself, while  participating in the first phase of the program (“survival training”), the  victim deliberately cut his left arm four times from wrist to elbow using a  pocket knife issued to him by the school. After cutting himself, the victim  approached a counselor and showed him what he had done, pleading with  the counselor to take the knife away before he hurt himself again. He also  asked the counselor to call his mother and tell her that he wanted to go  home. The counselor spoke with the victim, elicited a promise from him  not to hurt himself again, and gave the knife back. The next evening the  victim hung himself with a cord not far from his tent. Four hours passed  before the program chose to notify the family about the suicide. When the  owner of the program finally called the family to notify them, according to  the father, the owner said, “There was nothing we could do.”
In the aftermath of the suicide, the family learned that the program did not  have any procedures for addressing suicidal behavior even though it had  marketed itself as being able to provide appropriate therapy to its  students. Moreover, one of the program owners, whom the father  considered the head therapist, did not have any formal training to provide  therapy. The family also learned that the owner and another counselor had  visited their son’s campsite, as previously scheduled, the day he died.  During this visit, field staff told them about the self-inflicted injury and  statements the victim had made the night before. According to the father,  the owner then advised field staff that the victim was being manipulative  in an attempt to be sent home, and that the staff should ignore him to  discourage further manipulative behavior.
The owners and the program were indicted by a grand jury on criminal  charges of child neglect resulting in death. According to the transcript, the  judge who was assigned to the case pushed the parties not to choose a  bench trial to avoid a lengthy and complicated trial. The program owner  pleaded no contest to the charge of child neglect resulting in death with a  fine of $5,000 in exchange for dismissal of charges. The state conducted an  investigation into the circumstances and initially planned to close the  program. However, the program owners negotiated an agreement with the  state not to shut down the program in exchange for a change of ownership  and management. According to the victim’s father, the family of the victim  subsequently filed a civil suit and a settlement was reached for                 $1.2 million, which included the owners admitting and accepting personal  responsibility for the suicide.
This program remains open and operating. Within the last 18 months, a  group of investors purchased the program and are planning to open and  operate other programs around the country, according to the program  administrators with whom we spoke. As part of our work we also learned  that the program has a U.S. Forest Service permit however, because it has  not filed all required usage reports nor paid required permit fees in almost  8 years, it is in violation of the terms of the permit. We estimate that the  program owes the U.S. Forest Service tens of thousands of dollars,  although we could not calculate the actual debt.
section_title: Case Six
paragraphs: The victim was a 14-year-old male. According to police documents, the  victim’s mother enrolled him in a military-style Arizona boot camp in 2001  to address behavioral problems. The mother told us that she “thought it  would be a good idea.” In addition, she told us that her son suffered from  some hearing loss, a learning disability, Attention Deficit Hyperactivity  Disorder (ADHD), and depression. To address these issues her son was  taking medication and attending therapy sessions. According to the  mother, her son’s therapist had recommended the program, which he  described as a “tough love” program and “what  needed.” The  mother said she trusted the recommendation of her son’s therapist; in  addition, she spoke with other parents who had children in the program,  who also recommended the program to her. She initially enrolled her son  in a daytime Saturday program in the spring of 2001 so he could continue  attending regular school during the week. Because her son continued to  have behavioral problems, she then enrolled him in the program’s 5-week  summer camp, which she said cost between $4,600 and $5,700 (between  $131 and $162 per day). Her understanding was that strenuous program  activities took place in the evening and that during the day youth would be  in the shade.
Police documents indicate about 50 youth between the ages of 6 and 17  were enrolled in the summer program. According to police, youth were  forced to wear black clothing and to sleep in sleeping bags placed on  concrete pads that had been standing in direct sunlight during the day.  Both black clothing and concrete absorb heat. Moreover, according to  documents subsequently filed by the prosecutor, youth were fed an  insufficient diet of a single apple for breakfast, a single carrot for lunch,  and a bowl of beans for dinner. On the day the victim died, the  temperature was approximately 113 degrees Fahrenheit, according to the  investigating detective. His report stated that on that day, the program  owner asked whether any youth wanted to leave the program; he then  segregated those who wanted to leave the program, which included the  victim, and forced them to sit in the midday sun for “several hours” while  the other participants were allowed to sit in the shade. Witnesses said that  while sitting in the sun, the victim began “eating dirt because he was  hungry.” Witnesses also stated that the victim “had become delirious and  dehydrated… saw water everywhere, and had to ‘chase the Indians.’” Later  on the victim appeared to have a convulsive seizure, but the camp staff  present “felt he was faking,” according to the detective’s report. One staff  member reported that the victim had a pulse rate of 180, more than double  what is considered a reasonable resting heart rate for a teenager. The  program owner then directed two staff and three youth enrolled in the  program to take the victim to the owner’s room at a nearby motel to “cool  him down and clean up.” They placed the victim in the flatbed of a staff  member’s pickup truck and drove to the motel.
Over the next several hours, the following series of events occurred.
In the owner’s hotel room, the limp victim was stripped and placed into  the shower with the water running. The investigating detective told us  that the victim was left alone for 15 to 20 minutes for his “privacy.”  During this time, one of the two staff members telephoned the program  owner about the victim’s serious condition; the owner is said to have  told the staff person that “everything will be okay.” However, when  staff members returned to the bathroom they saw the victim facedown  in the water. The victim had defecated and vomited on himself.
After cleaning up the victim, a staff member removed him from the  shower and placed him on the hotel room floor. Another staff member  began pressing the victim’s stomach with his hands, at which point,  according to the staff member’s personal account, mud began oozing  out of the victim’s mouth. The staff member then used one of his feet to  press even harder on the victim’s stomach, which resulted in the victim  vomiting even more mud and a rock about the size of quarter. At this  point, a staff member again called the owner to say the boy was not  responding; the owner instructed them to take the victim back to the  camp. They placed the victim in the flatbed of the pickup truck for the  drive back.
Staff placed the victim on his sleeping bag upon returning to camp. He  was reportedly breathing at this time, but then stopped breathing and  was again put in the back of the pickup truck to take him for help.  However, one staff member expressed his concern that the boy would  die unless they called 9-1-1 immediately. The county sheriff’s office  reported receiving a telephone call at approximately 9:43 p.m. that  evening saying a camp participant “had been eating dirt all day, had  refused water, and was now in an unconscious state and not  breathing.” This is the first recorded instance in which the program  owner or staff sought medical attention for the victim. Instructions on  how to perform CPR were given and emergency help was dispatched.
The victim was pronounced dead after being airlifted to a local medical  center. The medical examiner who conducted the autopsy expressed  concern that the victim had not been adequately hydrated and had not  received enough food while at the camp. His preliminary ruling on the  cause of death was that “of near drowning brought on by dehydration.”  After a criminal investigation was conducted, the court ultimately  concluded that there was “clear and convincing evidence” that program  staff were not trained to handle medical emergencies related to  dehydration and lack of nutrition. The founder (and chief executive  officer) of the program was convicted in 2005 of felony reckless  manslaughter and felony aggravated assault and sentenced to 6-year and 5- year terms, respectively. He was also ordered to pay over $7,000 in  restitution to the family. In addition, program staff were convicted of  various charges, including trespassing, child abuse, and negligent  homicide but were put on probation. According to the detective, no staff  member at the camp was trained to administer medication or basic  medical treatment, including first aid. The mother filed a civil suit that was  settled for an undisclosed amount of money. The program closed in 2001.
section_title: Case Seven
paragraphs: The victim was a 16-year-old female. Because of defiant, violent behavior,  her parents enrolled her in a Utah wilderness and boarding school  program in 2001, which was a state-licensed program for youth 13 to 18  years old. The 5 month program cost around $29,000 (or about $193 per  day) and operated on both private and federal land. The parents also hired  a transport service at a cost of over $3,000 to take their daughter to the  program. We found that the director and another executive of this  wilderness program had both worked at the same program discussed in  our second case and the executive owned the program discussed in our  first case.
According to program documents and the statements of staff members, a  group hiking in this program would normally require three staff—one in  front leading the hike, one in the middle of the group, and one at the end  of the group. However, this standard structure had been relaxed on the  day the victim fell. It was Christmas Day, and only one staff member  accompanied four youth. While hiking in a steep and dangerous area that  staff had not previously scouted out, the victim ran ahead of the group  with two others, slipped on a steep rock face, and fell more than 50 feet  into a crevasse according to statements of the other two youth—one of  whom ran back to inform the program staff of the accident. The staff  radioed the base camp to report the accident, then called 9-1-1. One of the  staff members at the accident scene was an emergency medical technician  (EMT) and administered first aid. However, in violation of the program  licensing agreement, the first aid kit they were required to have with them  had been left at the base camp. An ambulance arrived about 1 hour after  the victim fell. First responders decided to have the victim airlifted to a  medical center, but the helicopter did not arrive until about 1-1/2 hours  after they made the decision to call for an airlift.
According to the coroner’s report, the victim died about 3 weeks later in a  hospital without ever regaining consciousness. She had suffered massive  head trauma, a broken arm, broken teeth, and a collapsed lung. As a result  of the death, the state planned to revoke the program’s outdoor youth  program license based on multiple violations. In addition to an  inappropriate staff-to-child ratio (four youth for one staff member, rather  than three to one), failure to prescreen the hiking area, and hiking without  a first aid kit, the state identified the following additional license  violations:    Program management did not have an emergency or accident plan in  place.
Two of the four staff members who escorted the nine youth in the  wilderness had little experience—one had 1 month of program  experience and the other had 9 days. Neither of them had completed  the required staff training.
The two most senior staff members on the trip had less than 6 months  of wilderness experience—but they remained at the camp while other  two inexperienced staff members led the hike.
A lawsuit filed by the family in November 2002 claims that the program did  not take reasonable measures to keep the youth in the program safe,  especially given the “hiking inexperience” of the youth and the  “insufficient number of staff.” Specifically, the suit claims that the  program’s executive director waited for an hour before calling assistance  after the victim fell. Additionally, the suit claims that staff only had one  radio and no medical equipment or emergency plan. The parents filed an  initial lawsuit for $6 million but eventually settled in 2003 for $200,000  before attorneys’ fees and health insurance reimbursement were taken  out.
The program closed in May 2002 due to fiscal insolvency. However, its  parent program—a boarding school licensed by the state—is still in  operation. We have not been able to determine whether the wilderness  director at the time of the victim’s death is still in the industry. However,  the other program executive remains in the industry, working as a referral  agent for parents seeking assistance in identifying programs for troubled  youth.
section_title: Case Eight
paragraphs: The victim, who died in 2002, was a 15-year-old female. The parents of the  victim told us that she suffered from depression, suicidal thoughts, and  bipolar disorder. She also reportedly had a history of drug use, including  methamphetamines, marijuana, and cocaine. Her parents explained that  they selected a program after researching several programs and consulting  with an educational advisor. Although the program was based in Oregon, it  operated a 3-week wilderness program in Nevada, which was closer to the  family home. The total cost of the program was over $9,200 (or about $438  per day), which included a nonrefundable deposit and over $300 for  equipment.
The parents of the victim drove their daughter several hundred miles to  enroll her in the program. Because of the distance involved, they stayed  overnight in a motel nearby. The next day, when the parents arrived home,  they found a phone message waiting for them—it was from the program,  saying that their daughter had been in an accident and that she was  receiving CPR. According to documents we reviewed, three staff members  led seven students on a hike on the first day of the program. The victim fell  several times while hiking. The last time she fell, she lost muscle control  and had difficulty breathing. The EMT on the expedition had recently  completed classroom certification and had no practical field experience.  While the staff called for help, the EMT and other staff began CPR and  administered epinephrine doses to keep her heart beating during the 3  hours it took a rescue helicopter to arrive. The victim was airlifted to a  nearby hospital where she was pronounced dead.
The victim’s death was ruled an accident by the coroner—heat stroke  complicated by drug-induced dehydration. According to other youth on  the hike, they were aware the victim had taken methamphetamines prior  to the hike. The victim had had a drug screening done 1 week before  entering the program; she tested positive for methamphetamine, which the  program director knew but the staff did not. However, the program did not  make a determination whether detoxification was necessary, which was  required by the state where the program was operating (Nevada),  according to a court document. The victim was also taking prescribed  psychotropic medications, which affected her body’s ability to regulate  heat and remain hydrated.
At the time the victim died, this private wilderness treatment program had  been in operation for about 15 years in Oregon. Although it claimed to be  accredited by the Joint Commission on Heath Care Organizations, this  accreditation covered only the base program—not the wilderness program  or its drug and alcohol component in which the victim participated.  Moreover, even though the wilderness program attended by the victim had  been running for 2 years, it was not licensed to operate in Nevada. The  district attorney’s office declined to file criminal child abuse and neglect  charges against two program counselors, although those charges had been  recommended by investigating officers. The parents of the victim were  never told why criminal charges were never filed. They subsequently filed  a civil lawsuit and settled against the program for an undisclosed sum.  Two other deaths occurred in this program shortly after the first—one  resulted from a previously unknown heart defect and the other from a  fallen tree.
Although the wilderness program had a federal permit to operate in  Nevada, it was not licensed by that state. After the death, that state  investigated and ordered the program closed. The parent company had  (and continues to maintain) state licenses in Oregon to operate as a drug  and alcohol youth treatment center, an outpatient mental health facility,  and an outdoor youth facility, as well as federal land permits from BLM  and the U.S. Forest Service. According to program officials, the program  has modified its procedures and policies—it no longer enrolls youth taking  the medication that affected the victim’s ability to regulate her body  temperature.
section_title: Case Nine
paragraphs: The victim was a 14-year-old male who died in July 2002. According to  documents we reviewed, the mother of the victim placed her son in this  Utah wilderness program to correct behavioral problems. The victim kept  a journal with him during his stay at the program. It stated that he had  ADHD and bipolar disorder. His enrollment form indicates that he also had  impulse control disorder and that he was taking three prescription  medications. His physical examination, performed about 1 month before  he entered the program, confirms that he was taking these medications.  We could not determine how much the program cost at the time.
According to documents we reviewed, the victim had been in the program  for about 8 days when, on a morning hike on BLM land, he began to show  signs of hyperthermia (excessively high body temperature). He sat down,  breathing heavily and moaning. Two staff members, including one who  was an EMT, initially attended to him, but they could not determine if he  was truly ill or simply “faking” a problem to get out of hiking. When the  victim became unresponsive and appeared to be unconscious, the staff  radioed the program director to consult with him. The director advised the  staff to move the victim into the shade. The director also suggested  checking to see whether the victim was feigning unconsciousness by  raising his hand and letting go to see whether it dropped onto his face.  They followed the director’s instructions. Apparently, because the victim’s  hand fell to his side rather than his face, the staff member who was an  EMT concluded that the victim was only pretending to be ill. While the  EMT left to check on other youth in the program, a staff member  reportedly hid behind a tree to see whether the victim would get up— reasoning that if the victim were faking sickness, he would get up if he  thought nobody was watching. As the victim lay dying, the staff member  hid behind the tree for 10 minutes. He failed to see the victim move after  this amount of time, so he returned to where the victim lay. He could not  find a pulse on the victim. Finally realizing that he was dealing with a  medical emergency, the staff member summoned the EMT and they began  CPR. The program manager was contacted, and he called for emergency  help. Due to difficult terrain and confusion about the exact location of the  victim, it took over an hour for the first response team to reach the victim.  An attempt to airlift the victim was canceled because a rescue team  determined that the victim was already dead.
According to the coroner’s report, the victim died of hyperthermia. State  Department of Human Services officials initially found no indication that  the program had violated its licensing requirements, and the medical  examiner could not find any signs of abuse. Subsequently, the Department  of Human Services ruled that there were, in fact, licensing violations, and  the state charged the program manager and the program owner with child  abuse homicide (a second degree felony charge). The program manager  was found not guilty of the charges; additionally, it was found that he did  not violate the program’s license regarding water, nutrition, health care,  and other state licensing requirements. Moreover, the court concluded that  the State did not prove that the program owner engaged in reckless  behavior. Later that year, however, an administrative law judge affirmed  the Department of Human Services’ decision to revoke the program’s  license after the judge found that there was evidence of violations. The  owner complied with the judge and closed the program in late 2003. About  16 months later, the owner applied for and received a new license to start  a new program. According to the Utah director of licensing, as of  September 2007, there have been “no problems” with the new program. We  could not find conclusive information as to whether the parents of the  victim filed a civil case and, if so, what the outcome was.
section_title: Case Ten
paragraphs: The victim was a 15-year-old male. According to investigative reports  compiled after his death, the victim’s grades dropped during the 2003–2004  school year and he was withdrawing from his parents. His parents  threatened to send him to a boarding or juvenile detention facility if he did  not improve during summer school in 2004. The victim ran away from  home several times that summer, leading his frustrated parents to enroll  him in a boot camp program. When they told him about the enrollment, he  ran away again—the day before he was taken to the program in a remote  area of Missouri. The 5-month program describes itself as a boot camp and  boarding school. Because it is a private facility, the state in which it is  located does not require a license. According to Internet documents, the  program costs almost $23,000 (or about $164 per day).
Investigative documents we reviewed indicate that at the time the parents  enrolled the teenager, he did not have any issues in his medical history.  Staff logs indicate that the victim was considered to be a continuous  problem from the time he entered the program—he did not adhere to  program rules and was otherwise noncompliant. By the second day of the  boot camp phase of the program, staff noticed that the victim exhibited an  oozing bump on his arm. School records and state investigation reports  showed that the victim subsequently began to complain of muscle  soreness, stumbled frequently, and vomited. As days passed, students  noticed the victim was not acting normally, and reported that he defecated  involuntarily on more than one occasion, including in the shower. Staff  notes confirmed that the victim defecated and urinated on himself  numerous times. Although he was reported to have fallen frequently and  told staff he was feeling weak or ill, the staff interpreted this as being  rebellious. The victim was “taken down”—forced to the floor and held  there—on more than one occasion for misbehaving, according to  documents we reviewed. Staff also tied a 20-pound sandbag around the  victim’s neck when he was too sick to exercise, forcing him to carry it  around with him and not permitting him to sit down. Staff finally placed  him in the “sick bay” in the morning on the day that he died. By  midafternoon of that day, a staff member checking on him intermittently  found the victim without a pulse. He yelled for assistance from other staff  members, calling the school medical officer and the program owners. A  responding staff member began CPR. The program medical officer called  9-1-1 after she arrived in the sick bay. An ambulance arrived about 30  minutes after the 9-1-1 call and transported the victim to a nearby hospital,  where he was pronounced dead.
The victim died from complications of rhabdomyolysis due to a probable  spider bite, according to the medical examiner’s report. A multiagency  investigation was launched by state and local parties in the aftermath of  the death. The state social services’ abuse investigation determined that  staff did not recognize the victim’s medical distress or provide adequate  treatment for the victim’s bite. Although the investigation found evidence  of staff neglect and concluded that earlier medical treatment may have  prevented the death of the victim, no criminal charges were filed against  the program, its owners, or any staff. The state also found indications that  documents submitted by the program during the investigation may have  been altered. The family of the victim filed a civil suit against the program  and several of its staff in 2005 and settled out of court for $1 million,  according to the judge.
This program is open and operating. The tuition is currently $4,500 per  month plus a $2,500 “start-up fee.” The program owner claims to have 25  years of experience working with children and teenagers. Members of her  family also operate a referral program and a transport service out of  program offices located separately from the actual program facility.  During the course of our review, we found that current and former  employees with this program filed abuse complaints with the local law  enforcement agency but that no criminal investigation has been  undertaken.
Mr. Chairman and Members of the Committee, this concludes my  statement. We would be pleased to answer any questions that you may  have at this time.
section_title: Contacts and Acknowledgments
paragraphs: For further information about this testimony, please contact Gregory D.  Kutz at (202) 512-6722 or kutzg@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this testimony.
This is a work of the U.S. government and is not subject to copyright protection in the  United States. It may be reproduced and distributed in its entirety without further  permission from GAO. However, because this work may contain copyrighted images or  other material, permission from the copyright holder may be necessary if you wish to  reproduce this material separately.