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. 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. 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.