    Residential Treatment Programs: Concerns Regarding Abuse and
    Death in Certain Programs for Troubled Youth (10-OCT-07,
    GAO-08-146T).

    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.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-08-146T
        ACCNO:   A77188
      TITLE:     Residential Treatment Programs: Concerns Regarding Abuse
    and Death in Certain Programs for Troubled Youth
         DATE:   10/10/2007
      SUBJECT:   Child abuse
    	     Crime victims
    	     Criminal liability
    	     Data collection
    	     Mental health care services
    	     Program evaluation
    	     Program management
    	     Regulation
    	     Reporting requirements
    	     Safety regulation
    	     State-administered programs
    	     Teenagers
    	     Program implementation
    	     Social programs
    	     National Child Abuse and Neglect Data
    	     System

    ******************************************************************
    ** This file contains an ASCII representation of the text of a  **
    ** GAO Product.                                                 **
    **                                                              **
    ** No attempt has been made to display graphic images, although **
    ** figure captions are reproduced.  Tables are included, but    **
    ** may not resemble those in the printed version.               **
    **                                                              **
    ** Please see the PDF (Portable Document Format) file, when     **
    ** available, for a complete electronic file of the printed     **
    ** document's contents.                                         **
    **                                                              **
    ******************************************************************
    GAO-08-146T

         * [1]Summary
         * [2]Background
         * [3]Widespread Allegations of Abuse and Death at Residential Tre
         * [4]Cases of Death at Selected Residential Treatment Programs

              * [5]Case One
              * [6]Case Two
              * [7]Case Three
              * [8]Case Four
              * [9]Case Five
              * [10]Case Six
              * [11]Case Seven
              * [12]Case Eight
              * [13]Case Nine
              * [14]Case Ten

         * [15]Contacts and Acknowledgments
         * [16]GAO's Mission
         * [17]Obtaining Copies of GAO Reports and Testimony

              * [18]Order by Mail or Phone

         * [19]To Report Fraud, Waste, and Abuse in Federal Programs
         * [20]Congressional Relations
         * [21]Public Affairs
         * [22]PDF6-Ordering Information.pdf

              * [23]Order by Mail or Phone

                     United States Government Accountability Office

    Testimony

    GAO

    Before the Committee on Education and Labor, House of Representatives

    For Release on Delivery      RESIDENTIAL TREATMENT PROGRAMS
    Expected at 10:30 a.m. EDT
    Wednesday, October 10, 2007
                                    Concerns Regarding Abuse and Death in Certain
                                    Programs for Troubled Youth

    										  Statement of Gregory D. Kutz, Managing
                                    Director
    										  Forensic Audits and Special Investigations
                                    Andy O'Connell, Assistant Director
    										  Forensic Audits and Special Investigations

    GAO-08-146T

    RESIDENTIAL TREATMENT PROGRAMS

      Concerns Regarding Abuse and Death in Certain Programs for Troubled Youth

        What GAO Found

    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. See
    the table below for detailed information related to three of the case
    studies.

                         Examples of Case Studies GAO Examined

    Sex/age: Female, 15;
    Date of death: May 1990;
    Cause of death: Dehydration;
    Case details:
    * Showed signs of illness for 2 days, such as blurred vision, vomiting
    water, and frequent stumbling;
    * Program staff thought she was faking her illness to get out of the
    program;
    * Collapsed and died while hiking;
    * Lay dead in the road for 18 hours;
    * Program brochure advertised staff as �highly trained survival
    experts�.

    Sex/age: Male, 15;
    Date of death: Sept. 2000;
    Cause of death: Internal bleeding;
    Case details:
    * Head-injury victim with behavioral challenges who refused to return
    to campsite;
    * Restrained by staff and held face down in the dirt for 45 minutes;
    * Died of a severed artery in the neck
    * Death ruled a homicide.

    Sex/age: Male, 14;
    Date of death: July 2002;
    Cause of death: Hyperthermia (high body temperature);
    Case details:
    * Experienced difficulty while hiking and sat down, breathing heavily
    and moaning;
    * Fainted and lay motionless;
    * One staff member hid behind a tree for 10 minutes to see whether the
    victim was �faking it�;
    * Staff member returned and found no pulse;
    * Died soon afterwards.

    Source: Records  including  police  reports, legal  documents,  and  state
    investigative documents.

    United States Government Accountability Office

    Mr. Chairman and Members of the Committee:

    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),^1 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.

    ^1According to the Administration for Children and Families (part of the
    U.S. Department of Health and Human Services), NCANDS is a voluntary
    national data collection and analysis system created in response to the
    requirements of the Child Abuse Prevention and Treatment Act.

    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.

                                        Summary

    We 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 cases with hundreds of plaintiffs, and claims
    of abuse and death that were posted on the Internet. For example,
    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 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.

    We also examined, in greater detail, 10 closed cases where a teenager died
    while enrolled in a private program. We found significant evidence of
    ineffective management in most of these 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
    most of the deaths we examined. For example:

    o In May 1990, a 15-year-old female was enrolled in a 9-week wilderness
    program. Although the program brochure claimed that counselors were
    "highly trained survival experts," they did not recognize the signs of
    dehydration when she began complaining of blurred vision, stumbling, and
    vomiting water 3 days into a hike. According to police documents, on the
    fifth day and after nearly 2 days of serious symptoms, the dying teen
    finally collapsed and became unresponsive, at which point counselors
    attempted to signal for help using a fire because they were
    not equipped with radios. Police documents state that the victim lay dead
    in a dirt road for 18 hours before rescuers arrived.

         o In another example, we learned that, in July 2001, a 14-year-old male
           enrolled in a boot camp became so dehydrated that he began to eat dirt
           from the desert floor. Witnesses said that when he eventually fell
           unconscious and appeared to have a seizure, the program director told
           staff members to put the victim in the flatbed of a pickup truck and
           drive him to a hotel. When they could not revive him at the hotel,
           they put him back in the flatbed of the truck, returned to the camp,
           and placed the teen's limp body onto his sleeping bag. The program
           director assured his staff that "everything will be okay" but the
           victim died soon afterwards.
         o In December 2001, on Christmas Day, a 16-year-old female was climbing
           in an extremely dangerous area unsupervised by program staff.
           According to documents we reviewed, the girl slipped, fell about 50
           feet into a crevasse, and died of massive brain trauma about 3 weeks
           later. An investigation revealed numerous licensing and safety
           violations with the program, including an improperly low
           staff-to-youth ratio, failure of staff to scout the hiking location
           prior to the hike, and no first aid kit (it was left at the base
           camp).

                                       Background

    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
    lessrestrictive 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.^2 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.

    ^2For addition information, see H. T. Ireys, L. Achman, and A. Takyi.  State
    Regulation of  Residential Facilities  for Children  with Mental  Illness.
    DHHS Pub.  No. (SMA)  06-4167 (Rockville,  Md.: Center  for Mental  Health
    Services, Substance  Abuse  and  Mental  Health  Services  Administration,
    2006).

    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.

    ^3Under Titles IV-B and IV-E of the Social Security Act and the Child  Abuse
    and Neglect Prevention and Treatment Act.

    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.

    Figure 1: Environments Where Wilderness Therapy Programs Operate

    Source: GAO.

    Note: These images show the surroundings that youth enrolled in a
    wilderness treatment program might encounter. Clockwise from the upper
    left, these images show (1) West Virginia woodlands, (2) an Oregon river,
    and (3) a Utah mountain range.

    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.

        Figure 2: Living Arrangements at Wilderness Therapy Programs GAO Visited

    Source: GAO.

    Note: The top two images show living arrangements at two wilderness
    therapy programs--a "time out" shelter (upper left) and an enrolled
    youth's campsite (upper right). The bottom two images show the girls' tent
    (lower left) and the shelter for group therapy and meetings (lower right)
    for the middle phase of a residential treatment program.

    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 militarystyle 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.

    Figure 3: Interior of a Boot Camp Facility That GAO Visited

    Source: GAO.

    Note: These images show the interior of a boot camp facility. Clockwise
    from the upper left, the images show (1) the overall layout of "the boot
    camp" room in the facility, where male enrollees spend the majority of
    their indoor time and sleep on the floor; (2) the limited supplies and
    personal items of enrollees, including a rolled sleeping bag and mat; (3)
    bathroom facilities; and (4) a room with bunk beds for youth in the
    advanced phase of the program.

    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.

    Figure 4: Security Features Employed at a Boarding School GAO Visited

    Source: GAO.

    Note: These images show the exterior of a boarding school. Clockwise from
    the upper left, the images show (1) a close-up of the video surveillance
    equipment and motion detectors in place on the outside of the school; (2)
    tall exterior fencing and motion detector; and (3) an angle of the
    facility exterior that clearly displays security features, including video
    monitoring, lighting, fencing, and wire mesh over the windows.

    A variety of ancillary services related to residential treatment programs
    are available for an additional fee in some programs. These services
    include:

         o Referral services and educational consultants to assist parents in
           selecting a program.
         o 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.
         o Additional individual, group, or family counseling or therapy sessions
           as part of treatment. These services may be located on the premises or
           nearby.
         o 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.

    Widespread Allegations of Abuse and Death at Residential Treatment Programs

    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:

    o 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.

         o 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.
         o 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.

    Cases of Death at Selected Residential Treatment Programs

    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.

         o 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
           lesscommon 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.
         o 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.
         o 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.

    Table 1: Summary of Victim Information

    Case: 1;
    Victim information: Female, 15, California resident;
    Program attended: Utah wilderness therapy program (death occurred in
    Arizona);
    Date of death: May 1990;
    Cause of death: Dehydration;
    Case details:
    * Died while hiking on fifth day of program;
    * Exhibited signs of illness for 2 days, such as throwing up water,
    falling down, and complaining of blurred vision;
    * Collapsed due to dehydration;
    * Lay dead for 18 hours on dirt road;
    * Program brochure given to parents had advertised program staff as
    "highly trained survival experts";
    * Died on federal land.

    Case: 2;
    Victim information: Female, 16, Florida resident;
    Program attended: Utah wilderness therapy program;
    Date of death: June 1990;
    Cause of death: Heat stroke;
    Case details:
    * Died while hiking on third day of program;
    * Program had not considered child's adjustment from a coastal, sea-
    level residence to a high desert wilderness area;
    * Died of "exertional heatstroke" while hiking;
    * Program owner acquitted of criminal charges but placed on state list
    of suspected child abusers.

    Case: 3;
    Victim information: Male, 16, Arizona resident;
    Program attended: Utah wilderness therapy program;
    Date of death: March 1994;
    Cause of death: Acute infection resulting from perforated ulcer;
    Case details:
    * Exhibited signs of physical distress for nearly 3 weeks, such as
    severe abdominal pain, significant weight loss (20 percent of body
    weight), loss of bodily functions, and weakness;
    * Collapsed and became unresponsive;
    * Air lifted to hospital and pronounced dead on arrival; * Died on
    federal land.

    Case: 4;
    Victim information: Male, 15, Oregon resident;
    Program attended: Oregon wilderness therapy program;
    Date of death: Sept. 2000;
    Cause of death: Severed artery;
    Case details:
    * Refused to return to campsite but did not behave violently;
    * Restrained by staff and held face down to the ground for almost 45
    minutes;
    * Died of severed artery in neck;
    * Death ruled a homicide;
    * Grand jury declined to issue an indictment; * Died on federal land.

    Case: 5;
    Victim information: Male, 14, Massachusetts resident;
    Program attended: West Virginia residential school and wilderness
    therapy program;
    Date of death: Feb. 2001;
    Cause of death: Suicide (hanging);
    Case details: * Attempted suicide twice before enrolling in program; *
    On the fifth day of program cut arm several times with camp-issued
    pocket knife; * Staff did not take the knife away; * Hung himself near
    his tent the next day; * Program had no suicide prevention plan.

    Case: 6;
    Victim information: Male, 14, Arizona resident;
    Program attended: Arizona boot camp;
    Date of death: July 2001;
    Cause of death: Dehydration;
    Case details:
    * On seventh day was punished for asking to go home;
    * Forced to sit in 113-degree desert heat;
    * Was delirious and dehydrated;
    * Taken to motel room, placed in shower tub, left unattended;
    * Staff returned victim to camp in the flatbed of a pickup truck and
    placed his limp body onto his sleeping bag;
    * Staff later found him unresponsive and he died at the hospital.

    Case: 7;
    Victim information: Female, 16, Virginia resident;
    Program attended: Utah wilderness therapy program;
    Date of death: Jan. 2002;
    Cause of death: Massive head trauma;
    Case details:
    * Fell while hiking on Christmas Day;
    * Staff had not scouted extremely dangerous area beforehand;
    * Staff had no medical equipment, against its licensing agreement;
    * Took about one hour for first paramedics to arrive;
    * Died on federal land.

    Case: 8;
    Victim information: Female, 15, California resident;
    Program attended: Oregon wilderness therapy program (also operated in
    Nevada at time of death);
    Date of death: May 2002;
    Cause of death: Dehydration/ heat stroke;
    Case details:
    * Died while hiking on first day of program;
    * Told others she had taken methamphetamines before the hike, but was
    not screened for drug before hike;
    * Experienced signs of distress for several hours while hiking;
    * Collapsed and stopped breathing;
    * Died of heat stroke complicated by the methamphetamines and
    prescription medication;
    * Died on federal land.

    Case: 9;
    Victim information: Male, 14, Texas resident;
    Program attended: Utah wilderness therapy program;
    Date of death: July 2002;
    Cause of death: Hyperthermia (excessive body temperature);
    Case details:
    * On a 3-mile hike in desert heat;
    * Complained of thirst and refused to continue hike;
    * Left in the sun for an hour and stopped breathing;
    * Staff member hid behind a tree for 10 minutes thinking the victim was
    "faking" illness;
    * Help arrived over an hour after death;
    * Died on federal land.

    Case: 10;
    Victim information: Male, 15, California resident;
    Program attended: Missouri boot camp and boarding school;
    Date of death: Nov. 2004;
    Cause of death: Complications of rhabdomyolysis due to a probable
    spider bite;
    Case details:
    * Displayed signs of distress for several days;
    * Program's medical officer told staff victim was "faking it";
    * Became lifeless and could hardly move;
    * Punished for being too weak to exercise and forced to wear a 20-pound
    sandbag around his neck;
    * Autopsy reported death was caused by complications of rhabdomyolysis
    due to a probable spider bite, but also found numerous bruises all over
    the victim's body.

          Source: Records including police reports, legal documents, and state
                                investigative documents.

    Case One

    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, "[The owner] wishes to conduct a
    wilderness survival program for children for profit, without state
    regulation" and she "hide[s] the children from the investigating state
    authorities and appear[s] 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.

    Case Two

    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 [my
    daughter] who could handle any emergency... they boasted of a 13-year
    flawless safety record, [and] 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.

                                       Case Three

    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.^4

    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.

    ^4The program consisted of four phases. At the start of the second phase,
    students were required to fast for 2 days. During this phase, students
    slept under tarpaulins and, at the end of their fast, they were each given
    a supply of food and told that they were responsible for cooking and
    rationing it themselves. This food supply was the same for all
    participants and was supposed to last each of them for a week.

      Case Four

    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.

                                       Case Five

    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.^5
    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.

    ^5Cutting is a common practice of superficially cutting oneself to draw
    attention and is often associated with adolescent mental health and
    behavioral issues. It is not considered an attempt to commit suicide,
    based on information in the American Psychiatric Association's 2003
    Practice Guidelines for the Assessment and Treatment of Patients with
    Suicidal Behaviors.

    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.

    Case Six

    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 [her son] 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.^6 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.

         o 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.
         o 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.

    ^6This is  according  to  information  from the  U.S.  National  Library  of
    Medicine, National Institutes of Health.

    o 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 5year 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.

    Case Seven

    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:

         o Program management did not have an emergency or accident plan in
           place.
         o 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.

    o 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.

    Case Eight

    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.^7
    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.

    ^7According to its Web site, the Joint Commission on Health Care Organizations
    evaluates and accredits nearly 15,000 health care organizations and programs in
    the United States. It maintains state-of-the-art standards that focus on
    improving the quality and safety of care provided by health care organizations.
    Its comprehensive accreditation process evaluates an organization's compliance
    with these standards and other accreditation requirements.

    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.

    Case Nine

    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.

    Case Ten

    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.^8 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.

    ^8According to  the  National Library  of  Medicine, rhabdomyolysis  is  the
    breakdown of  muscle  fibers resulting  in  the release  of  muscle  fiber
    contents into the bloodstream.

    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.

    Contacts and Acknowledgments

    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.

      (192250)

    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.

    References

    Visible links

    *** End of document. ***