Residential Programs: Selected Cases of Death, Abuse, and	 
Deceptive Marketing (24-APR-08, GAO-08-713T).			 
                                                                 
In October 2007, GAO testified before the Committee regarding	 
allegations of abuse and death in private residential programs	 
across the country such as wilderness therapy programs, boot	 
camps, and boarding schools. GAO also examined selected closed	 
cases where a youth died while enrolled in one of these private  
programs. Many cite positive outcomes associated with specific	 
types of residential programs. However, due to continuing	 
concerns about the safety and well-being of youth enrolled in	 
private programs, the Committee requested that GAO (1) identify  
and examine the facts and circumstances surrounding additional	 
closed cases where a teenager died, was abused, or both, while	 
enrolled in a private program; and (2) identify cases of	 
deceptive marketing or questionable practices in the private	 
residential program industry. To develop case studies of death	 
and abuse, GAO conducted numerous interviews and examined	 
documents from eight closed cases from 1994 to 2006. GAO used	 
covert testing along with other investigative techniques to	 
identify, for selected cases, deceptive marketing or questionable
practices. Specifically, posing as fictitious parents with	 
fictitious troubled teenagers, GAO called 14 programs and related
services. GAO did not attempt to evaluate the benefits of private
residential programs and its results cannot be projected beyond  
the specific programs and services that GAO reviewed.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-713T					        
    ACCNO:   A81865						        
  TITLE:     Residential Programs: Selected Cases of Death, Abuse, and
Deceptive Marketing						 
     DATE:   04/24/2008 
  SUBJECT:   Child abuse					 
	     Children						 
	     Crime victims					 
	     Criminal liability 				 
	     Employee training					 
	     Employees						 
	     Foundations (organizations)			 
	     Information and referral services			 
	     Investigations by federal agencies 		 
	     Marketing						 
	     Mental health care services			 
	     Noncompliance					 
	     Program abuses					 
	     Program evaluation 				 
	     Program management 				 
	     Regulation 					 
	     Schools						 
	     State-administered programs			 
	     Teenagers						 
	     Therapy						 
	     Training utilization				 
	     Wrongful death					 
	     Program implementation				 
	     Social programs					 

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GAO-08-713T

   

     * [1]Summary of Investigation
     * [2]Background
     * [3]Cases of Death and Abuse at Selected Residential Programs

          * [4]Case 3 (Death)
          * [5]Case 4 (Death)
          * [6]Case 5 (Abuse)

     * [7]Deceptive Marketing and Questionable Practices in Selected P
     * [8]Contacts and Acknowledgments
     * [9]GAO's Mission
     * [10]Obtaining Copies of GAO Reports and Testimony

          * [11]Order by Mail or Phone

     * [12]To Report Fraud, Waste, and Abuse in Federal Programs
     * [13]Congressional Relations
     * [14]Public Affairs

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Testimony: 

Before the Committee on Education and Labor, House of Representatives: 

United States Government Accountability Office: 
GAO: 

For Release on Delivery: 
Expected at 10:00 a.m. EDT: 
Thursday, April 24, 2008: 

Residential Programs: 

Selected Cases of Death, Abuse, and Deceptive Marketing: 

Statement of Gregory D. Kutz, Managing Director: 
Forensic Audits and Special Investigations: 

GAO-08-713T: 

GAO Highlights: 

Highlights of GAO-08-713T, a testimony before the Committee on 
Education and Labor, House of Representatives. 

Why GAO Did This Study: 

In October 2007, GAO testified before the Committee regarding 
allegations of abuse and death in private residential programs across 
the country such as wilderness therapy programs, boot camps, and 
boarding schools. GAO also examined selected closed cases where a youth 
died while enrolled in one of these private programs. 

Many cite positive outcomes associated with specific types of 
residential programs. However, due to continuing concerns about the 
safety and well-being of youth enrolled in private programs, the 
Committee requested that GAO (1) identify and examine the facts and 
circumstances surrounding additional closed cases where a teenager 
died, was abused, or both, while enrolled in a private program; and (2) 
identify cases of deceptive marketing or questionable practices in the 
private residential program industry. 

To develop case studies of death and abuse, GAO conducted numerous 
interviews and examined documents from eight closed cases from 1994 to 
2006. GAO used covert testing along with other investigative techniques 
to identify, for selected cases, deceptive marketing or questionable 
practices. Specifically, posing as fictitious parents with fictitious 
troubled teenagers, GAO called 14 programs and related services. GAO 
did not attempt to evaluate the benefits of private residential 
programs and its results cannot be projected beyond the specific 
programs and services that GAO reviewed. 

What GAO Found: 

In the eight closed cases GAO examined, ineffective management and 
operating practices, in addition to untrained staff, contributed to the 
death and abuse of youth enrolled in selected programs. The practice of 
physical restraint also figured prominently in three of the cases. The 
restraint used for these cases primarily involved one or more staff 
members physically holding down a youth. See the table below for 
detailed information related to three of the case studies. 

Examples of Case Studies GAO Examined: 

Sex/age: Male, 14ï¿½18; 
Date of death/abuse: 1994 to 1998;
Case details: 
* Victim was restrained over 250 times while attending the program; in 
at least two cases, restraint lasted over 12 hours; 
* One method of restraint included wrapping the victim in a blanket and 
tying him up; 
* Was required to attend the program for 4 years and was held against 
his will after his 18th birthday. 

Sex/age: Male, 16; 
Date of death/abuse: March 1998; 
Case details: 
* For several weeks, victim complained of chest pain and difficulty 
breathing; 
* Staff forced him to do push-ups and carry cinder blocks as punishment 
for refusing an assigned task; 
* Victim died from an accumulation of infectious pus in his chest; 
* Autopsy found more than 70 injuries on his body, including some from 
blunt force. 

Sex/age: Male, 16; 
Date of death/abuse: February 2006; 
Case details: 
* Three staff members held the victim facedown to restrain him; 
* After 10 minutes of restraint, victim said he could not breathe and 
was eventually taken to the hospital; 
* School was aware victim suffered from asthma, but staff members who 
restrained him said they were not; 
* Victim died of abnormal heartbeat. 

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

Posing as fictitious parents with fictitious troubled teenagers, GAO 
found examples of deceptive marketing and questionable practices in 
certain industry programs and services. For example, one Montana 
boarding school told GAOï¿½s fictitious parents that their child must 
apply using an application form before they are admitted. But after a 
separate call, a program representative e-mailed an acceptance letter 
for GAOï¿½s fictitious child even though an application was never 
submitted. In another example, the Web site for one referral service 
states: ï¿½We will look at your special situation and help you select the 
best school for your teen with individual attention.ï¿½ However, GAO 
called this service three times using three different scenarios related 
to different fictitious children, and each time the referral agent 
recommended a Missouri boot camp. Investigative work revealed that the 
owner of the referral service is married to the owner of the boot camp. 
GAO also called a program established as a 501(c)(3) charity that 
advocated a potentially fraudulent tax scheme. The scheme involves the 
friends and family of a child making tax-deductible ï¿½donationsï¿½ to the 
charity, which are then credited to an account in the program the child 
is enrolled in. GAO referred this charity to the Internal Revenue 
Service for criminal investigation. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-713T]. For more 
information, contact Gregory Kutz at (202) 512-6722 or [email protected]. 

[End of section] 

Mr. Chairman and Members of the Committee: 

Thank you for the opportunity to continue the discussion of private 
residential programs for troubled youth that we began last fall. 
[Footnote 1] In the context of this and our prior testimony, we are 
using the term residential program to refer to those private entities 
across the country and abroad that call themselves wilderness therapy 
programs, therapeutic boarding schools, academies, behavioral 
modification facilities, ranches, and boot camps, among other names. 
Many of these programs are privately owned and operated. Private 
residential 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, and 
psychological counseling for illnesses such as depression and attention 
deficit disorder. Parents trying to help their troubled child may also 
seek help from referral services and educational consultants, which 
generally purport to assess the needs of the child and recommend an 
appropriate program. 

Many cite positive outcomes associated with specific types of 
residential programs. However, in our previous testimony, we identified 
thousands of allegations of abuse, some of which resulted in death, at 
residential programs across the country and in American-owned and 
American-operated facilities abroad. We also examined 10 closed civil 
or criminal cases where a teenager died while enrolled in a private 
program and 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 for enrolled 
children; and reckless or negligent operating practices, including a 
lack of adequate equipment. 

Due to your continuing concern about the safety and well-being of youth 
enrolled in private residential programs, and to assist the Committee 
in its consideration of the need for federal legislation in this area, 
you requested that we (1) identify and examine the facts and 
circumstances surrounding additional closed cases where a teenager 
died, was abused, or both, while enrolled in a private program; and (2) 
identify cases of deceptive marketing or other questionable practices 
in the private residential program industry. 

To identify case studies, we reviewed numerous closed criminal or civil 
cases in which a court or state agency was asked to decide whether a 
private residential program was responsible for the death or abuse of 
an enrolled teenager. We also reviewed administrative cases where state 
agencies made rulings regarding the death or abuse of a teenager. When 
identifying cases, we specifically excluded 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 also excluded 
cases related to the programs we examined for our October 10, 2007, 
testimony. We focused on deaths or instances of abuse between the years 
1994 and 2006 to illustrate the long-standing issues presented by 
private residential programs. We limited our cases to closed criminal 
cases and, thus, did not include ongoing cases from the last several 
years. We selected eight cases--four cases of death and four cases of 
abuse--based on several factors including the victim's age, the program 
location, the type of program the victim attended, and the date of 
death or abuse. We then examined, in more detail, the facts and 
circumstances of the case. To validate the facts and circumstances, 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. 

To identify cases of deceptive marketing or other questionable 
practices in the private residential program industry, we used a 
variety of approaches and investigative techniques. Posing as 
fictitious parents with fictitious troubled children, our undercover 
investigators made telephone calls to a nonrepresentative selection of 
10 private residential programs and 4 referral services. Like 
legitimate parents with troubled teenagers, we identified these 
programs and referral services through Internet searches and magazine 
advertisements. To assess the accuracy and reasonableness of the 
information we obtained during each undercover call, we performed 
additional follow-up work that included, but was not limited to, making 
additional undercover calls; comparing the information we received with 
other marketing information provided by the program; reviewing relevant 
laws, regulations, and trade organization statements; performing 
announced, agreed upon site visits (i.e., not undercover); and speaking 
with cognizant state and federal officials, including the Internal 
Revenue Service (IRS). 

We performed our work from November 2007 through April 2008 in 
accordance with the quality standards for investigations set forth by 
the President's Council on Integrity and Efficiency. As we noted in our 
prior testimony, it is important to emphasize that residential programs 
are intended to help youth with serious problems, including life- 
threatening addictions and diseases. We did not attempt to evaluate the 
benefits of residential programs in dealing with these serious 
problems. In addition, it is not possible to generalize the results of 
our investigation as applying to all residential programs, whether 
privately or publicly funded, or referral services and educational 
consultants and others in the residential program industry. Moreover, 
it is difficult to develop a picture of the overall industry, its 
practices, and efforts to oversee it. For example, while states often 
regulate publicly funded programs, a number of states do not license or 
otherwise regulate certain types of private programs. GAO is completing 
a more comprehensive review of state and federal oversight of 
residential programs and expects to issue a report soon. 

Summary of Investigation: 

In the eight closed cases we examined, ineffective management and 
operating practices, in addition to untrained staff, contributed to the 
death and abuse of youth enrolled in selected programs. In the most 
egregious cases of death and abuse, the cases exposed problems with the 
entire operation of the program. The practice of physical restraint 
also figured prominently in three of the cases. The restraint used for 
these cases primarily involved one or more staff members physically 
holding down a youth. Examples of some case studies follow: 

* A 16 year-old male who suffered from asthma and chronic bronchitis 
complained of chest pain and had difficulty breathing for several 
weeks. Staff at the Arizona boot camp he was attending punished him for 
refusing to do an assigned task and forced him to do push-ups and carry 
cinder blocks; meanwhile, a program nurse told him the breathing 
problems were "in your head." In March 1998, the victim died from an 
accumulation of infectious pus in his chest, and an autopsy found more 
than 70 injuries, including blunt-force injuries, on his body-- 
indicating he had been physically abused before his death. 

* A teenage male was required to attend a behavior modification program 
in New Jersey for 4 years, and was held against his will after he 
turned 18. Records show that the victim was restrained more than 250 
times while attending the program. Incident reports filed by program 
staff document that after he had turned 18, the victim was restrained 
on 26 separate days, with at least two restraints lasting more than 12 
hours. Restraints were imposed any time he showed reluctance to 
participate in the program, and for other reasons; on one occasion, he 
said he was wrapped in a blanket and tied up after attempting to escape 
the program. 

* In February 2006, a 16-year-old male with a history of asthma became 
unresponsive while being restrained at a Pennsylvania treatment 
facility. He died 3 hours later in a hospital. An investigation into 
the death found that the facility had documentation of the victim's 
history of asthma, and that its training manual for restraint 
procedures cautioned against the risk of decreased oxygen intake during 
restraints for youth with asthma. However, all three staff members 
involved in the restraint that led to the victim's death told 
investigators that they were unaware of any medical conditions that 
needed to be considered when restraining the victim. 

In three of the eight cases we examined, the victim was placed in the 
program by the state or in consultation with state authorities. 

Posing as fictitious parents with fictitious troubled teenagers, we 
also found examples of deceptive marketing and questionable practices 
in the private residential program industry. Deceptive marketing 
included potential fraud, false statements, and misleading 
representations related to a range of issues including tax deductions, 
education, and admissions policies. We also found undisclosed conflicts 
of interest. Examples of deceptive marketing included the following: 

* One Montana boarding school told us that parents must submit an 
application form in order for their child to be considered for 
admission in the program. However, after a separate call by a 
fictitious parent, a program representative e-mailed us that our 
fictitious daughter had been approved for admission into the program 
and subsequently sent an acceptance letter. This acceptance into the 
school was based on a 30-minute telephone conversation. We did not fill 
out any application form. 

* The Web site for one referral service we called says: "We will look 
at your special situation and help you select the best school for your 
teen with individual attention." However, we called this service three 
times using three different scenarios related to different fictitious 
children, and each time the referral agent recommended a Missouri boot 
camp. Investigative work revealed that the owner of the referral 
service is married to the owner of the boot camp, but this relationship 
was never disclosed during the call, raising the issue of conflict of 
interest. 

* The representative for a 501(c)(3) foundation suggested our 
fictitious parents take advantage of a fund-raising approach that is 
potentially a fraudulent tax scheme. The representative said that this 
"popular" option would allow friends, family, business acquaintances, 
churches, and other organizations to make tax-deductible donations that 
would then be credited to our fictitious child's tuition in a private 
program. After we briefed an IRS official on the representation by this 
foundation, he told us that the foundation is potentially committing 
tax fraud and that those who obtain tax benefits for donations in the 
suggested manner may be responsible for back taxes, as well as 
penalties and interest. 

A link to selected audio clips from these calls is available at: 
[hyperlink, http://www.gao.gov/media/video/gao-08-713t/]. 

Background: 

Since the early 1990s, state agencies and private companies have set up 
hundreds of residential programs and facilities in the United States. 
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. A 
wide array of government or private entities, including government 
agencies and faith-based organizations, operate these programs. Some 
residential programs advertise themselves as focusing on a specific 
client type, such as those with substance abuse disorders or suicidal 
tendencies. 

As we reported in our October 2007 testimony, no federal laws define 
what constitutes a residential program, nor are there any standard, 
commonly recognized definitions for specific types of programs. For our 
purposes, we define programs based on the characteristics we have 
identified during our work. For example: 

* Wilderness therapy programs place youth in different natural 
environments, including forests, mountains, and deserts. 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. These 
programs are typically 28 days in length at a minimum, but parents can 
continue to enroll their child for longer at an additional cost. 

* Boot camps are residential programs in which strict discipline and 
regime are dominant principles. Many boot camps emphasize behavioral 
modification elements, and some military-style boot camps also 
emphasize uniformity and austere living conditions. Boot camps might be 
included as part of a wilderness therapy school or therapeutic 
boarding, but many boot camps exist independently. These programs are 
offered year-round and some summer programs last up to 3 months. 

* Boarding schools (also called academies) are generally advertised as 
providing academic education beyond the survival skills a wilderness 
therapy program might teach. These programs frequently 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. While these programs advertise year-round 
education, the length of stay varies for each student; contracts can 
require stays of up to 21 months or more. 

* Ranch programs typically emphasize remoteness and large, open spaces 
available on program property. Many ranch programs advertise the 
therapeutic value of ranch-related work. These programs also generally 
provide an opportunity for youth to help care for horses and other 
animals. Although we could not determine the length of a typical stay 
at ranch programs, they operate year-round and take students for as 
long as 18 months. 

See appendix I for further information about the location of various 
types of residential programs across the United States. In addition to 
these programs, the industry includes a variety of ancillary services. 
These include referral services and educational consultants to assist 
parents in selecting a program, along with transport services to pick 
up a youth and bring him or her to the program location. Parents 
frequently use a transport service if their child is unwilling to 
attend the program. 

Private programs generally charge high tuition costs. For example, one 
wilderness program stated that their program costs over $13,000 for 28 
days. In addition to tuition costs, these programs frequently charge 
additional fees for enrollment, uniforms, medical care, supplemental 
therapy, and other services--all of which vary by program and can add 
up to thousands of extra dollars. Costs for ancillary services vary. 
The cost for transport services depends on a number of factors, 
including distance traveled and the means of transportation. Referral 
services do not charge parents fees, but educational consultants do and 
typically charge thousands of dollars. Financial and loan services are 
also available to assist parents in covering the expense of residential 
programs and are often advertised by programs and referral services. 
See appendix II for further information about the cost of residential 
programs across the United States. 

There are no federal oversight laws--including reporting requirements-
-pertaining specifically to private residential programs, referral 
services, educational consultants, or transportation services, with one 
limited exception. The U.S. Department of Health and Human Services 
oversees psychiatric residential treatment facilities (PRTFs) receiving 
Medicaid funds. In order to be eligible to receive funds under 
Medicaid, PRTFs must abide by regulations that govern the use of 
restraint and seclusion techniques on patients. They are also required 
to report serious incidents to both state Medicaid agencies and, unless 
prohibited by state law, state Protection and Advocacy agencies. In 
addition, the regulations require PRTFs to report patient deaths to the 
Centers for Medicare and Medicaid Services Regional Office.[Footnote 2] 

Cases of Death and Abuse at Selected Residential Programs: 

In the eight closed cases we examined, ineffective management and 
operating practices, in addition to untrained staff, contributed to the 
death and abuse of youth enrolled in selected programs. Furthermore, 
two cases of death were very similar to cases from our October 2007 
testimony, in that staff ignored the serious medical complaints of 
youth until it was too late. The practice of physical restraint figured 
prominently in three of the cases. The restraint used for these cases 
primarily involved one or more staff members physically holding down a 
youth. Ineffective operating practices led to the most egregious cases 
of death and abuse, as the cases exposed problems with the entire 
operation of the program. Specifically, the failure of program leaders 
to ensure that appropriate policies and procedures were in place to 
deal with the serious problems of youth; ineffective management 
practices that led to questionable therapeutic or operational 
practices; and the failure of the program to share information about 
enrolled youth with the staff members who were attending to them 
created the environments that resulted in abuse and death. Moreover, in 
cases involving abuse, the abuse was systemic in the program and not 
limited to the incident discussed in our case studies. In three of the 
eight cases we examined, the victim was placed in the program by the 
state or in consultation with state authorities.[Footnote 3] 

See table 1 for a summary of the cases of death we examined. 

Table 1: Summary of Eight Closed Cases (Four Deaths): 

Case: 1; 
Victim information: Male, 16, California resident; 
Program Attended: Arizona boot camp; 
Date of death: March 1998; 
Cause of death: Empyema (accumulation of infectious pus in the chest); 
Case details: 
* Victim suffered from asthma and chronic bronchitis; 
* For a period of several weeks, victim complained of chest pain and 
difficulty breathing, but a program nurse said that his breathing 
problems were in his head; 
* Staff punished him for refusing an assigned task, and forced him to 
do push-ups and carry cinder blocks; 
* Victim eventually became unresponsive, at which point staff finally 
realized that his condition required medical attention; 
* Victim was declared dead at a hospital; 
* Autopsy found more than 70 injuries, including some from blunt force, 
on his body, indicating that the victim had been physically abused 
before his death. 

Case: 2; 
Victim information: Male, 14, Texas resident; 
Program Attended: Texas wilderness therapy program; 
Date of death: September 2004; 
Cause of death: Cardiopulmonary Arrest; 
Case details: 
* Victim's hiking group became lost and spent several unforeseen hours 
in temperatures that reached 98 degrees (a reported heat index of near 
105 degrees); 
* During the hike, victim stopped and complained that he was too hot 
and tired and refused to go on, but he was encouraged to continue; 
* Victim said he didn't feel well and was dizzy, then stumbled and 
fell; 
* Staff thought he was "faking"; 
* When victim began to vomit, staff rolled him on his side; 
* Victim stopped breathing and was later pronounced dead; 
* Died on federal land. 

Case: 3; 
Victim information: Male, 12, Texas resident; 
Program Attended: Texas residential treatment center; 
Date of death: December 2005; 
Cause of death: Suffocation; 
Case details: 
* Victim was angry and started banging his head against the ground; 
* A 5 feet 10 inch, muscular staff member placed the 87-pound victim 
into a facedown restraint; 
* Several witnesses claimed they saw the staff member lying across the 
back of the victim; 
* Victim complained he couldn't breathe and eventually became 
unresponsive, at which point the staff member removed the restraint; 
* After the victim had lain unresponsive for about a minute, the staff 
member rolled him over and found that he was pale; 
* Attempts to revive victim failed. 

Case: 4; 
Victim information: Male, 16, Pennsylvania resident; 
Program Attended: Pennsylvania psychiatric residential treatment 
center; 
Date of death: February 2006; 
Cause of death: Abnormal heartbeat; 
Case details: 
* Victim was placed under "intense observation" for attempting to run 
away from the program; 
* Victim was ordered to put the hood of his sweatshirt down so that 
staff could see his face, but victim refused; 
* Three staff members brought the victim to another room and placed him 
in restraint face down; 
* After 10 minutes of the restraint, victim complained that he couldn't 
breathe; 
* Despite staff attempts to make the victim more comfortable, victim 
became unresponsive; 
* Victim died at the hospital 3 hours later from an abnormal heartbeat; 
* Program was aware victim suffered from asthma, but staff members who 
restrained the victim claimed they were not aware of this. 

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

[End of table] 

See table 2 for a summary of the cases of abuse we examined. For 
reporting purposes, we continue the numbering of case studies in this 
table, starting with five. 

Table 2: Summary of Eight Closed Cases (Four Abuse): 

Case: 5; 
Victim information: Male, 14-18, New York resident; 
Program attended: New Jersey residential behavior modification program; 
Date(s) of abuse: 1994 to 1998; 
Case details: 
* Victim and parents were interviewed separately by staff during his 
first visit to the program; 
* Victim encountered 6 hours of intense questioning during which he 
felt forced to confess to activities he says he did not take part in, 
such as illegal drug use and sex; 
* Victim was restrained more than 250 times while attending the 
program; in at least two cases restraint lasted longer than 12 hours; 
* One method of restraint included wrapping the victim in a blanket and 
tying him up; 
* Victim was required to attend the program for 4 years and was held 
against his will after his 18th birthday. 

Case: 6; 
Victim information: Male, 17, Washington resident; 
Program attended: Mississippi faith-based academy and boot camp; 
Date(s) of abuse: April 1999; 
Case details: 
* Victim jumped off a building and broke his left arm; the bone of his 
arm was exposed, but he was not given medical attention for 2 weeks; 
* Students and staff harassed the victim, with some boys subjecting him 
to physical abuse; 
* On one occasion, victim was beaten unconscious by staff and other 
students; 
* On another occasion, a staff member's pit bull bit the victim in the 
crotch; 
* Victim had previously attended boarding school in case 7. 

Case: 7; 
Victim information: Male, 15, California resident; 
Program attended: Utah boarding school; 
Date(s) of abuse: November 2004; 
Case details: 
* Victim was verbally abused and punched, kicked, and slapped by other 
students, under direction of one of the school's owners; 
* Victim was hit and pushed down stairs by the same school owner; 
* On multiple occasions throughout his stay in the school, victim was 
locked in a bathroom and a closet and forced to sleep on a shelf as 
punishment. 

Case: 8; 
Victim information: Male, 14, California resident; 
Program attended: Colorado boarding school; 
Date(s) of abuse: May 2006; 
Case details: 
* Staff member assaulted victim by grabbing him by the arm, pushing him 
into a stairwell, and slamming his face into a wall; 
* Victim's face was visibly bruised, including a black eye; 
* Victim was forced to kneel on the floor for hours with his knees at 
the point where the floor meets the wall and his nose touching the 
wall. 

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

[End of table] 

The following three narratives describe selected cases in further 
detail. 

Case 3 (Death): 

The victim, who died in 2005, was a 12-year-old male. Documents 
obtained from the Texas Department of Family and Protective Services 
indicate that the victim had a troubled family background. He was taken 
into state care along with his siblings at the age of 6. According to 
child protective service workers who visited the family's home, the 
victim and his siblings were found unsupervised and without 
electricity, water, or food. Some of the children were huddled over a 
space heater, which was connected to a neighbor's house by extension 
cord, in order to keep warm. As a ward of the state, the victim spent 
several years in various foster placements and youth programs before 
being placed in a private residential treatment center in August 2005. 
The program advertised itself as a "unique facility" that specialized 
in services for boys with learning disabilities and behavioral or 
emotional issues. The victim's caretakers chose to place him in this 
program because he was emotionally disturbed. Records indicate that he 
was covered by Medicaid. 

On the evening of his death, the victim refused to take a shower and 
was ordered to sit on an outside porch. According to police reports, 
the victim began to bang his head repeatedly against the concrete floor 
of the porch, leading a staff member to drag him away from the porch 
and place him in a "lying basket restraint" for his own protection. 
During this restraint, the 4 feet 9ï¿½ inch tall, 87-pound boy was forced 
to lie on his stomach with his arms crossed under him as the staff 
member, a muscular male 5 feet 10 inches tall, held him still. Some of 
the children who witnessed the restraint said they saw the staff member 
lying across the victim's back. During the restraint, the victim fought 
against the staff member and yelled at him to stop. The staff member 
told police that the victim complained that he could not breathe, but 
added that children "always say that they cannot breathe during a 
restraint." According to police reports, after about 10 minutes of 
forced restraint, the staff member observed that the victim had calmed 
down and was no longer fighting back. The staff member slowly released 
the restraint and asked the victim if he wanted a jacket. The victim 
did not respond. The staff member told police he interpreted the 
victim's silence as an unwillingness to talk due to anger about the 
restraint. He said he waited for a minute while the victim lay silently 
on the ground. When the victim did not respond to his question a second 
time, he tapped the victim on the shoulder and rolled him over. The 
staff member observed that the victim was pale and could not detect a 
pulse. All efforts to revive the victim failed, and he was declared 
dead at a nearby hospital. 

When the staff member demonstrated his restraint technique for the 
police, they found that his technique violated the restraint policies 
of the program. These policies prohibited staff from placing any 
pressure on the back of a person being restrained. The report added 
that this staff member was reprimanded for injuring a youth in 2002 as 
a result of improper restraint. After this incident, program 
administrators banned the staff member from participating in restraints 
for 1 month. The reprimand issued by program administrators over this 
incident noted that the staff member had actually trained other staff 
members in performing restraints, making the matter more serious. The 
police reports also cite one of the staff member's performance 
evaluations that noted that he had problems with his temper. According 
to the reports, one of the youth in the program said the staff member 
could become agitated when putting youth in restraint. 

Although the Texas Department of Family and Protective Services alleged 
that the victim's death was due to physical abuse, the official 
certificate of death stated that it was an accident and a grand jury 
declined to press charges against the staff member performing the 
restraint. However, the victim's siblings obtained a civil settlement 
against the program and the staff member for an undisclosed amount. The 
program remained open until May 2006, when a 12-year-old boy drowned on 
a bike outing with the program. According to records from law 
enforcement, child protection workers, and the program, the boy fell 
into the water of a rain-swollen creek and was sucked into a culvert. 
He died after several weeks on life support. The Texas Department of 
Family and Protective Services cited negligent staff supervision in its 
review of this second death and revoked the program's license to 
operate as a residential treatment center. However, the program's 
directors also ran a summer camp for children with learning 
disabilities and social disorders licensed by the Texas Department of 
State Health Services, until they resigned from their positions in 
March 2008. 

Case 4 (Death): 

The victim was 16 years old when he died, in February 2006, at a 
private psychiatric residential treatment facility in Pennsylvania for 
boys with behavioral or emotional problems. He was a large boy--6 feet 
1 inch in height and weighing about 250 pounds--and suffered from 
bipolar disorder and asthma. The cost for placement in this facility 
was primarily paid for by Medicaid. 

According to state investigative documents we obtained, the victim was 
placed in intensive observation after he attempted to run away. As part 
of the intensive observation, he was forced to sit in a chair in the 
hallway of the facility and was restricted from participating in some 
activities with other residents. On the day of his death, staff allowed 
the victim to participate in arts, crafts, and games with the other 
youth, but would not let him leave the living area to attend other 
recreational activities. Instead, staff told the victim that he would 
have to return to his chair in the hallway. In addition, staff told him 
that he would have to move his chair so that he could not see the 
television in another room. The victim complied, moving his chair out 
of view of the television, but put up the hood of his sweatshirt and 
turned his back toward the staff. The staff ordered him to take down 
his hood but he refused. When one of the staff walked up to him and 
pulled his hood down, the victim jumped out of his chair and made a 
threatening posture with his fists, saying he did not want to be 
touched. The staff member and two coworkers then brought the victim to 
another room and held him facedown on the floor with his arms pulled up 
behind his back. The victim struggled against the restraint, yelling 
and trying to kick the three staff members holding him down. After 
about 10 minutes, the victim became limp and started breathing heavily. 
He complained that he was having difficulties breathing. One staff 
member unzipped his sweatshirt and loosened the collar of his shirt, 
but rather than improve, the victim became unresponsive. The staff 
called emergency services and began CPR. The victim was taken by 
ambulance to a hospital, where he died a little more than 3 hours 
later. In the victim's autopsy report his death was ruled accidental, 
as caused by asphyxia and an abnormal heartbeat (cardiac dysrhythmia). 

Following the victim's death, an investigation by the Pennsylvania 
Department of Health found that the policies and procedures for youth 
under intense observation do not prohibit them from watching 
television, nor do they require that youth keep their face visible to 
staff at all times. The investigation also found that the facility had 
documentation of the victim's history of asthma, and that its training 
manual for restraint procedures cautioned against the risk of decreased 
oxygen intake during restraints for children with asthma. However, all 
three staff members involved in the restraint told investigators that 
they were unaware of any medical conditions that needed to be 
considered when restraining the victim. In addition, the investigation 
found that the facility did not provide timely training on the 
appropriate and safe use of restraint. The state's Protection and 
Advocacy organization, Pennsylvania Protection & Advocacy, Inc. (PP&A), 
conducted its own investigation of the facility and found that staff 
members inappropriately restrained children in lieu of appropriate 
behavioral interventions, which resulted in neglect and abuse. Of the 
45 residents interviewed by PP&A investigators, 29 said that staff at 
the facility subjected them to restraints. The residents reported that 
the restraints could last as long as 90 minutes and caused breathing 
difficulties. They also stated that staff often placed their knees on 
residents' backs and necks during restraints. One resident reported 
that the blood vessels in his eyes "popped" during a restraint. Another 
resident said that his nose hit the ground during the restraint, 
causing him to choke on his own blood. Further, some of the residents 
reported that staff provoked them and that staff did not make any 
effort to de-escalate the provocations before implementing a restraint. 

No criminal charges were filed in regard to the victim's death. The 
victim's mother filed a civil suit over her son's death against the 
facility, which is currently pending. Her son's death was not the only 
fatal incident at this facility. Only 2 months before the victim's 
death, in December 2005, a 17-year-old boy collapsed at the facility 
after a physical education class, and later died at a nearby hospital. 
His death was attributed to an enlarged heart. This facility remains 
open. 

Case 5 (Abuse): 

This abuse victim was sent to a private drug and addiction treatment 
program in July 1994 at the age of 14. He was attending public school 
in the major metropolitan area where his family lived. The abuse victim 
told us that he had problems at school, including poor grades, truancy, 
a fight with other students, and that he had been suspended. After the 
victim was questioned by police about an assault on a girl at his 
school, a family friend with ties to the behavior modification program 
recommended the program to the victim's parents. According to the 
victim, his first visit to the school turned into an intense intake 
session where he was interviewed by two program patients. Although the 
victim denied using drugs, the interviewers insisted that he was not 
being honest. After about 6 hours of questioning, the victim told the 
interviewers what he thought they wanted to hear--that he was smoking 
pot, did cocaine, and cut school to get high--so that he could end the 
interview. The interviewers used these statements to convince the 
victim's parents to sign him into the program for immediate 
intervention and treatment. He ended up staying in the program for the 
next 4 years--even after he turned 18 and was held against his will. 

According to program records, the program's part-time psychiatrist did 
not examine or diagnose him until he had been in the program for 14 
days. This lack of psychological care continued, as program records 
indicate he was examined by the psychiatrist only four times during his 
entire stay. He was restrained more than 250 times while in the 
program, with at least 46 restraints lasting one hour or longer. The 
victim said some restraints were applied by a group of four or five 
staff members and fellow patients. According to the victim, they held 
him on his back, with one person holding his head and one person 
holding each limb. These restraints were imposed whenever the victim 
showed any reluctance to do what he was told, or, the victim told us, 
for doing some things without first obtaining permission from program 
staff. On one occasion, while he was staying with a host family and 
other patients, he attempted to escape from the program. The victim 
claims that they restrained him by wrapping him in a blanket and tying 
him up. According to the victim, when he turned 18, he submitted a 
request to leave the program but his request was denied because he had 
not followed the proper procedure and was a danger to himself. For 
expressing his desire to leave the program, he was stripped of all 
progress he had made to that point, and was prevented from further 
advancing until the program director decided he was be eligible. 
Incident reports filed by program staff document that after he had 
turned 18, the victim was restrained on 26 separate days, with at least 
two restraints lasting more than 12 hours. 

According to program rules, failure of the parents to follow program 
rules and fully support and participate in the program would jeopardize 
their son's treatment and progress and put him at risk of expulsion. 
Having been led to believe that the program was the only way to help 
him overcome his alleged addictions and problems, his family complied 
with the program's demands. Moreover, the program required parents and 
siblings over age 8 to attend twice weekly group therapy meetings. 
According to the victim, these meetings lasted for many hours, 
sometimes stretching into the early morning. He added that when the 
victim's father refused to attend the therapy meetings for fear of 
losing his job, the program told him to quit. When he would not quit 
his job or miss work to attend the meetings, the victim said that the 
program convinced his mother to leave her husband. After his parents 
separated, the program would not allow the victim to have contact with 
his father. The victim said that the program never told the victim's 
family that all the drug tests they performed on him returned negative 
results, including the initial tests done when he entered the program. 

In February 1998, the State of New Jersey terminated the program's 
participation in the Medicaid program, holding that the program did not 
qualify as a children's partial care mental health program because of 
its noncompliance with client rights standards and its failure to meet 
various staff requirements, such as staff-to-client ratios and 
requisite education and experience levels for staff. The program 
subsequently closed in November 1998, citing financial problems. About 
a year later, in September 1999, an administrative law judge rejected 
an appeal by the program to overrule the state's termination of its 
Medicaid participation. The judge noted in his decision that the 
program effectively operated as a full-time residential facility. 
Moreover, he noted that all group staff at the program were either 
current or former patients, and only two members of the program staff 
met the educational requirements to qualify as direct-care 
professionals. 

The victim filed a civil lawsuit against the program, director, and a 
psychiatrist, which resulted in a $3.75 million settlement. Other civil 
suits filed by former patients included one patient who was committed 
to the program at the age of 13 and spent 13 years in the program. This 
patient reached a similar settlement against the program, director, and 
psychiatrists for the sum of $6.5 million. In addition, a third former 
patient secured a $4.5 million settlement against the program, 
director, and psychiatrists. 

Deceptive Marketing and Questionable Practices in Selected Programs and 
Services: 

Posing as fictitious parents with fictitious troubled teenagers, we 
found examples of deceptive marketing and questionable practices 
related to 10 private residential programs and 4 referral services. The 
most egregious deceptive marketing practices related to tax incentives 
and health insurance reimbursement, and were intended to make the high 
price of the programs appear more manageable for our fictitious 
parents. We also found examples of false statements and misleading 
representations related to a range of issues including education and 
admissions, as well as undisclosed conflicts of interest. In addition, 
we identified examples of questionable practices related to the health 
of youth enrolled in programs and the method of convincing reluctant 
parents to enroll their children. Although general consumer protection 
laws apply to these programs and services, there are no federal laws or 
regulations on marketing content and practices specific to the 
residential program industry. 

A link to selected audio clips from these calls is available at: 
[hyperlink, http://www.gao.gov/media/video/gao-08-713t/]. See table 3 
for a selection of representations made by programs and referral 
agents. 

Table 3: Cases of Deceptive Marketing and Questionable Practices: 

Source: 1. 501(c)(3) charity foundation; 
Representation: Foundation representative described a funding mechanism 
whereby (1) parents solicit friends, relatives, and others to make 
financial donations to the foundation and have them specify on their 
donation checks a numbered code representing the child; (2) the 
foundation tracks the donation amount on behalf of the child, then 
deducts an administrative fee and pays the program the remaining 
donation amount on behalf of that child; and (3) friends and family 
deduct the charitable donations on their tax return; 
Comments: An IRS official told us that the foundation is potentially 
committing tax fraud and that individuals who follow the program's 
recommendation may be responsible for back taxes, as well as penalties 
and interest for taking an improper charitable deduction. 

Source: 2. Montana boarding school; 
Representation: Program representatives told one fictitious parent that 
an application form must be filled out before a child is admitted to 
the boarding school; 
Comments: After a call to this program by a different fictitious 
parent, we received an acceptance letter for our fictitious child even 
though we never applied for admission. 

Source: 3. Texas wilderness program; 
Representation: Program representative stated that earth science 
credits earned in the program are "fully transferable" and that other 
institutions "can't deny" the credit; 
Comments: Education credits can be denied by schools for any reason and 
are not intrinsically transferable. 

Source: 4. Texas wilderness program (same as case number 3); 
Representation: Program representative said that the program will 
provide parents with a detailed bill after their child completes the 
program and that health insurance companies will reimburse expenses; 
Comments: Representatives for both a health care insurer and a 
behavioral health company told us that parents who follow this advice 
run a real risk of not being reimbursed, especially if the health 
insurance company requires pre-approval of counseling or other mental 
health services. 

Source: 5. Texas wilderness program (same as case numbers 3 and 4); 
Representation: Program representative said a trade organization, the 
National Association of Therapeutic Schools and Programs (NATSAP), 
"absolutely" performs inspections of the program; 
Comments: NATSAP does not perform inspections of its member programs. 

Source: 6. Referral service "A"; 
Representation: Referral agent stated that behavioral modification 
schools are "specialty schools" and that tuition costs are tax 
deductible under Section 213 of the Internal Revenue Tax code; 
Comments: The two programs recommended by the referral agent do not 
appear to meet the requirements of IRS regulations for special schools; 
according to an IRS authority on Section 213 with whom we spoke, this 
is questionable tax advice and parents should consult a tax advisor. 

Source: 7. Referral service "A"; 
Representation: The referral agent warned our fictitious parent that 
his wife might "freak out" about sending her daughter to a boarding 
school, and stated: "I want you to tell her it's a college prep 
boarding school...if she thinks that you want to send her daughter to a 
place where there are drug addicts and people that are all screwed up, 
she will look at you and say 'no way'"; 
Comments: In order to secure the business of our fictitious parent, the 
referral agent gave us questionable ethical advice. 

Source: 8. Referral service "B"; 
Representation: Referral agent stated that the program he recommended 
"feed[s] the child a whole-grain diet" and that along with exercise and 
rest, "the bipolar, the depression, those kind of things, they just go 
away after awhile"; 
Comments: Although diet and sleep may be beneficial, there was no 
discussion during the call for a health care provider to confirm the 
child's diagnosis of bipolar disorder or depression and whether to 
continue medication. 

Source: 9. Referral service "B"; 
Representation: Web site for this referral service states: "We will 
look at your special situation and help you select the best school for 
your teen with individual attention"; 
Comments: Referral agents recommended the same Missouri boot camp to 
three different fictitious parents with three fictitious children 
having very different problems; the referral service is owned by the 
husband of the woman who owns the Missouri boot camp, but the conflict 
of interest was not disclosed. 

Source: 10. Referral services "A" and "C"; 
Representation: When investigators called the phone number of referral 
service "A" the receptionist answered the call using the name of 
referral service "C"; 
Comments: Referral services "A" and "C" represent themselves as 
separate entities, with separate names, Web sites, phone numbers, and 
magazine advertisements, suggesting that they provide objective advice. 

Source: GAO. 

[End of table] 

Case 1: One of our fictitious parents called this foundation pretending 
to be a parent who could not afford the cost of a residential program 
for his child. A representative of the foundation explained that their 
"most popular" method of fund-raising involved the friends and 
relatives of the enrolled youth making tax-deductible donations to the 
foundation, which in turn credited 90 percent of these "donations" 
specifically to pay for tuition in a program the child was attending. 
The foundation assigns a code number to each child, which parents 
ensure is listed on the donation checks. The representative also 
provided a fund-raising packet by mail that instructs the parents of 
troubled teens: "You are able to contact family, friends, business 
acquaintances, affiliates, churches, and professional/fraternal 
organizations that you know. Don't forget corporate matching funds 
opportunities from your employer too." The packet also included two 
template letters to send in soliciting the funds. According to an IRS 
official with the Tax Exempt and Governmental Entities Division, this 
practice is inappropriate and represents potential tax fraud on the 
part of the foundation. Furthermore, those who claim inappropriate 
deductions in this fashion would be responsible for back taxes, as well 
as penalties and interest. Based on this information, we referred this 
nonprofit foundation to the IRS for criminal investigation. 

Case 2: The program representative at a Montana boarding school told 
our fictitious parent that they must submit an application form before 
their child can be accepted to the school. However, after a separate 
undercover call made to this school by one of our fictitious parents, 
the program representative e-mailed us stating that our fictitious 
daughter had been approved for admission into the program and 
subsequently sent an acceptance letter. The acceptance letter stated 
that our fictitious child "has been approved for our school here in 
Montana." This admission was based entirely on one 30-minute telephone 
conversation, in which our fictitious parent described his daughter as 
a 13-year-old who takes the psychotropic medication Risperdal, attends 
weekly therapy sessions, has bipolar disorder, and been diagnosed with 
Reactive Attachment Disorder. We did not fill out an application form 
for the school. Moreover, this program had previously recommended that 
our fictitious parents seek advice from the 501(c)(3)foundation 
discussed in Case 1 to help finance the cost of the program. It appears 
that parents do not have assurance about the integrity of the 
admissions process at this boarding school. 

Case 4: One fictitious parent asked the representative for a Texas 
wilderness therapy program whether there was any possibility that a 
health insurance company would cover the cost of the program. The 
representative replied that, at the completion of the program, the 
bookkeeper for the program would generate an itemized statement of 
billable charges that could be submitted to an insurance company for 
reimbursement. She emphasized that we should not call ahead of time to 
seek pre-approval, because then we would be "up the creek." She added 
that this was "just the way insurance companies like it" and stated 
that health insurance companies reimburse "quite a bit." She gave an 
example of one insurance company that reimbursed for over $11,000-- 
almost the entire cost of the 28-day wilderness program. 
Representatives for both a health care insurer and a behavioral health 
company told us that parents who follow this advice run a real risk of 
not being reimbursed, especially if the health insurance company 
requires pre-approval of counseling or other mental health services. In 
this case, our fictitious parent was being led into believing that a 
large portion of the tuition for the program would be covered by health 
insurance even if pre-approval for the charges was not obtained in 
writing in advance of the services. 

Case 6: One referral agent we called stated that behavioral 
modification schools are "specialty schools" and that tuition costs are 
tax deductible under Section 213 of the Internal Revenue Tax code. The 
referral agent also stated that transportation costs related to 
bringing our fictitious child to and from the school were tax 
deductible under this section. However, the two programs recommended by 
the referral service do not appear to meet the requirements of IRS 
regulations for special schools. Our review of Section 213 of the 
Internal Revenue Tax code shows that it relates to medical expenses and 
specifies that, if medical expenses and transportation for treatment 
exceed 7.5 percent of a taxpayer's adjusted gross income, the excess 
costs can be deducted on Schedule A of IRS Form 1040. Even if these 
expenses were deductible under this section, only expenses above 7.5 
percent of the adjusted gross income would be deductible, rather than 
the full amount as suggested by the referral agent. An IRS authority on 
Section 213 with whom we spoke stated that the referral service 
provided us with questionable tax advice and that parents should 
consult a tax advisor before attempting to claim a deduction under this 
section. Parents improperly taking this deduction could be responsible 
for back taxes, as well as penalties and interest. 

Case 9: On its Web site, referral service "B" invites parents to call a 
toll-free number and states: "We will look at your special situation 
and help you select the best school for your teen with individual 
attention." Our undercover investigators called this referral service 
pretending to be three separate fictitious parents and described three 
separate fictitious children to the agents who answered the phone. 
Despite these three different scenarios, we found the referral service 
recommended the same residential program all three times--a Missouri 
boot camp. Our investigation into this referral service revealed that 
the owner of the referral service is the husband of the boot camp 
owner. This relationship, was not disclosed to our fictitious parents 
during our telephone calls, which raises the issue of a potential 
conflict of interest. It appears that parents who call this referral 
service will not receive the objective advice they expect based on 
marketing information on the Web site. 

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: 

[End of section] 

For further information about this testimony, please contact Gregory D. 
Kutz at (202) 512-6722 or [email protected]. Contact points for our Offices 
of Congressional Relations and Public Affairs may be found on the last 
page of this testimony. 

[End of section] 

Appendix I: Private Residential Program Locations: 

In our examination of case studies for this testimony and our prior 
testimony, we found that the victims of death and abuse came from 
across the country and attended programs that were similarly located in 
numerous states. Figure 1 contains a map indicating where victims lived 
and the location of the program they attended. 

Figure 1: Map of Case Study Victims from October 2007 Testimony and 
This Testimony: 

[See PDF for image] 

This figure is a map of the United States depicting the state of 
residence of victims and the location of the residence programs they 
attended. The following data is depicted: 

State of residence (male/female): Connecticut (male); 
Location of residential program: West Virginia. 

State of residence (male/female): New York (male); 
Location of residential program: New Jersey. 

State of residence (male/female): Pennsylvania (male); 
Location of residential program: Pennsylvania. 

State of residence (male/female): Virginia (female); 
Location of residential program: Utah. 

State of residence (male/female): Florida (female); 
Location of residential program: Utah. 

State of residence (male/female): Texas (male); 
Location of residential program: Texas. 

State of residence (male/female): Texas (male); 
Location of residential program: Texas. 

State of residence (male/female): Texas (male); 
Location of residential program: Utah. 

State of residence (male/female): Arizona (male); 
Location of residential program: Arizona. 

State of residence (male/female): Arizona (male); 
Location of residential program: Utah. 

State of residence (male/female): Arizona (female); 
Location of residential program: Nevada. 

State of residence (male/female): California (male); 
Location of residential program: Arizona. 

State of residence (male/female): California (male); 
Location of residential program: Colorado. 

State of residence (male/female): California (male); 
Location of residential program: Utah. 

State of residence (male/female): California (male); 
Location of residential program: Missouri. 

State of residence (male/female): California (female); 
Location of residential program: Utah. 

State of residence (male/female): Oregon (male); 
Location of residential program: Oregon. 

State of residence (male/female): Washington (male); 
Location of residential program: Mississippi. 

Note: The icons in figure 1 represent the state of residence for each 
case study victim and the state in which each residential program is 
located. The icons do not reflect specific geographic locations within 
states. 

Source: GAO. 

[End of figure] 

Private residential programs are located nationwide and rely heavily on 
the Internet for their marketing. Although Web sites list 48 of the 50 
states where parents can find various types of programs, we found that 
they do not list programs in Nebraska and South Dakota, nor do they 
indicate the existence of programs in the District of Columbia. 
Notably, we did not find Web sites that list states with boot camps but 
instead instruct parents to call for locations and details. Figure 2 
illustrates the types of programs and the states in which they are 
located, excluding boot camps. 

Figure 2: Private Residential Programs Nationwide: 

[See PDF for image] 

This figure is a map of the United States depicting the location of 
Private Residential Programs. The following data is depicted: 

State: Alabama: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state. 

State: Alaska: 
One or more therapeutic boarding schools located in state. 

State: Arizona: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state; 
One or more ranch programs located in state. 

State: Arkansas: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state. 

State: California: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state; 
One or more ranch programs located in state. 

State: Colorado: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state; 
One or more ranch programs located in state. 

State: Connecticut: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state. 

State: Delaware: 
One or more therapeutic boarding schools located in state. 

State: Florida: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state. 

State: Georgia: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state. 

State: Hawaii: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state. 

State: Idaho: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state; 
One or more ranch programs located in state. 

State: Illinois: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more ranch programs located in state. 

State: Indiana: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state. 

State: Iowa: 
One or more therapeutic boarding schools located in state. 

State: Kansas: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state. 

State: Kentucky: 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state. 

State: Louisiana: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more ranch programs located in state. 
 
State: Maine: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state; 
One or more ranch programs located in state. 

State: Maryland: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state. 

State: Massachusetts: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state. 

State: Michigan: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state. 

State: Minnesota: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state. 

State: Mississippi: 
One or more therapeutic boarding schools located in state. 

State: Missouri: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state. 

State: Montana: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state; 
One or more ranch programs located in state. 

State: Nevada: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state. 

State: New Hampshire: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state. 

State: New Jersey: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state. 

State: New Mexico: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state; 
One or more ranch programs located in state. 

State: New York: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state. 

State: North Carolina: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state. 

State: North Dakota: 
One or more therapeutic boarding schools located in state. 

State: Ohio: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state. 

State: Oklahoma: 
One or more therapeutic boarding schools located in state. 

State: Oregon: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state; 
One or more ranch programs located in state. 

State: Pennsylvania: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state; 
One or more ranch programs located in state. 

State: Rhode Island: 
One or more boarding schools located in state; 
One or more wilderness programs located in state. 

State: South Carolina: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state; 
One or more ranch programs located in state. 

State: Tennessee: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state; 
One or more ranch programs located in state. 

State: Texas: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state; 
One or more ranch programs located in state. 

State: Utah: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state; 
One or more ranch programs located in state. 

State: Vermont: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state; 
One or more ranch programs located in state. 

State: Virginia: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state. 

State: Washington: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state; 
One or more ranch programs located in state. 

State: West Virginia: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state; 
One or more wilderness programs located in state. 

State: Wisconsin: 
One or more boarding schools located in state; 
One or more therapeutic boarding schools located in state. 

State: Wyoming: 
One or more boarding schools located in state. 

States with no programs: 
Nebraska; 
South Dakota. 

Source: GAO analysis of information available on referral service Web 
sites. 

[End of figure] 

[End of section] 

Appendix II: Cost of Private Residential Programs: 

Our undercover calls to selected programs revealed that most private 
programs charge a high tuition for their services. Table 4 contains 
information related to the high cost of these programs based these 
phone calls. 

Table 4: Basic Monthly Costs of Programs: 

Number: 1; 
Type of program: Boarding school; 
Location: Georgia; 
Source of information: Referral service; 
Basic monthly cost: $3,166. 

Number: 2; 
Type of program: Boot camp; 
Location: Missouri; 
Source of information: Referral service; 
Basic monthly cost: $4,500. 

Number: 3; 
Type of program: Boarding school; 
Location: North Carolina; 
Source of information: Referral service; 
Basic monthly cost: $4,500. 

Number: 4; 
Type of program: Boarding school; 
Location: South Carolina; 
Source of information: Referral service; 
Basic monthly cost: $3,166. 

Number: 5; 
Type of program: Boarding school; 
Location: South Carolina; 
Source of information: Referral service; 
Basic monthly cost: $2,795. 

Number: 6; 
Type of program: Boarding school; 
Location: Colorado; 
Source of information: Program; 
Basic monthly cost: $2,795 - $2,995. 

Number: 7; 
Type of program: Boarding school; 
Location: Georgia; 
Source of information: Program; 
Basic monthly cost: $8,120[A]. 

Number: 8; 
Type of program: Boarding school; 
Location: Montana; 
Source of information: Program; 
Basic monthly cost: $3,495. 

Number: 9; 
Type of program: Boarding school; 
Location: New York; 
Source of information: Program; 
Basic monthly cost: $5,160. 

Number: 10; 
Type of program: Boarding school; 
Location: Tennessee; 
Source of information: Program; 
Basic monthly cost: $8,700[B]. 

Number: 11; 
Type of program: 
Boarding school; 
Location: Utah; 
Source of information: Program; 
Basic monthly cost: $6,500[B]. 

Number: 12; 
Type of program: Wilderness program; 
Location: Georgia; 
Source of information: Program; 
Basic monthly cost: $12,600. 

Number: 13; 
Type of program: Wilderness program; 
Location: North Carolina; 
Source of information: Program; 
Basic monthly cost: $13,020. 

Number: 14; 
Type of program: Wilderness program; 
Location: Texas; 
Source of information: 
Program; Basic monthly cost: $13,020. 

Source: GAO analysis of information obtained during undercover calls to 
programs and referral services. 

[A] This is for the first 90 days; the cost drops afterwards. 

[B] This includes therapy. 

[End of table] 

According to program and service representatives with whom we spoke, 
the basic cost could be discounted. For example, one program told us if 
parents paid for a full year upfront, they would be given a $200-per- 
month discount. This does not include fees by transport services for 
taking a child to a program. Moreover, although program and service 
representatives quoted these as basic program costs, they also 
mentioned additional one-time charges, such as an enrollment fee that 
can be as much as $4,600, uniform costs, or other items such as 
supplies. In addition, some programs charge extra for therapy, 
including one-on-one therapy. 

[End of section] 

Footnotes: 

[1] GAO, Residential Treatment Programs: Concerns Regarding Abuse and 
Death in Certain Programs for Troubled Youth, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-08-146T] (Washington, D.C.: Oct. 
10, 2007). 

[2] 42 C.F.R. ï¿½ï¿½ 483.350-.376. 

[3] For an illustration showing the states where victims resided and 
the location of the programs they attended, both for this testimony and 
our October 2007 testimony, see app. I. 

[End of section] 

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