A report released by t he Government Accountability Office (GAO) in October
identified thousands of allegations of patient mistreatment at"
residential treatment programs" across the country.
The GAO report cited allegations of abuse, some of which involved patient
deaths, at what the report refers to as residential treatment programs—
such as "boot camps" and "wilderness therapy programs"
that treat substance abuse and behavioral problems—between 1990 and
2007. The report did not define residential treatment programs other than
describing them as "intended to provide a less-restrictive alternative
to incarceration or hospitalization for youth who may require intervention to
address emotional or behavioral challenges."
The allegations included reports of abuse and death recorded by state
agencies and the Department of Health and Human Services (HHS) between 1990
and 2004. The allegations in the GAO report were detailed in pending civil and
criminal trials involving hundreds of plaintiffs, along with claims of abuse
and death posted online.
During 2005 alone, 33 states reported 1,619 staff members involved in
incidents of abuse in residential programs, according to the National Child
Abuse and Neglect Data System (NCANDS). Critics of the programs estimate
10,000 to 20,000 children are enrolled in them each year.
The GAO report came at the request of the House Education and Labor
Committee to verify whether allegations of abuse and death at residential
treatment programs were widespread and to examine the circumstances of closed
cases in which teenagers died while enrolled in private residential
The investigation follows the establishment of hundreds of residential
treatment programs and facilities for troubled youth since the early 1990s by
state agencies and private companies.
Although many programs have received the praise of parents for providing
professional and competent staff who helped to improve children's lives,
others have raised concerns that have resulted in media attention and
"Sporadic news accounts of specific incidents have built a record
that should never have been ignored, but shamefully was," said Rep.
George Miller (D-Calif.), chair of the Education and Labor Committee, at a
hearing on the report in October. "The federal government has completely
failed to grasp the urgency of this situation."
The overarching problem identified by the GAO report was the lack of a
single Web site, federal agency, or other entity that collects comprehensive
nationwide data on public and private residential treatment programs, which
treat boys and girls for a variety of "addiction, behavioral, and
The NCANDS database, operated by HHS, collects some data from states, but
data submission is voluntary, and not all states with residential treatment
programs contribute information.
Due to the lack of centralized information on such programs, the GAO
investigators said it was not possible to generalize the results of their
investigation to all residential treatment programs, whether privately or
publicly funded. The information shortfall complicates the effort to obtain an
overall picture of even the extent of the "residential treatment program
For example, while states often regulate publicly funded programs, a number
of states do not license or otherwise regulate private programs. This lack of
oversight extends into the design and approaches of these programs, whose
leaders decide how to describe them without even standard definitions for such
treatment approaches as "wilderness therapy programs" or"
The GAO plans to conclude an industrywide review in 2008, providing a more
comprehensive look at such programs.
Petros Levounis, M.D., chair of APA's Council on Children, Adolescents, and
Their Families, told Psychiatric News that addiction specialists have
long thought that programs like those identified in the GAO report are much
less effective in the treatment of addiction than therapeutic approaches based
on positive motivation. The confrontational treatment approaches they use were
abandoned by mainstream addiction programs 30 years ago after they were found
"We tried this type of confrontation route and very strict discipline
and found it simply doesn't work," said Levounis, director of the
Addiction Institute of New York and chief of the Division of Addiction
Psychiatry at St. Luke's and Roosevelt Hospitals. "It is particularly
detrimental for people who suffer from other mental illnesses, as well, such
as schizophrenia or depression or bipolar disorder."
The report's findings that many programs have dangerous conditions and"
tremendous side effects" are additional reasons for keeping
children with co-occurring mental disorders away from such treatment
approaches, he said.
The report echoes concerns raised by a 2006 study funded by the Substance
Abuse and Mental Health Services Administration of residential treatment
facilities serving adolescent populations, which indicated that they often
lacked comprehensive services for the participants, especially when other
co-occurring illnesses were involved. For instance, almost all
adolescent-focused, residential substance abuse treatment facilities conduct
comprehensive substance abuse assessments. However, only half of those
facilities also conduct comprehensive mental health assessments, which are
recommended as part of an integrated treatment approach.
Children with co-occurring mental illnesses in such residential treatment
programs, Levounis said, are at best deprived of safe and effective treatments
for their dual diagnosis—in terms of medication or
psychotherapy—and at worst, they are at risk for death or severe
Levounis suggested a multipronged response to the findings, including
regulatory changes to establish minimum quality assurance, that program
participants have access to physicians and mental health professionals, and
that there be an adequate patient-to-staff ratio.
"Also, all of us need to keep working to debunk the myth of harsh
confrontation being the ultimate weapon against severe addiction," he
Miller previously introduced legislation that would provide resources to
states to help them create licensing standards for private residential