The Troubled Teen Industry’s Troubling Lack of Oversight

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The federal government must step in to regulate an industry fraught with youth abuse.

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“You might only be 15, but as far as we can go to kick your ass is how far we’re going to get,” State Senator Brad Molnar (R-Mont.) reportedly commented in opposition to a state bill that aims to improve oversight of the troubled teen industry. This statement comes amid renewed calls by survivors, advocates, and legislators to tackle the rampant physical, psychological, and sexual abuse of youth in residential treatment facilities (RTFs).

This rhetoric, this industry’s actions, and the federal government’s inaction in response to mounting demands for reform are unequivocally unacceptable.

The troubled teen industry encompasses a variety of RTFs, including therapeutic and behavioral treatment facilities, attitude-adjustment schools, boot camps, and wilderness programs. An estimated 50,000 teenagers were residing in such facilities as of 2020. Residents are often enrolled in these programs by parents with behavioral concerns, but youth may also be funneled into these facilities from foster care and juvenile detention. Due to a lack of access to local and community-based treatment options, residents are often sent to RTFs across state lines, complicating efforts to regulate and monitor these facilities.

Teens may be subject to legally and ethically dubious tactics before they ever step foot on the grounds of the RTF, with the advent of an industry practice dubbed “gooning” by which youth are placed into these facilities against their will. Some parents hire transport services to stage kidnappings of their children, violently extracting teens from their homes in the middle of the night and delivering them to RTFs thousands of miles away.

Once there, RTFs advertise care, promise behavior modification, and seek to “fix” whatever parents may deem wrong with their teenage kids. But RTFs too often punish mental health and behavior, instead of treating it. Actual, evidence-based treatment, such as cognitive behavior therapy or trauma-informed care, is frequently supplanted by cruel, archaic methods of physical, emotional, and sexual abuse.

In 2020, Cornelius Fredericks, a Black teenager residing at Lakeside Academy in Michigan, was restrained for over 10 minutes for throwing a sandwich. He lost consciousness, went into cardiac arrest, and died 30 hours later. In 2022, Paris Hilton, celebrity businesswoman and critic of the troubled teen industry, described how she and other female residents were wakened in the middle of the night and subjected to invasive physical examinations by male staff who were not medical professionals.

Other survivors have spoken out about tactics employed at these centers, including excessive force, extended use of restraint and isolation, humiliation, denial of sleep and nutrition, overuse and misuse of psychiatric medication, and chemical restraint, which is the practice of administering sedatives and other drug products to subdue a patient.

While at the RTFs, however, residents are often unable to communicate these abuses to their parents or caretakers. Former residents report facilities placing them under constant surveillance, monitoring their calls and letters, and refusing contact with their families as punishment. Some RTFs even go so far as to instruct parents to dismiss any complaints as their teens’ attempts to manipulate their way out of treatment.

But these reports of abuse are far from figments of adolescent imagination. In 2007, the Government Accountability Office (GAO) conducted a study to verify the extent of abuse and deaths at RTFs. GAO found thousands of allegations of abuse dating back to 1990. It lamented that exact figures were impossible to ascertain because no comprehensive, national data existed. This remains true today.

In 2021, the National Disability Rights Network published a comprehensive report on the conditions of teens in for-profit RTFs, which uncovered abuse in RTFs that is “current, ongoing, and is not limited to any one corporation or geographic region.”

What is truly troubling is that, despite the mounting evidence of pervasive and systematic mistreatment, the troubled teen industry continues to perpetrate these harms, collect profits, and evade comprehensive oversight.

No national accreditation or licensing law exists that governs for-profit RTFs. The U.S. Department of Health and Human Services (HHS), the U.S. Department of Justice (DOJ), and the U.S. Department of Education have the authority to regulate some RTFs in some respects, such as through DOJ supervision of state juvenile justice systems. But by and large, RTFs often fall outside of these categorical spheres of oversight. Many are privately owned. Many self-identify as boarding schools, outdoor programs, and religious entities that are exempt from most licensing or regulatory standards.

Although most states have not attempted to close these regulatory loopholes, for the handful that have, state oversight continues to fall short. State agencies typically lack the resources needed for robust investigation and oversight, and they often lack the authority to penalize non-complaint RTFs. Even if a state shuts down an RTF’s operations, the owners can simply shutter their locations in one state and open new facilities in another.

The clear need for substantial federal intervention has been met with hollow gestures. In the wake of a 2008 GAO report urging federal oversight, members of Congress proposed a law in the U.S. House of Representatives. The same bill continued to be introduced every year for a decade, but it has never passed. A new bill was introduced in 2021, passing the House this time. It was sent to the U.S. Senate, where it languished without further action.

HHS’s Office of Inspector General announced plans to analyze reports of abuse and neglect in a sample of six states, but no report appears yet to have been issued. In July 2022, Senators Patty Murray (D-WA) and Ron Wyden (D-OR) sent letters to four major RTF companies to demand information and documentation in response to reports of abuse. It is unclear if the letters were ever answered.

As the U.S. Congress waits for answers to questions it has already asked, and seeks more information about realities it already knows but refuses to reckon with, the troubled teen industry continues to rake in billions of dollars in revenue, much of which comes from taxpayer dollars. In 2016, for example, Sequel, a privately owned, for-profit RTF company, reported that a combined 72 percent of its $200 million in revenue came from Medicaid, county, local, and state governments, and school districts. In 2020, United Health Services, another company providing residential behavioral treatment services, agreed to pay $117 million in fines to settle a False Claims Act action which alleged the company had administered and billed medically unnecessary inpatient behavioral services.

RTFs charge up to $800 per day, per resident. These large payouts have attracted the attention of private equity investors who have cited the “favorable regulatory environment” as reason to invest in RTFs. The drive to minimize costs pushes RTF companies to “fill the beds” while spending as little as possible on staffing. As a result, RTFs employ individuals with no experience in counseling and no background checks, then fail to train them and underpay them. One former executive of Universal Health Services reportedly explained that his bonus was tied to his ability to reduce the ratio of staff to residents to levels below those minimally required by law.

It is exactly the lack of supervision and lack of qualified and trained staff that contributes to the types of abuses that occur too often in RTFs.

And yet, the failure of regulation, law, and ethics persists. Although society acknowledges the right of those with mental illnesses to refuse treatment, do kids in RTFs have any real choice when they are sedated against their will?

The legal system provides for due process protections for people, including children, when they face the prospect of civil commitment, but why does it not provide protection for these children?

What makes teenagers less deserving of dignity and autonomy, and less capable of consent?

Federal intervention is imperative to ensure those individuals subjected to abuses by the troubled teen industry get the support they deserve. Congress must name an agency responsible for regulating RTFs and must allocate the funds to carry out these actions.

Furthermore, the law should define RTFs broadly to crack down on various self-identified categorical exemptions, create a national database for reports of abuse, and outline mechanisms for penalizing noncompliance. Crucially, the law should contain an RTF resident bill of rights to ensure that the protection of youth is given the top priority. It should ensure responsiveness to the demands of survivors too.

Congress must commit to supporting the most vulnerable of teenagers instead of casting them aside. These young people are worthy of treatment, capable of change, and deserving of dignity.