Policy Brief

Residential and wilderness facilities caring for at-risk youth present a distressing prevalence of physical, sexual, emotional, and psychological abuse and neglect. Regulatory gaps, inconsistent definitions and communication barriers between agencies exacerbate this issue. The problem is further magnified by inadequately trained personnel and understaffing in residential facilities, leading to unsafe environments for vulnerable youth. The overrepresentation of youth of color and a lack of cultural competence among facility staff cause discrimination and perpetuation of an oppressive system. A lack of standardized data collection affects incident reporting, intervention, and the ability to track and prevent abuse. 

Existing policies fail to provide sufficient protection for institutionalized youth, rendering them exceptionally vulnerable to abuse and mistreatment. These statistics underscore the pressing need for targeted policy reforms aimed at safeguarding young individuals from institutional child abuse.

The well-documented maltreatment and abuse within the troubled teen industry raise profound concerns about the systemic harm caused by these unethical methods.

• • GAO Report in 2008 found more than 350 youths have died in residential youth facilities between 1990 and 2007. 
  • In fiscal year 2005, over 1,619 reported allegations of abuse and neglect, including sexual abuse perpetrated by staff members. 
  • There have been 79 restraint-related fatalities between 1993 and 2018 in residential facilities within 30 states.

Abuse within facilities includes physical, sexual, emotional, and neglect. It is critical to acknowledge the severity of these forms of abuse and take appropriate measures to prevent incidents from occurring.

• • Physical abuse within these facilities often involves violent acts or aggressive behavior directed at residents, frequently manifesting as unjustified and excessive restraints, leading to injuries and fatalities. 
  • Sexual abuse within residential facilities is influenced by several factors, including the vulnerability of residents, a pronounced power imbalance, limited reporting capabilities, severe and lasting trauma for survivors, potential cover-ups, and the overall lack of effective prevention mechanisms in place.
  • Emotional and psychological abuse takes the form of verbal intimidation, humiliation, isolation, or manipulation of a young person’s emotions and self-esteem, leaving lasting scars on their mental well-being and development. 
  • Neglect is also a pervasive issue, with inadequate care, nutrition, and supervision sometimes leading to tragic deaths due to insufficient medical attention. 

The maltreatment, abuse, and death of youth in residential facilities were significantly influenced by insufficient training, inadequate supervision, ineffective management, poor operating practices, and untrained staff.   Further contributing factors of abuse within these programs highlight the need to oversee these facilities. 

• • Insufficient training in trauma-informed care, de-escalation techniques, and child psychology leaves staff ill-equipped to handle the unique needs of the children under their care.  
  • There is a lack of evidence-based curriculum working with families and at-risk youth facilitated by residential treatment facilities.
  • There is no regional database for sharing substantiated allegations of abuse by staff in residential facilities, which means other providers may unknowingly hire individuals with histories of maltreatment in another state. 

These problems persist across various facilities in the troubled teen industry, spanning decades and indicating systemic issues that demand immediate and comprehensive reform. The prevalence of institutional child abuse, neglect, and fatalities underscores the urgent need for stricter oversight, clear regulations, and robust accountability measures to ensure the safety and well-being of young residents in these programs.

GAO, Residential Facilities: Improved Data and Enhanced Oversight Would Help Safeguard the Well-
Being of Youth with Behavioral and Emotional Challenges, GAO-08-346 (Washington, D.C.: May 13,
2008).

Nunno, M.A., McCabe, L.A., Izzo, C.V. et al. A 26-Year Study of Restraint Fatalities Among Children and Adolescents in the United States: A Failure of Organizational Structures and Processes. Child Youth Care Forum 51, 661–680 (2022). https://doi.org/10.1007/s10566-021-09646-w

GAO, Residential Facilities: Improved Data and Enhanced Oversight Would Help Safeguard the Well-
Being of Youth with Behavioral and Emotional Challenges

GAO, HHS Should Facilitate Information Sharing Between States to Help Prevent and Address
Maltreatment in Residential Facilities, GAO-22-104670 (Washington, D.C.: January 24, 2022).

The Troubled Teen Industry places a significant burden on public systems, as children are often placed in these facilities through various means, including involvement from local school districts, individualized education programs, the juvenile justice system, the foster care system, court orders related to custody disputes, mental health service providers, and even refugee resettlement programs. Public funding at various levels contributes significantly to the growth of residential facilities. However, there is a lack of tracking and data sharing for these funds, leading to accountability gaps. 

• • In Fiscal year 2004, the federal funding to states had financed more than 200,000 youths in residential facilities. 
  • According to 2020 data released by the Justice Policy Institute, the average state cost for the secure confinement of a young person is now $588 per day, or $214,620 per year.
  • When youth are placed out-of-state, the government pays nearly double the cost.
  • The 2015 economic impact of 59 behavioral programs in Utah resulted in $269 Million in Earnings, $423 Million in State Gross Domestic Product (Utah GDP), and $22 Million in State and Local Tax Revenue. Almost 90% of this revenue comes from out-of-state placements, predominantly from California.
  • States pay Sequel Youth & Family Services amounts anywhere from $275 to more than $800 a day, per child to provide residential behavioral health services. Medicaid reimburses Sequel for medical and psychiatric health treatment for children who qualify. .
    • In Alabama alone, Sequel received nearly $25 million in Medicaid payments from 2018 to 2020 despite reports of substandard conditions to state agencies for years.
    • California entities paid Sequel $17 million to house Californian youth in 2016.
    • Sequel reported $200 million in revenue in fiscal year 2016, 90% of this coming from government sources like the Department of Children Services and Medicaid. 
  • Universal Health Services netted $11.37 billion in annual revenue in 2019. 
    • Behavioral health care brought in 45.8% of FY19 revenue. 
    • Approximately one-third of UHS’s Behavioral Division’s revenues are derived from taxpayer dollars, such as Medicare, TRICARE, and Medicaid, with the remaining two-thirds from commercial payers. 

American Bar Association, Commission on Sexual Orientation and Gender Identity Section of Civil Rights and Social Justice. 2023.

National Disability Rights Network, Desperation Without Dignity: Conditions of Children Placed in For Profit Residential Facilities. October 2021.

Tennert, J., Economic Impact of Utah’s Family Choice Behavioral Healthcare Interventions Industry. Kem C. Gardner Policy Institute. May 2016. https://gardner.utah.edu/wp-content/uploads/2016_FamilyChoiceBehavioralInterventions_Final.pdf

Rappleye, H., Kingkade, T., Snow, K. A profitable ‘death trap’: Sequel youth facilities raked in millions while accused of abusing children. NBC News. December 2020.

https://apple.news/AuORAjpNWTgWCQi0TgPu02g

https://www.sfchronicle.com/projects/2020/california-youth-sequel/

National Disability Rights Network, Desperation Without Dignity: Conditions of Children Placed in For Profit Residential Facilities.

Universal Health Services, Inc. Form 10-K. 2012. https://www.sec.gov/Archives/edgar/data/352915/000119312513084679/d444706d10k.htm

Teamsters Local 456 Pension Fund v. Universal Health Services, Inc, Miller, and Filton, 2:17-cv-02817-LS. 2017.

Over the years, the Troubled Teen Industry has evaded effective regulation and oversight, primarily due to significant gaps in the existing regulatory framework. These facilities often exist in a regulatory gray area, permitting them to elude the scrutiny and accountability they desperately need. As a result, many children in these facilities do not receive the necessary oversight and protection they deserve. 

Inconsistent Regulation and Loopholes: The lack of uniform national standards contributes to inconsistencies in the regulation and oversight of the Troubled Teen Industry. These inconsistencies give rise to a lack of jurisdiction to prevent abuse and create regulatory gaps that allow entities to evade necessary licensing requirements, undermining the overall accountability and protection for at-risk youth.

• • • The U.S. Department of Health and Human Services, the Department of Justice, and the Department of Education are responsible for ensuring the well-being of youths in residential treatment facilities. 
      • Their oversight is hindered by a lack of authority to enforce accountability in facilities not receiving federal funds.
    • State agencies are limited in their oversight due to multiple agencies contracted within a facility, creating gaps in overseeing these facilities. 
    • State agencies lack effective communication about negative findings or suspended/revoked licenses between agencies, hampering accountability.  
    • Youths sent out-of-state rely on the care of the facilities due to irregular visits from parents, social workers, or court-appointed special advocates. When children are sent out-of-state to residential facilities, the lack of consistent jurisdiction, definitions of abuse, and communication between state and interstate agencies creates uncertainties and risks of maltreatment.

Lack of Standard Definition and Distinction: Without a standardized definition of institutional child abuse and established jurisdiction within the realm of child abuse prevention, addressing the issue becomes challenging. The industry’s distinct nature, characterized by its focus on at-risk youth and questionable methodologies, necessitates a tailored regulatory approach. The absence of a clear distinction hampers the development of industry-specific standards and oversight.

• • • In fiscal year 2021, there were 1,591 residential facilities in operation with 71 different facility types for youth residential facilities. 
    • Particular government and private facilities, such as juvenile justice facilities and private schools, have been exempted from licensing requirements by state agencies. 

Inadequate Data Collection: Inefficient data sharing among states and agencies creates barriers to comprehensive information gathering, hindering problem identification. This data scarcity impacts oversight and accountability, making it challenging to hold facilities accountable for abusive practices, especially when children are placed out of state.

• • • Each state has its own definition of child abuse and neglect based on federal law, resulting in no standard definition of maltreatment across states.
    • The reliability of maltreatment data for residential facilities is impacted by missing data and inconsistencies in how states collect and report information to the U.S. Department of Health and Human Services. (HHS)
    • Child maltreatment data is reported to HHS voluntarily by state officials. Certain states are legally restricted from collecting data on private facilities, which can result in missing or inaccurate data. 
    • Underreporting can stem from various factors, including fear, stigma, lack of awareness, and perceived barriers to reporting.

Institutional Child Abuse remains poorly defined, leaving children in institutional settings uniquely unprotected. The absence of standardized definitions and national standards, combined with exemptions for certain facilities from licensing requirements, allows for inadequate regulation. Government agencies face considerable challenges due to a lack of authority, staffing constraints, and poor communication, particularly when children are placed out-of-state. Issues with inadequate reporting and data collection allow this issue to go unreported and unaddressed.

GAO, Residential Facilities: Improved Data and Enhanced Oversight Would Help Safeguard the Well-
Being of Youth with Behavioral and Emotional Challenges

GAO, HHS Should Facilitate Information Sharing Between States to Help Prevent and Address
Maltreatment in Residential Facilities

National Disability Rights Network, Desperation Without Dignity: Conditions of Children Placed in For
Profit Residential Facilities

GAO, Residential Facilities: Improved Data and Enhanced Oversight Would Help Safeguard the Well-
Being of Youth with Behavioral and Emotional Challenges

GAO, HHS Should Facilitate Information Sharing Between States to Help Prevent and Address
Maltreatment in Residential Facilities

Executive Summary:

The Institutional Child Abuse Prevention Act 2024 seeks to address the critical issue of institutional child abuse occurring within residential or outdoor wilderness programs that provide care for children. 

Purpose:

The purpose of this act is to amend the existing Child Abuse Prevention and Treatment Act (CAPTA) to specifically address institutional child abuse as a distinct category of child abuse. This amendment introduces mandatory reporting requirements and preventive measures to ensure the safety and well-being of children under the care of such institutions.

The Institutional Child Abuse Prevention Act (ICAPA) would work into the existing structure of the Child Abuse Prevention and Treatment Act (CAPTA) by creating a new section or title specifically focused on institutional child abuse. Here’s how it would fit into the different sections of CAPTA:

Congressional Findings:

• • ICAPA would expand the findings in CAPTA to recognize institutional child abuse as a pressing issue.

General Definitions:

• • ICAPA introduces its own set of definitions, particularly defining terms related to institutional child abuse, including the different forms of abuse (physical, sexual, psychological) and the improper use of restraint.

Title I – General Program:

• • ICAPA adds a new section within Title I or a separate title that establishes jurisdictional authority for the Department of Human Services to utilize and improve child protection systems to effectively intervene and prevent institutional child abuse.
  • Outlines mandatory reporting requirements for institutions, including residential and outdoor programs.
  • Requires Federal reporting of data related to institutional child abuse cases, ensuring that information on such cases is accurately documented and reported.
  • Prohibits retaliation for mandated reporters.

Title II – Community-Based Grants:

• • ICAPA may propose changes or additional sections within Title II to allocate funds to community-based initiatives specifically aimed at providing services for struggling families, diverting need for residential placement and preventing institutional child abuse.

The Institutional Child Abuse Prevention Act’s function within CAPTA is to address the gap in protecting children in institutional care. By creating specific provisions for institutional child abuse it strengthens reporting, prevention, and accountability measures in these settings. The implications are significant, as it holds institutions responsible for ensuring the welfare and safety of the children under their care, and enforces immediate action against violators, thereby contributing to a safer and more secure environment for vulnerable youth.

The “Institutional Child Abuse Prevention Act 2024” is a vital response to the pervasive issue of institutional child abuse, particularly within the Troubled Teen Industry. This legislation recognizes the urgent need for reform in these programs, where vulnerable youth have been subjected to maltreatment and neglect.

The Act serves as a beacon of hope for those who have suffered the enduring trauma of institutional child abuse. By defining institutional child abuse comprehensively and mandating reporting, it acknowledges the problem and actively addresses it. Through confidentiality provisions and anti-retaliation measures, it aims to protect those who bravely come forward to report abuse.

In the intersection of the Institutional Child Abuse Prevention Act and the Child Abuse Prevention and Treatment Act (CAPTA), we find a harmonious synergy where the former integrates children’s specific protection and safety within institutional settings, bridging the regulatory gaps and enhancing child welfare. This marks a significant stride toward a brighter, safer future for our youth, emphasizing our collective commitment to safeguarding their rights and well-being.

As we move forward, we must remain vigilant in ensuring the effective implementation of these legislative measures, standing firm in our resolve to protect the most vulnerable among us and offering them the safe and nurturing environment they deserve.