A multi-disciplinary taskforce has formed at the Louis de la Parte Florida Mental Health Institute to study the issues raised in this article, and the authors wish to thank and acknowledge the other members of this taskforce: Lenore Behar, Amy Green, Barbara Huff, Charles Huffine, Christina Kloker-Young, Wanda B. Mohr and Christine Vaughn.

The Exploitation of Youth and Families in the Name of "Specialty Schooling:" What Counts as Sufficient Data? What are Psychologists to Do?

EXPLOITATION IN THE NAME OF "SPECIALTY SCHOOLING"
What Counts as Sufficient Data? What are Psychologists to Do?

Despite an expanding evidence base regarding promising and effective practices in children's mental health, and the implementation of these practices in a growing number of communities, an alarming treatment phenomenon is now occurring. Since the early 1990's, hundreds of private residential treatment facilities have been established across the country and abroad, and thousands of American youth are now receiving services in these institutions. Many of these programs identify themselves as private "therapeutic boarding schools," "emotional growth schools," or "specialty boarding schools." Unlike accredited and licensed residential treatment centers that are required to meet clear and comprehensive standards with regard to the treatment they provide, many of these new programs are not currently subject to any licensing or monitoring as mental health facilities in a number of states. It is the unlicensed and unregulated programs that are the focus of this article.

Highly disturbing reports have been published in the public media describing financial opportunism by program operators, poor quality treatment and education, rights violations and abuse of youth in these facilities (Dibble, 2005; Rowe, 2004; Aitkenhead, 2003; Weiner, 2003d; Kilzer, 1999). Outrage has been expressed by youth, family members and program employees (Rock, 2005; Rowe, 2004; Rubin, 2004; Aitkenhead, 2003; Rimer, 2001). The former director of one program expressed her dismay by sending a letter to the regional Department of Child Welfare calling for the program to be closed immediately because it "takes financial advantage of parents in crisis, and puts teens in physical and emotional risk" (Weiner, 2003a, 39 ). Multiple state investigations have been conducted and lawsuits have been filed in response to reports of abuse, neglect and mistreatment of youth in "therapeutic boarding schools." In numerous cases the lawsuits have led to convictions or high cost settlements (Hechinger & Chaker, 2005; Dukes, 2005; Rock, 2005).

Several states already have good laws on licensing and regulation of these facilities and other states have responded to these growing concerns by proposing (and in a few states passing) legislation to monitor and regulate the full range of residential programs for youth, including "therapeutic boarding schools." An example of such legislation is Utah Senate Bill 107, which was signed into law in March, 2005; this bill defines "therapeutic schools" and clearly specifies that these programs must be licensed and regulated like all other residential treatment facilities for youth (S. 107, 2005). Beyond the state level, Federal Bill HR 1738, the End Institutionalized Child Abuse Bill, was introduced in Congress in April, 2005; this bill proposes to provide funding to states to support the licensing and monitoring of the full range of child residential treatment programs.

Although policymakers have begun to take action, there has been little response from the field of children's mental health. In particular, there has been no acknowledgement of the reports of abuse in "therapeutic boarding schools" and similar programs by the American Psychological Association. In one sense, the lack of response from psychologists is consistent with our epistemological framework and commitment to the scientific method; we typically gather data first, and then analyze and interpret it, prior to developing a response or course of action. Currently, there are no comprehensive, systematically collected data available about private, unregulated residential treatment, so the lack of response at this time might seem appropriate. In addition to valuing the science of psychology, however, we also aspire to safeguard the welfare and rights of those whom we seek to serve, and we say that we are aware that special safeguards may be necessary to protect the rights and welfare of vulnerable persons or communities (Ethical Principles of Psychologists and Code of Conduct, 2002). It is therefore important that we educate ourselves about the current residential treatment phenomenon and then respond, as psychologists, in a manner consistent with our principles and our mission. Although the increased and unregulated institutionalization of youth is far from what we may have hoped for or predicted, it is occurring nonetheless, and we cannot ignore it any longer.

The following review is a summary of the issues that have been identified in the accounts that have been published to date regarding residential treatment programs that are not licensed or accredited as such, but continue to operate. These accounts have been featured in publications including the New York Times, the Washington Post, and Time Magazine, and have been aired on BBC News and National Public Radio. The series of articles published in 2003 by Tim Weiner at the New York Times is particularly comprehensive, and is based on interviews and correspondence with more than 200 parents, youth, staff members and program officials. Lou Kilzer has also reported extensively on the topic in the Denver-Rocky Mountain News (Kilzer, 1999). It should be noted that these series do not address all residential treatment and neither does this article. They specifically raise concerns about unlicensed and unregulated private programs that serve youth with emotional and behavioral challenges.

A "Booming Industry"
It is difficult to determine exactly how many private residential treatment programs billed as "specialty schools" currently exist. In a white paper titled, "Unregulated Youth Residential Care Programs in Montana" the author noted that, "Because private behavioral healthcare programs are not required to be licensed or registered with any state agency, it is a bit like knowing about an 'undiscovered lake' in the mountains (Montana Department of Public Health and Human Services [DPHHS], 2003)." Regardless, an Internet search using the term "troubled teen therapeutic boarding school" easily identifies a few hundred facilities, many of which are listed on websites such as strugglingteens.com, familyfirstaid.org and natsap.org. In January, 2004, the Chicago Tribune reported, "Even in a lackluster economy, business for therapeutic schools is booming. While exact numbers are hard to come by, a trade association and other experts say the schools are a $1 billion to $1.2 billion industry that serves 10,000 to 14,000 school-age children (Rubin, 2004, 8)." Some of these residential programs house over 500 youth in a single facility (Cole, 2004; Weiner, 2003a; Weiner, 2003d). According to reports in the Wall Street Journal and the New York Times, the cost of each program generally ranges from $30,000 to $80,000 per year (Hechinger & Chaker, 2005; Rimer, 2001). Medicaid and most health insurance plans will not pay for youth to attend these programs, so families are typically paying out of pocket, sometimes mortgaging their homes or borrowing money from relatives to pay for "tuition" (Cole, 2004; Rubin, 2004; Rimer, 2001). It is the very fact that this involves a private transaction between a family and a program that makes it possible for the programs to operate outside of public monitoring.

How the Programs Describe and Market Themselves
Residential facilities that self-identify using the labels of "therapeutic boarding school," "emotional growth school" or "specialty boarding school" seem to emphasize non-pathologizing approaches in their marketing materials. One program conveys this by stating, "Labels and diagnoses are left at the door and students are identified and accepted as being intrinsically valuable and good." Phrases like, "respecting dignity and integrity," "uncovering true potential" and "accepting personal responsibility" are frequently incorporated into the program mission statements. At the same time, these programs are often quite explicit in marketing to families of youth with psychiatric diagnoses, claiming expertise in treating a variety of serious conditions including PTSD, Bipolar Disorder and Eating Disorders (NATSAP Directory, 2005).

In terms of the services marketed within these programs, various mental health interventions are described, including individual, group and family therapy, substance abuse counseling, cognitive-behavioral therapy, behavior management (sometimes described in terms of "point systems" and "level systems"), and the maintenance of a therapeutic milieu. Other less traditional interventions are described in some of the institutions, including equine therapy, canine therapy, and wilderness therapy. The educational opportunities in these institutions are often highlighted in marketing materials with phrases such as "extensive college-preparatory curriculum," a "boutique educational package customized for each participant," and education "custom-tailored to each student's unique needs (NATSAP Directory, 2005)."

There appear to be three major ways in which these programs are currently marketed: through the Internet, through "educational consultants," and through participating family referrals. Many programs host their own websites and are listed as well on "referral sites," which offer web-based surveys for parents to complete to determine whether their children are exhibiting problems that would benefit from residential placement. "Educational consultants" are also available to connect families with programs. The qualifications and credentials of these consultants vary (Rubin, 2004) and there is no evidence of educational requirements or state regulations for this profession. It is reported that some referral sources receive a commission by certain residential facilities for each family they recruit, although this arrangement is not regularly made explicit to families (Rock, 2005a; Hayes, 2003). Some programs also encourage families whose youth are attending the program to recruit other families they know; for each new admission, the referring family receives a month of "tuition-free" services (Aitkenhead, 2003). Families have reported sending their children to programs on the recommendation of other parents without ever further investigating the program or services described (Cole, 2004). Actual Services Delivered Although the services and educational resources described in marketing materials may be highly appealing to families seeking support, many of these programs seem to provide far less than they advertise. With regard to mental health intervention, therapy is often provided by staff members who have no formal clinical training, and therapeutic interventions suggestive of gross incompetence are commonly reported (Cole, 2004; Aitkenhead, 2003; Kilzer, 1999; Weiner, 2003a; Weiner, 2003d). Harsh and punitive behavioral modification practices have been repeatedly documented (Romboy, 2005; Weiner, 2003c; Kilzer, 1999). Some youth have reported that they were required to discipline other youth in the facility in order to progress within the behavioral modification level system (Lukes, 2005; Weiner, 2003a). Psychiatrists are not regularly part of the treatment team, and incorrect dosing (Romboy, 2005) as well as frequent over-medication of program participants has been reported (Weiner, 2003d). Education has been described as a series of monitored study halls without trained, licensed teachers (Rowe, 2004; Aitkenhead, 2003) and some programs issue "diplomas" that would not be officially recognized by state Departments of Education (Garifo, 2005). Some facilities are explicit about their refusal to accept accountability for delivering the services they advertise (Kilzer, 1999; Weiner, 2003a). For example, in one program, parents are required to sign a contract that "states plainly that the program 'does not accept responsibility for services written in sales materials or brochures' or promises made by 'staff or public relations personnel (Weiner, 2003a, 25).'"

Abuse of Youth by Program Staff
Highly disturbing incidents of physical, emotional and sexual abuse as well as rights violations have been documented in a number of reports (Hechinger & Chaker, 2005; Rock, 2005; Garifo, 2005; Harrie & Gehrke, 2004; Bryson, 2004b; Weiner, 2003b; Montana DPHHS, 2003). In some programs, parents are instructed by staff to immediately dismiss their children's reports of abuse as attempts at manipulation (Aitkenhead, 2003; Weiner, 2003c). Emotional abuse has been reported in terms of verbal abuse, humiliation, forced personal self-disclosure followed by mockery and extreme fear inducement (Hechinger & Chaker, 2005; Rock, 2004; Aitkenhead, 2003; Weiner, 2003b; Weiner, 2003d; Kilzer, 1999). Criminal probes relating to allegations of sexual assault by staff members have occurred in multiple programs as well (Hechinger & Chaker, 2005; Bryson, 2004b; Hayes, 2003; Weiner, 2003d; Montana DPHHS, 2003; Kilzer, 1999).

Excessive and Abusive Seclusion and Restraint Practices
In a number of programs, the seclusion and restraint procedures are significantly more restrictive than the standards generally accepted by mental health licensing and accrediting bodies. In one program, youth described lying on their stomachs in an isolation room for 13 hours a day, for weeks or months at a time, with their arms repeatedly twisted to the breaking point (Rowe, 2004; Weiner, 2003c; Aitkenhead, 2003). A youth from one Montana facility reported that he spent six months in isolation (Weiner, 2003d). Signed affidavits from former employees of a therapeutic boarding school in northern Utah indicate that youth in that program were restrained face down in manure (Romboy, 2005; Stewart, 2005). In some programs, parents sign contracts authorizing program staff to use mechanical restraints on the youth for unlimited periods of time (Kilzer, 1999). The restraint practices in one institution were described by a former resident as, "a completely degrading, painful experience….they pin you down in a five-point formation and that's when they start twisting and pulling your limbs, grinding your ankles (Aitkenhead, 2003, 9)." Records allegedly documenting the use of handcuffs, belts, pepper spray and duct tape to restrain youth have been cited as well (Bryson, 2005b; Dibble, 2005).

Rights violations
Some programs restrict youth rights without clear clinical justification. Restricted rights include prohibitions against: written and phone contact with family members for the initial two to six months (Kilzer, 1999; Aitkenhead, 2003); privacy, even in bathrooms and showers (Aitkenhead, 2003; Kilzer, 1999); and wearing shoes, which could facilitate running away (Kilzer, 1999). There is no indication that families or youth are provided with information about how to contact advocacy groups if they have concerns about the treatment and care the youth receives. This is quite unlike accredited psychiatric hospitals and residential treatment centers, which are required to post hotline numbers that youth and family members can call if they believe their rights are being violated.

"Escort" Services
Families frequently hire "professional escort services" to transport youth to the residential facilities (Bryson, 2005; Rowe, 2004; Cole, 2004; Labi, 2004; Rimer, 2001). It is estimated that more than twenty escort companies are currently in operation, and to date they are not state-regulated (Labi, 2004). Parents pay escorts as much as $1800 to enter their sleeping children's bedrooms in the middle of the night, awaken them, handcuff and/or leg iron them if they protest or resist, and travel with them to the residential programs where they will be admitted (Labi, 2004; Weiner, 2003a). Parents sign a notarized power-of-attorney authorizing the escort(s) to " take 'any act or action' on the parents' behalf during the transport (Labi, 2004, 16," and promising that the family will not sue the escort(s) "for any injuries caused by 'reasonable restraint'" (Labi, 2004, 16).

Neglectful Conditions Some of these programs are neglectful, in terms of environmental safety and cleanliness, nutrition and medical care. Unsanitary living conditions have been described repeatedly (Bryson, 2005; Romboy, 2005; Stewart, 2005; Harrie & Gehrke, 2004; Labi, 2004; Weiner, 2003d; Aitkenhead, 2003; Kilzer, 1999). Youth have contracted scabies while living at some residential facilities (Romboy, 2005; Weiner, 2003d; Kilzer, 1999). Unhealthy diets are maintained for youth in a number of programs (Romboy, 2005; Labi, 2004; Weiner, 2003d; Weiner, 2003a; Aitkenhead, 2003; Kilzer, 1999). Authorities have reported that they found expired medications in a program investigated in December, 2004 (Dibble, 2005), and other programs were recently investigated for medical neglect as well (Rock, 2005; Romboy, 2005).

Limited Rights of Youth Although numerous lawsuits have been filed to hold programs accountable for alleged misrepresentation, mistreatment and abuse, it is commonly understood that youth currently have little legal standing to challenge their placement in these programs (Kilzer, 1999). Barbara Bennett Woodhouse, the director of the Center on Children & the Law at the University of Florida, stated, "The constitution has been interpreted to allow teens effectively to be imprisoned by private companies like [escort services] and private schools like [unregulated "specialty boarding schools"]---as long as their parents sign off. If these were state schools or state police, the children would have constitutional protections, but because it is parents who are delegating their own authority, it has been very difficult to open the door to protection of the child (Labi, 2004, 79)."

Minimal to Nonexistent Regulatory Oversight
Limited to nonexistent regulatory oversight is evident in many states and there is a lack of federal legislation requiring oversight of private residential treatment programs (Hechinger & Chaker, 2005; Garifo, 2005; Gehrke, 2005; Rubin, 2004). Thus, institutions are able to market themselves and provide treatment without accountability, which in turn makes it possible for programs to take advantage of youth and families. Even when parents inquire about program licensure or accreditation, the response they receive may be misleading. Programs often cite accreditation by the regional Association of Schools and Colleges and Universities as "Special Purpose Schools;" however, this process only relates to the educational component of a program and does not address therapeutic or behavioral components or standards relating to overnight care (Montana DPHHS, 2003).

Proposed Response
A number of issues are raised by the current operation of hundreds of private residential treatment facilities marketed as "specialty boarding schools," many of which are reportedly exploiting families and mistreating and abusing youth. The first issue relates to the need for responsible and effective oversight. As a society, one of our primary duties is to provide for the protection and safety of our citizens, particularly vulnerable populations such as minors. Within health care, concerns about safety contribute to the development of licensing, regulatory, monitoring, and accreditation procedures for organizations, as well as for professions. Laws and procedures regarding the reporting of child abuse and neglect, and the investigation of complaints, are primary mechanisms to help keep children safe. In response to the growing number of reports regarding mistreatment and abuse of youth in "therapeutic boarding schools" and other similar programs, responsible and effective oversight is crucial in all states. All facilities that serve minors with emotional and behavioral challenges need to be licensed and regularly monitored, with particular emphasis placed on those services provided to address the emotional and behavioral needs of youth. All such facilities also need procedures in place for the reporting of abuse. This is particularly important since accounts in the public media indicate that many of the private treatment facilities are not open to routine visits by family and/or professionals and operate outside public scrutiny.

The issue we are raising here is not whether residential care is needed for some youth, or whether private residential treatment programs are effective. Clearly there is a need for residential care for some youth, and some programs are likely very high quality. Rather, the issue of central concern is whether appropriate standards exist such that all programs providing intervention to youth with identified emotional and behavioral challenges are licensed and monitored with regard to the residential treatment they provide, and are maintaining conditions that protect the safety of those who are served.

A second issue reflected in the recent, dramatic growth of residential treatment facilities is the need to increase access to effective care for children and families in their own homes and communities so that residential care is used only when needed and not by default because other services are unavailable. Progress has been made through efforts such as the system of care grant program of the federal Center for Mental Health Services (2002) and through local and state initiatives, but there clearly is a need for great improvement, as described by the President's New Freedom Commission (2003), and the Child and Family Subcommittee of the President's New Freedom Commission (Huang et al., in press). Significant progress has been made in developing individualized, culturally competent, and intensive interventions to be provided in communities; now the "reach" of these efforts needs to be extended.

A third issue related to the proliferation of unregulated residential treatment programs for youth is the use of the worldwide web as a powerful marketing tool. With the growth of access to the Internet by the general public, the mental health field must recognize that families will be the target of intensive, impressive, and effective marketing strategies, and that such marketing makes it difficult for both families and formal service providers to distinguish high quality programs from low quality programs. Such marketing creates a need for professional organizations such as the American Psychological Association to develop resources and provide information to help families make considered and sound choices among treatment options.

There is also a need for professional organizations, including the American Psychological Association, to take a stand on issues such as the need for increased oversight of "therapeutic boarding schools" and similar programs, and the need for adequate protections for children in these programs. In the late 1980s, when there was concern about the marketing practices of private for-profit psychiatric hospitals, a Resolution on Advertising by Private Hospitals was issued by APA's Division of Child, Youth, and Family Services (1986). Such action is needed again in the face of multiple, publicized reports that families are being exploited and children are being mistreated and abused in unregulated and unmonitored facilities, and youth have no mechanism to report abuse.

It would certainly be easier to take a strong stand if there were an abundance of carefully and systematically collected data describing who is served in these programs, how they are served, how often abuse and mistreatment takes place, and what the overall outcomes are for the programs and youth. Given the fact that the programs of such great concern are not accountable to the public, these data are unavailable now and not likely to become available in the near future. In the face of multiple reports in the media, and multiple interviews with children, parents, and former staff of such programs, is there not now sufficient information to take action to protect children from abuse and families from exploitation? We strongly believe that the answer to that question is a resounding "Yes!" We cannot continue to look the other way or use the absence of data as an excuse for inaction. The time for action is now.