Policy Memo

The Issue

Today, there are an estimated 120,000 – 200,000 minors in congregate care facilities across the United States. These youth are pipelined into residential placements each year by state child welfare and juvenile justice systems, mental health providers, refugee resettlement agencies, school districts’ individualized education programs, and by parents. Many of these youth have prior trauma histories before placement, issues only exacerbated by extended separation from their communities once placed in an institutional setting.

This industry receives an estimated $23 billion dollars of annual public funds to purportedly treat the behavioral and psychological needs of vulnerable youth, yet it operates without meaningful oversight. The cost per child, per day for residential treatment ranges from $250-$800, for an annual cost of up to $292,000 per year, per child. The industry’s lack of transparency and accountability for care has led to widespread physical, emotional, and sexual abuse of youth, resulting in hospitalizations, prolonged trauma and even hundreds of child deaths. Youth are too often denied access to legal counsel, advocacy, and the most basic rights to personal safety and satisfactory living conditions.

States and facilities have long neglected to track the placement and lengths of stay of youth, ensure quality care, report critical incidents and deaths, develop best practices, and account for outcomes of care. Without data, or means to track and address findings of institutional abuse, our nation’s understanding of this issue is severely limited. We must being by developing systems and infrastructure that will prevent catastrophic abuse and increase our understanding of evidence-based practices for youth in these settings.

Congregate Care

SICAA defines the term Congregate Care Program or Facility (CCP/CCF) as a public or private entity that, with respect to one or more children who are unrelated to the owner or operator of the program, purports to provide housing, treatment, or modify behaviors in a residential environment, such as:

  • Wilderness programs
  • Boot camps
  • Residential treatment programs
  • Therapeutic boarding schools
  • Behavioral modification programs
  • Foster case facilities
  • Youth justice facilities

*The term “CCP/CCF” does not include a psychiatric hospital licensed by the State.

What We’re Seeing

Investigations have collectively shown trends in congregate care facilities. Abuses reported consistently across congregate settings include:

  • Inhumane and degrading discipline
  • Social isolation or solitary confinement
  • Physical, mechanical, and chemical restraint
  • Physical and medical neglect
  • Sexual assault, harassment, and grooming
  • Conversion and aversion “therapy”
  • Forced medication and overmedication
  • Lack of individualized treatment
  • Prohibition of communication with parents, lawyers, and advocates
  • Restricted access to education
  • Sleep/food deprivation

Reports Confirm Govt. Action is urgently needed

For decades, investigative reports have cited weaknesses in regulation & oversight, inconsistent licensing, decentralized jurisdiction, lack of reporting, and lack of meaningful state action.

GAO Reports

A 2008 Government Accountability Office (GAO) report, Residential Programs: Selected Cases of Death, Abuse, and Deceptive Marketing, found “ineffective management and operating practices, in addition to untrained staff, contributed to the death and abuse of youth,” yet no federal action was taken to address the GAO’s findings.

The 2022 GAO report, “HHS Should Facilitate Information Sharing Between States to Help Prevent and Address Maltreatment in Residential Facilities,” was conducted because “News media have reported several incidents of youth being maltreated by staff employed at residential facilities. Some of these youth were in the child welfare system and some had special needs. States oversee these facilities, and often contract with private operators to operate them. Little information is publicly available about incidents of maltreatment in federally funded residential treatment facilities for youth.” GAO recommended that HHS, in consultation with Education, facilitate information sharing among states on promising practices for preventing and addressing maltreatment in residential facilities.

Desperation Without Dignity: NDRN

The 2021 National Disability Rights Network’s report gave a grueling look at for-profit residential centers:

  • “Physical abuse, often masked as punishment or a control tactic, is not uncommon in RFs”
  • “Children in RFs report sexual assault at the hands of staff”
  • “…overuse and misuse of psychiatric medication during monitoring visits at youth residential facilities”
  • “Youth were found to lack adequate access to clean water and proper sanitation & have limited recreational space”
  • “…investigators noted blood and feces on the walls and floors of the residence halls during a monitoring visit”
  • “Some youths reported that they are unable to obtain academic credit for education completed at RFs, putting them at a significant disadvantage upon return to their communities”

Away from Home: Think of Us

Think of Us’ 2021 study surveyed 78 youth with recent lived experience in institutional placements. They found:

  • “Institutional placements failed to meet the mandate of child welfare”
  • “Institutional placements were carceral”
  • “Institutional placements were punitive”
  • “Institutional placements were traumatic and unfit for healthy child and adolescent development”
  • “Institutional placements felt like they didn’t have a way out”

How Private Equity Profits off of youth behavioral health services

2022 Private Equity Stakeholder Project report “The Kids Are Not Alright” describes:

  • “Cost-cutting tactics at private-equity-owned youth behavioral companies, such as cutting staff, relying on unlicensed staff, and failing to maintain facilities, can lead to abuse, neglect, and unsafe living conditions for youth under the care of those companies”
  • “Despite horrific conditions at some private-equity-owned youth services companies, private equity firms have been able to reap massive profits (Alaris Royal generated $71 million profit on investment in Sequel”

Recent Incidents and Headlines

*This is a condensed list of examples

Assault + Neglect

  • South Carolina, 2022 (Windwood Farm Home for Children): Staff is accused of striking a child in the face, lifting him up, pinning him against a wall, and dropping him to the ground.
  • Utah, 2021 (Daniel’s Academy): Counselor shot a 17-year-old boy in the leg with a pellet gun inside the facility and offered the underage witnesses Playboy magazines to keep them quiet.
  • Ohio, 2021 (Sequel Pomegranate; Torii Behavioral Health): Investigation uncovered systematic cases of abuse and neglect, violations of safety and treatment standards, inappropriate use of restraint, peer-to-peer bullying and staff intimidation, and infringement of civil rights.
  • Arkansas, 2021 (Centers for Youth and Families): Investigation uncovered an “alarming uptick” in harmful incidents, including four physical restraints that broke or fractured youths’ bones and failures to immediately report incidents in which children were injured.
  • Pennsylvania, 2021 (Liberty Ridge): Children allege forced labor such as dragging heavy logging chains around the facility, isolation, restraints with zip ties, deprivation of food and water, and physical violence as punishment.
  • North Carolina, 2021 (Jackson Springs): Minor’s orbital bone fractured during a restraint. The child was taken to the hospital 4 days later by a CPS investigator.
  • Utah, 2019 (Provo Canyon School, UHS): 14-year-old foster child with an intellectual and developmental disability was restrained 30 times, beaten by fellow students 4 times, and put into seclusion at least 9 times in a 3 month period. She told her caseworker that she “thought she would die in the facility.”
  • Utah, 2018 (Havenwood Academy): Police found a youth girl in a horse trough with her hands zip tied. The facility used the horse trough as a form of “therapeutic discipline,” for three years, according to state records.


  • Utah, 2022 (Maple Lake Academy): Facility failed to provide medical care to client who reported continually worsening symptoms of illness for over a week. Despite requests from parents for child to receive care, child died.
  • Michigan, 2020 (Lakeside Academy, Sequel Youth & Services): Cornelius Frederick, 16, died of restraint asphyxia when seven men restrained him for 12 minutes for allegedly throwing a sandwich.
  • Florida, 2020 (Teen Challenge): Naomi Wood, 17, was found dead in her room. She had been vomiting for 24 hours and had filed numerous medical requests for weeks regarding stomach pain. She never saw a doctor.
  • National, 2017 (Mentor): US Senate Committee on Finance found that at least 86 children died in a 10-year period in custody of Mentor. “Mentors death rate among foster children is 42% higher than the national average.”

Federal Investigations

  • Missouri, 2022 (Piney Ridge Academy): Pays $500,000 settlement for submitting false Medicaid claims for 13 children.
  • Iowa, 2022: State pays $5 million after boys at a state school were unlawfully put in seclusion rooms in full-body restraints.
  • Nevada, 2021: U.S. DOJ Investigating Nevada officials on suspicion of violating the civil rights of hundreds of children who they’ve institutionalized unnecessarily.
  • Alabama, 2021: Federal class action lawsuit filed against Alabama DHR for “unnecessarily trapping vulnerable children in expensive facilities and impending their long-term process.”
  • Alaska, 2021: U.S. DOJ opens investigation to determine whether the State of Alaska unnecessarily institutionalizes children with behavioral health conditions.
  • Delaware, 2020 (Universal Health Services, UHS): UHS & related entities required to pay $122M to settle false claims act allegations relating to medically unnecessary inpatient behavioral health services & illegal kickbacks.

Sexual Assault

  • Massachusetts, 2021 (Hillcrest RTC): Surveillance cameras caught 41-year-old employee, Douglas Agyeh, raping a female student under 16.
  • Missouri, 2021 (Circle of Hope Girls Ranch): Owners were charged on 100 criminal counts including statutory rape, sodomy, and physical abuse and neglect.
  • Pennsylvania, 2021 (Devereux Advanced Behavioral Health): Federal class action lawsuit filed for not protecting children from sexual abuse by staff, failures to report child abuse, negligent hiring of unsuitable personnel, and woeful supervision.
  • Utah, 2020 (Provo Canyon School, UHS): 25-year-old staff was charged with first degree felony sodomy on a child and second degree felony enticing a minor for abusing a 12-year-old girl at the facility.

Limited Oversight

  • Nevada, 2021 (Never Give Up): Facility continually under investigation for allegations of abuse, drugs, and undrinkable water. Former owners were previously charged with 45 counts of felony child abuse in 2019.
  • Colorado, 2021 (Ridgeview Youth Services Center, YJ&FC): Closed by CO’s DHS due to failure to enforce children’s rights to be free from physical abuse or neglect and all forms of sexual exploitation, administering new psychotropic medication without guardian consent, among others.
  • Montana, 2021 (Reflections Academy): A 17-year-old died by suicide. Allegations of negligence and harmful treatment methods trail the RTC’s director, Mickey Manning, from each program she has been employed including Spring Creek Lodge and Clearview Horizons. Civil suits allege a rang of psychological, emotional, and sexual abuse.

The Stop Institutional Child Abuse Act (SICAA)

SICCA is a comprehensive bill that will prevent abuse and neglect by establishing rights, enhancing oversight, and providing funding for community-based care. SICCA does the following:

Youth in Congregate Care Bill of Rights

SICAA establishes the “Youth in Congregate Care Bill of Rights.” Every child should have the right:

  • to physical well-being, including
    • freedom from abuse and neglect; including all forms of physical, psychological, and sexual abuse, neglect, exploitation, financial exploitation, and excessive medication; the right to be free from institutional abuse and neglect
    • freedom from aversive behavioral interventions
    • freedom from physical, mechanical, and chemical restraint or seclusion
    • protection against unreasonable search and seizure; including the use of strip searches or cavity searches as a means of punishment
  • to social and emotional well-being, including
    • prohibition of long periods of forced silence, restriction of communication with staff, caregivers, child protective services, law enforcement, or advocates
    • sufficient educational and life skills imparted onto them
    • reasonable daily access to outdoors
  • to have essential needs met
  • to individualized and appropriate treatment that is culturally competent, trauma-informed, and most supportive of each youth’s personal liberty and development
  • to be free from abusive, humiliating, degrading, or traumatizing treatment by staff or other youth; including
    • the ability to report mistreatment anonymously without fear of reprisal
    • access a protection and advocacy agency

Defines Terms

Defines terms, including congregate care program, congregate care facility, institutional child abuse and neglect.

Provides Necessary Funding

Through HHS, provides grant funding to:

  • Protection & Advocacy (P&A) organizations for the purposes of identifying and reporting violations of the bill of rights to a SICAA Commission.
  • Community-based alternatives to congregate care programs and facilities

Additional Provisions

Licensing Requirements

Requires states & eligible entities to establish licensing requirements for all congregate care programs/facilities in the state/entity.

  • Requirements must include a certification that the congregate care program/facility ensures the rights of every single youth in its purview. These licensing plans will be approved (or denied) by the SICAA Commission
  • Failure to establish licensure results in HHS’s ability to withhold PHSA funding under parts H&I (Title V)

SICAA Commission

Establishes the SICAA Commission, housed under HHS, which will:

  • refer cases of child abuse and neglect, as well as other violations of the youth bill of rights, to the Attorney General for further investigation and/or prosecution
  • review data from P&A reports and make this data available publicly, with breakdowns by state
  • review licensing plans from states/eligible entities
  • issue a report every two years with consolidated data above and updated policy recommendations for best practices

To Co-sponsor, contact:

Emma Preston
Congressman Ro Khanna’s Office

Matt Traylor
Senator Jeff Merkley’s Office

For organizations & allies:

Support the Stop Institutional Child Abuse Act by adding your signature HERE to the SICAA sign-on letter, joining a vast coalition of national, state, local entities and individuals dedicated to upholding the safety and dignity of youth in congregate care settings.

Contact Unsilenced & Paris Hilton’s Team

Caroline Cole
Co-CEO, Unsilenced

Rebecca Mellinger
Head of Impact, Paris Hilton