Welcome to teenhelpindustry.info

Here you will find bits of information about teen treatment facilities in the US and abroad.

Please read our disclaimer.

November 2007

Handle With Care
The state continues to license a Midstate youth treatment facility where two have died and many others have been abused

by Elizabeth Ulrich

Nashville Scene

November 8, 2007

The Chad Youth Enhancement Center is a privately owned residential treatment facility nestled in the rolling hills off of a winding, two-lane road just southeast of Clarksville. Barns fashioned out of untreated wood and horses tucked behind white fences dot the pristine grazing land that leads to the facility’s 20 tree-lined acres.

Just a few yards from an empty pasture marked by a few intermittent hay bales, Chad’s gym, school building and three dormitories sit, looking clinical and quite unremarkable. Chad is a place where kids—some criminals or drug addicts, or with serious emotional and behavioral disorders—go to get help. All are between the tender ages of 7 and 17, and most have problems so severe that other facilities will not admit them. It’s what Chad prides itself on: taking the most troubled and disadvantaged children “to overcome those obstacles that may be hindering their healthy emotional growth.”

Chad is also a place where two teens have died in two years. And where allegations of excessive use of force, and verbal and physical abuse at the hands of the facility’s staff have slowly piled up in the offices of Tennessee state regulators for nearly a decade.

In 2005 medics arrived at Chad to find the body of Linda Harris, a 14-year-old resident from Amityville, N.Y., limp on the floor of the hallway outside of her room.

According to a brief police office report, Harris had“become unruly by not staying in bed and was flashing the boys”when Chad staff pulled the girl’s arms behind her back and escorted her to a time-out room. It was at this point that Harris “became limp and fell on the floor”and the Chad staffers sat down next to her and held her arms behind her back as she lay on her stomach.

After approximately 30 seconds, according to the report, staff let her go as Harris remained belly down and appeared to be crying. A few minutes later, the Chad employees noticed that her breathing had slowed, so they rolled her over and called 911. While an ambulance was en route, Harris stopped breathing. She was pronounced dead after arrival at Gateway Medical Center in Clarksville.

But law enforcement told a different story: a local sheriff’s official said their office received a call that night saying that Harris had stopped breathing after being physically restrained by a male Chad staffer who fell to the floor with the girl while redirecting her to the time-out room.

Either way, Harris died only a few days after a New York judge sent her to Chad for emotional problems that had become too much for her father, a single dad, to handle. And either way, Tennessee medical examiner Dr. Bruce Levy ruled Harris’ death “natural.” After all, she was morbidly obese: Harris carried an estimated 400 pounds on her 5-foot-6-inch frame. Plus she was asthmatic.

While the Montgomery County Sheriff’s Office investigated Harris’ death, they didn’t bring any charges against the Chad staffers who restrained her. Levy ruled that her death was a result of cardiac hypertrophy—an enlarged heart because of her chronic bronchial asthma. Harris’ weight was a contributory cause of her death, Levy found.

So life at Chad moved along.

In a November 2005 visit to the center, Department of Children’s Services (DCS) licensing consultant Linda McLeskey noted that more Chad residents felt unsafe at the facility than at other programs DCS had encountered. Less than one month had passed since Harris met her death at the hands of the very people enlisted to help her. And the effect it had on the resident psyche was lasting. “When asked why they felt unsafe, [residents] often reported they were afraid to be restrained because they didn’t want to be hurt,” McLeskey wrote.

Sue Marshall—not her real name—worked as a licensed practical nurse at Chad for roughly one year and recalls the effect that Harris’ death had on residents. “A lot of girls were having nightmares at night after that because probably none of them had seen another person die,” Marshall says. “And you know, of course the first thing they are going to assume is that the staff was at fault.”

According to one expert on restraint asphyxia, those girls may have been right. After reviewing Levy’s autopsy report and police files on Harris’ death, paramedic and author Charly Miller concludes, “It doesn’t fly that her death was natural.”

Though Levy says he stands by his original findings, he tells the Scene that “to some extent that we can’t quantify,” Harris’ death was caused by “the stress of the situation she was in.”

Miller says it’s quite possible that it was the restraint that killed Harris, especially because Chad staff held her on the floor—belly down. Miller says patients with abdominal fat have an increased risk of restraint asphyxia for one simple reason: when an obese person is forced to lay on their belly, the excess stomach fat pushes up into the lungs, making it difficult to breathe until finally, the lungs give.

“But they can keep moving because their extremity muscles are still working after their diaphragm gives out,” Miller says. “And uneducated restrainers think,‘Oh, well, they must be breathing because they’re moving.’ That’s not true.”So Chad staffers might not have realized that Harris had stopped breathing until it was too late, Miller says.

Before Levy even ruled that Harris died of natural causes, DCS—the department that, along with Tennessee’s Department of Mental Health and Developmental Disabilities, was licensing Chad—stopped placing Tennessee children there. New York stopped too. “All we knew was that a child had died under unknown circumstances,” says DCS spokesman Rob Johnson. “The department already had some concerns, so they just elected to go ahead and pull the remaining children out.” Most of those concerns were about Chad’s use of restraint.

But Tennessee regulatory agencies did not revoke Chad’s license, which meant that other states—Kentucky and Pennsylvania, for example—continued sending children there. When asked why Tennessee regulators would keep Chad’s doors open when they wouldn’t even send the state’s own kids there, Johnson says it was simple: Chad met the state’s licensing standards.

“It’s somewhat akin to, does a restaurant pass standards for health inspections when they go in there?” Johnson says. “Yes, they may pass the standards, but it may be that the health inspector may not choose to take his own family there to dine. It’s somewhat analogous. Tennessee has its standards for how it wants its children to be treated when they’re in state custody.”

Chad is where DCS sent Sharon Pruett’s 16-year-old son, John Boy, for rehab in 2004. It’s where Pruett says her son became a broken boy after a counselor pushed him up against a wall, kneed him in the groin and strangled him until three staffers pried the man off of the teenager.

When Pruett moved her family from Chicago to rural Tennessee, she had grand visions of her two kids growing up in a small town in the friendly South, away from the hustle of big-city life. But even in the town of Hurricane Mills—home of Loretta Lynn’s Coal Miner’s Daughter Museum—Boy, a baseball player who did well in school, found trouble.

Before he was 16, Boy was addicted to methamphetamine. Pruett suspected that he was using drugs, and she says state officials told her that she could not get him into a treatment center unless she filed charges against him for being unruly. When she did, a judge ruled that Boy was a danger to his mother and younger sister and, against Pruett’s wishes, placed him in DCS custody. Soon after, Pruett says DCS put her son on house arrest for a 90-day, in-home treatment.

When Boy overdosed in September 2004, Pruett took him to the emergency room. DCS caseworkers soon followed to take a scared, sobbing Boy away to Chad in the wee hours of the morning. It was his first time away from home.

DCS officials told Pruett that her son would stay at Chad only temporarily—until they could place him in another drug treatment program. Pruett couldn’t understand why Boy would be living in a facility—and sharing a bedroom with—children those in the mental health world dub “level three” residents, kids who are a mere step away from being locked down in a detention center or placed in a full-on psychiatric ward. “My son was never arrested,” she says. “My son is not a bad boy. He did not burn houses. He did not hurt anybody. He was hurting himself with a drug problem. I questioned, I begged, I cried, I did everything [to keep him out of Chad].”

Less than three weeks into her son’s stay, Pruett got a call from her son and his therapist. “Mom, I was attacked last night,” Boy said over the therapist’s speakerphone.“You need to get me out of here.This man attacked me, and he broke my glasses.”

Pruett just began to cry. But Boy wouldn’t go into more detail, Pruett says, because he was scared it might happen again. He didn’t tell her that he hadn’t slept much since the attack the night before, which began after Boy called counselor Calvin Nelms a “fucking dick” when the man accused Boy of stealing another resident’s toiletries.

He didn’t say that Nelms had grabbed him by his shirt collar, pressed his hands against Boy’s throat, lifted him up off the floor and slammed him against the wall before throwing Boy down, kneeing him in the groin and strangling him until three employees intervened.

But Boy did tell his mother that his attacker was still working at Chad. Pruett says the facility acknowledged that they couldn’t fire Nelms because they were understaffed. Later, the family found out that Nelms, who admitted that he overreacted, had been placed on probation for his involvement in two or three similar incidents in the year-and-a-half he had worked at Chad, according to DCS files.

When Boy appeared in court a day after the attack, a judge ordered his immediate removal from the facility. Two months later, a Montgomery County court issued a warrant for Nelms’ arrest in the assault. But Pruett never received a subpoena to appear in court on Nelms’charge. His case was dismissed.

Pruett says Chad was the beginning of the end for her son. Before Chad, Boy was committed to getting better. But when he got home, he just didn’t care anymore. “He was just a different person when he came out of Chad,” she says. “He lost interest. It was like he didn’t trust people. He was just angry.”

She finds it ironic that Chad is dubbed an “enhancement center.”

“This doesn’t improve a child,”she says.“They’re just babies, and they’re going to come out being 10 times worse.”

Things did get worse for Boy. After bouncing among treatment programs for several years, he was shot to death in an unrelated incident in September of last year. But Pruett says she’s still committed to seeing Chad shut down. “How many lives have to be ruined, threatened and how many people have to be killed before they finally shut it down?” she says. “This facility is horrible. And I don’t see that it has changed at all.”

Omega Leach came to Chad from Pennsylvania—one of several states that still sent its most troubled children to Chad after the death of Harris. Leach arrived on May 2, 2007. One month later, he would be dead.

The online message board that accompanied one news story of his death was besmirched with comments keyed in by outsiders—people who dubbed Leach a bad kid who probably would’ve died on the streets anyway. “People out in the general population can refer to a kid who we now know was murdered as being a thug and saying he deserves what he gets,” says Holly Lu Conant Rees, chair of the Disability Coalition on Education of Tennessee. “And what difference does it make whether he dies in a facility or, you know, he gets in a gun battle out on the street? There seems to be a lack of empathy and understanding about the circumstances that led a child to be placed in a facility like Chad.”

To most, he was, quite simply, a delinquent—a boy with a criminal record stretching from his early teens. Leach grew up in Southwest Philadelphia, a rough-and-tumble neighborhood marked by abject poverty and violent crime. In the handful of years before his short stint at Chad, police arrested Leach twice and dubbed him “out of control.” His first offense—threatening students and teachers at his middle school and telling one teacher he would “shoot him full of shells”—landed Leach in a private facility in Virginia before he was even 15.

By 16, he was home again, only to be arrested months later for speeding through Southwest Philly in a stolen Nissan. This time, a Philadelphia judge thought a psychiatric program in the pastoral lands of Middle Tennessee, more than 800 miles from Leach’s home, might do the trick. And Leach wasn’t the first Philly kid to find his way to Chad. The city’s Department of Human Services had been sending children from neglectful or abusive homes there since 2001. And in 2006, the city’s judges began to follow suit, sending a new crop of kids to Chad: those with criminal records.

But Leach grappled with severe emotional issues too. State records show that he had been diagnosed with mood disorder, oppositional defiant behavior and conduct disorder, a condition marked by aggression, the propensity to initiate physical fights and to seriously violate rules and societal norms—such as those you might find in a rigidly structured treatment program.

The American Psychiatric Association would characterize Leach as someone who suffers from a “disruptive behavior disorder.” According to a 2000 report by Wanda and Brian Mohr in the Archives of Psychiatric Nursing, children with conduct disorder share remarkably similar risk factors, such as histories marked by trauma, physical abuse or neglect.

Janice LeBel, director of program management for the Child and Adolescent Division of the Massachusetts Department of Mental Health, has worked 20 years in the oversight of residential programs for children with the most severe mental and behavioral disorders, and she says she’s yet to see a youth with Leach’s diagnosis who doesn’t also have a history of trauma.

And according to the Mohrs’ research, children in treatment facilities who suffer from such disruptive behavior disorders also have another commonality: they’re more likely to be placed in some sort of restraint.

Given Leach’s diagnosis, it’s not a surprise that, when a Chad counselor confronted Leach and told him to leave his dorm room on the afternoon of June 2, Leach reportedly shoved and then tried to choke the counselor.

As the two struggled into the hallway, one of the facility’s surveillance cameras caught what would be one of the last acts of Leach’s young life. Sgt. Brian Prentice with the Montgomery County Sheriff’s Office says the tape shows Leach and the counselor rolling around in the hallway in a “full-on fight.”The pair then spilled back into Leach’s room—away from the camera’s eye.

Another counselor and a nurse then ran into the room as the first counselor walked out, seemingly exhausted. The rest of what happened in that room is speculative. According to statements, it seems that a counselor restrained Leach stomach down on the floor of his dorm room with his arms bowed behind his back.

The surveillance camera didn’t catch anything else—except the staffers later sprinting from the room in a frantic search for a defibrillator. Leach was dead.

But staff accounts of what happened in that room didn’t account for one thing: strangulation. When Levy performed an autopsy, he says Leach “had a series of superficial injuries from the struggle all over his body—kind of what you would expect from that type of a close physical struggle, falling on the ground, rolling around.” That accounts for the fight in the hallway.

But Levy also found “scattered superficial blunt force injuries” and “hemorrhages into soft tissues and muscles of the neck.” They were injuries that Levy says were “certainly consistent with some kind of strangulation.” Because of those findings, Levy ruled the death a homicide.

The two counselors involved in the restraint, Milton Francis and Randall Rae, have been suspended from Chad pending the results of a Montgomery County Sheriff’s Office investigation. Neither has been formally charged in Leach’s death.

Incident reports outlining Chad’s physical holds from the last two years alone stack inches tall. Most appear to be hastily handwritten, and many tell chilling, albeit scant, tales of run-ins with residents that resulted in “protective holds.” During a hold, at its least severe, a resident will be held upright with their hands and arms pinned behind their backs. At the worst, a hold can bring a swift and strong “takedown”to the ground, where a resident will be held, face down, arms bowed behind the back.

In May 2006, staff placed a boy in a hold, subsequently breaking the rotator cuff in the boy’s left shoulder—an injury that required a trip to the emergency room, but apparently did not require staff who recorded the incident to go into any great detail as to how the bone was broken when reporting the event to the state. The next month, another boy was “out of control and being aggressive to staff,” according to staff who placed him in a hold. But again, they left out details of how that hold put a gash in the boy’s chin that was severe enough to merit a trip to the ER for four stitches.

It’s not supposed to be this way. Chad adheres to the Handle With Care method of restraint. And according to its brochure, the program’s primary restraint technique—the method that Chad uses with residents in a standing position—gives staff an “unprecedented mechanical advantage without pain or injury.” In the event that staff find an upright hold insufficient and initiates a takedown, the brochure boasts, “there is no impact.”

Still, by many accounts, Handle With Care—at least as it’s used at Chad—is infused with anything but gentle care. When she worked at Chad, Marshall says she would see staff restrain residents “too hard and with anger vs. discipline.” In fact, the first time she saw one of the physical holds in action, it was more than she—a nurse of almost 20 years—could bear. “I ran out of the building crying because I didn’t know that kids—human beings—could be treated so forcefully,”she says.

The facility’s Behavioral Health Incident Report logs for 2006 show that staff physically restrained as many as 10 residents in a single day. In his investigation of Chad, Terry McMoore, director of Clarksville’s Urban Resource Center, found that Chad made 216 911 calls since October 2001, 33 of them for ambulances.

While experts warn that death can occur within six minutes of a hold, many Chad residents endured restraints—for three minutes, 15 minutes, 20 minutes or more—and escaped physically unscathed. While Chad’s own policy dictates that such holds can be used only if a resident’s behavior is violent enough to destroy property or harm the resident or others—never as punishment or retaliation—the facility’s own records tell a different story.

When a resident identified as a “little boy” left his bed in a wing of the facility that staff called the “Little House” one night in April, it wasn’t long before he found himself in a hold. One Chad staffer described it this way: “Little Boys [sic] not wanting to go to quiet time or bedtime. He came out of room again and was escorted by Ms. Jennifer but struggled with her.” Staff then placed the boy in a standing hold for three minutes.

Less than a month later, staff placed another resident, whose gender was not specified, in a hold for 15 minutes after the resident “began to escalate” when he or she wanted to retrieve a tennis ball in one of the facility’s classrooms. Marshall says such school-day restraints were common. “If [a resident] would continue to act up through the class period and so forth, it would end up a restraint,” she says.

According to Chad documents, residents were restrained for the simplest of childhood acts or missteps—even the proverbial glass of spilled milk. When one girl began crying alone in a corner of the facility in May, she refused to tell Chad staff what was wrong. Instead, she asked to speak to a supervisor. But when she grew weary of waiting, she walked out of the room and headed out of the building. Staffers put her in a standing hold for three minutes. When recording the reason for the restraint, a Chad employee checked the box next to “in danger or has harmed self, as evidenced by behavior or ideation.” The report failed to mention how the girl acted dangerously.

Three days later, staff restrained a boy when he walked up to a Chad employee, who already had another resident in a hold, and simply implored the staffer to “let him go.”

Other incident reports describe the facility as a chaotic place. In July, staff member Jermaine Clemmons was walking through the facility’s cafeteria where he found residents loud and out of their seats. He asked a female resident what was happening. The girl then threw milk at another Chad employee because, according to a report, the staff member was “saying things about her.” After one staffer unsuccessfully tried to escort the girl from the cafeteria, Clemmons placed her in escort and transported her to the education building, where she “was non compliant [sic] and was simply placed in a standing hold.”

That simple placement lasted 20 minutes. Clemmons didn’t provide any other details about the hold or any explanation as to exactly how the girl was noncompliant, or how she had become a danger to herself or others.

When the Scene asked if such force—and if as many as 10 restraints a day—in a therapeutic environment seems excessive, one industry expert offers an audible sigh. “That’s real violence going on,” Janice LeBel says. “That’s horrific risk for the youth and for the staff. And I think, over time, when staff aren’t given other tools, [restraint] becomes confused with a treatment intervention. But there is nothing therapeutic about it at all.”

But Tennessee’s Department of Mental Health and Developmental Disabilities has a different answer. Tracey Robinson-Coffee, director of licensure there, says she can’t answer questions about whether Chad’s restraint count is excessive because “to be fair, you know, you’re not dealing with the average population of youth out there....It’s not like everybody is doing as they’re being told: Get up, go to school, go to lunch, whatever. There’s things that happen in the facility, and I can’t say that one [restraint] a day is not excessive or it is excessive.”

There are many experts in the mental health field who believe that, for children who have been abused or have experienced some sort of trauma, physical restraint can be all the more agonizing. In testimony before the National Council on Disability, an independent federal agency, mental health service provider Marcie Kelley characterized her experience being restrained: “As a survivor of sexual abuse, I personally have found the use of restraints on me more traumatizing than being sexually abused. Being put in restraints is a much longer, traumatic ordeal than being raped.”

But Bruce Chapman, creator of the Handle With Care method, sees it quite differently. On his website,The Compassionate Neanderthal, and in a collection of his “unsolicited commentary,” Chapman writes that children in crisis “‘get the difference between doing something for a child and doing something to a child.” And where many advocates and abuse sufferers see restraint as traumatizing, Chapman writes, “On the contrary, it can be a moment of healing when the physical contact is initiated out of genuine concern and duty to the child.”

Even so, Chapman advises: “No person in his right mind wants to wrestle with a kid if he or she doesn’t have to....If you know childcare workers within your agency who routinely place themselves and children at risk, you have a bigger problem than Handle With Care training can fix.”

By DCS’s own account, Chad has had a constant turnover of employees, many of whom are college students and military personnel from the Clarksville area. And according to former Chad employees, it was these untrained applicants—those without any experience working in the mental health field or with kids with such extreme mental and behavioral issues—who would become the resident counselors who worked the most closely with Chad residents.

“They could have been someone who worked at Burger King and came out and put in an application to be a [resident counselor],” Marshall says.“These are the hands-on people who are with the kids 24-7.They’re people just right off the street that go through a week orientation program, and there were times when there were people there who weren’t over 20 or 21 themselves.”

There is little indication that Chad has been exceedingly selective in its hiring process. During its 2005 annual inspection of the facility, DCS reviewed nearly 20 staff files and found that only five contained documentation of references, but none had the required three references.

But all Chad employees are trained in Handle With Care—everyone from the nurses and teachers to the cafeteria workers, Marshall says. In fact, many are trained more than once, some on an annual refresher basis and others after particularly violent incidents of restraint. According to Chad’s policy, all employees undergo eight hours of training in Handle With Care upon hire.

In documents obtained by the Scene, nurse and former Chad employee Charles Wood wrote that most training in-services were “a joke” where “all answers were given at each booth,” so staffers had “no reason to learn them.” Wood reported that he attended all of the in-services, from Handle With Care recertification to suicide prevention, in approximately one hour. And Marshall says the initial week of orientation was the most—and often the only—training counselors had before working with residents.

LeBel says the behavior children can display in facilities such as Chad is absolutely frightening for staff who don’t have adequate training.“You can’t effectively ask people to step into a setting with children with mental health needs if they haven’t been educated,” she says. “Some providers require two weeks, one week [of training] and it varies...but until staff have been educated to understand what they’re looking at, particularly trauma and the impact of trauma, they can’t possibly know the needs of the youth that they’re serving.”

DCS had concerns about Chad’s staff too. In November 2005, McLeskey visited Chad on behalf of DCS and interviewed 55 residents. According to her report, residents said they heard staff call children “stupid” and “retarded.” Two staff members also reported hearing staff use derogatory names with residents. But it hasn’t been enough to stop licensing the facility.

McLeskey thought it necessary to remind Chad that “verbal abuse, ridicule and humiliation” are not acceptable forms of punishment, and she asked administrators to train employees to deal with resident behavior without resorting to abusive language. “Our impression is that there are a large number of immature employees who may not have the skills or the training necessary to deal with the issues and behaviors of the residents at Chad,” McLeskey wrote.

Denna Smith was 44 years old when she started working as a counselor at Chad in December 2005. Smith had been working 40-hour weeks at the center for less than two months, making $8.50 an hour, when she received a “corrective action notice.” Though the notice doesn’t detail Smith’s behavior, the supervisor outlines that she would be placed on “coaching status” so that she could learn to “remain calm and in control” when dealing with residents.

The supervisor writes that the “situation you’re being counseled on was handle [sic] the wrong way, especially when you know what kind of resident your [sic] working with.” Though the resident’s name is redacted, the supervisor identifies the child as “one of the most confrontational, defiant residents” at Chad.

The supervisor created an “action plan to achieve required performance” for Smith to follow: She would take a Handle With Care refresher course. About four months later, two Chad employees filed handwritten complaints about Smith, who, despite that refresher, didn’t seem to have calmed much.

According to one staff report, two girls began horseplaying in the cafeteria line when one employee reprimanded them. But Smith stepped in and yanked one of the girls out of the line and into an adjacent room, where another employee saw that Smith “threw her stuff out and was getting ready to fight.” Others reported seeing Smith moving toward the girl and saying, “You want to fight me? If you want to fight, let’s go.” In a report to Tennessee regulators, Chad’s risk manager wrote that Smith then shoved the girl.

When confronted about the incident, Smith denied it, became defensive and said, “I don’t have to take this shit” and quit. But it seems Smith had been verbally abusive long before she stormed out of Chad—the shoving incident was merely the catalyst for employee disclosure.

One staffer recalled a fight between Smith and another employee where the women exchanged insults, calling each other a “bitch” and “fat hog” in front of residents. Another counselor writes of an evening when a girl waiting in line for dinner asked what time it was, and Smith told her “that she was fat enough and that she was going to eat eventually.” The counselor said the girl went into the lobby for a timeout and returned crying.

Buddy Turner, divisional vice president at Universal Health Services (UHS), a King of Prussia, Pa., for-profit corporation that owns Chad and more than 100 other behavioral health facilities across the country, says UHS bought Chad in the fall of 2005 along with a handful of other facilities. When asked if it is indeed typical for Chad to hire counselors with little to no experience in the mental health field, Turner says they try to give priority to applicants with degrees and any human services experience. “There are employees that come to us that have not had experience working with kids, but again, those individuals, if they’re hired, go through an extensive state-approved training plan before they ever work with kids.”

But once they complete that training, virtually anyone at Chad can place a child in a physical hold. While Chad’s protective hold procedures outline that licensed practitioners (LIP)—doctors, nurses and licensed clinical social workers—must approve the use of a hold on a resident, any employee with a bachelor’s degree or two years experience working at a mental health inpatient facility will do the trick in the absence of an LIP.

Disability Coalition on Education in Tennessee’s Conant Rees bristles at the policy. “Good mercy,” she says. “I don’t see where there would be any preparation in completing...your bachelor’s degree in how to safely engage in a pretty intense, high-level behavioral intervention—one that has life-threatening implications.”

In 2005, the Montgomery County Sheriff’s Office called DCS to report that three of Chad’s male residents had beaten and attempted to strangle another male resident at the facility. Even though the state requires Chad to report incidents of harm immediately, this was the first DCS had heard of it.

Chad didn’t report the incident to law enforcement either. Sheriff’s officers got the news from the resident’s sister.

So DCS gave Chad 30 days to retrain its staff on the state’s reporting requirements for suspected abuse and neglect. Two days after the sheriff’s office made that call to DCS, Chad had a staff meeting to hand out a new reporting policy to its staff “to read and ask questions,” the center’s director of human resources reported. And Chad promised to teach new hires about the revamped policy.

The new policy outlined a clear chain of command for reporting harm or suspected abuse and neglect: notify the nurse on duty, who will then contact the Chad administrators, who should report the incident to DCS. At this point, staff are required to make documented attempts to reach the resident’s family. And the supervisor of nursing determines whether the resident should be transported to the emergency room.

It’s a familiar cycle that Tennessee regulatory bodies have developed with the facility: They identify the facility’s shortfalls, Chad responds—action plan in hand—and promises to fix said shortfalls. Inevitably, Chad continues to err.

State official Robinson-Coffee doesn’t see it that way. “It’s not like they were a red flag in our office,” she says. “We just go out and do our surveys and investigations when we got complaints, and they rectified whatever the situation was at that time. I mean, I wouldn’t put them in the category of a problem facility.”

She might not, but one Kentucky family would.

When the family of a 13-year-old boy placed their son in Chad on June 1, they were hopeful. Their son had never committed any sort of crime and, unlike many Chad youths, had not been ordered to attend treatment by a judge. His family enrolled him voluntarily for medical care.

On Aug. 26 of this year—less than three months after he began treatment—another 13-year-old male resident raped him.

According to a Chad incident report, the Kentucky boy was in a bathroom stall at the facility when he was approached by another resident who began banging on the door and threatening him. When the boy opened the door, the resident pushed his way into the stall and told the boy that if he didn’t pull his pants down, he would hit him.

When the boy refused, the resident hit him in the back and forced penetration on him while holding the boy’s mouth shut. Before leaving the stall, the resident threatened the boy and told him to stay quiet. And the boy did, for five minutes as he sat alone in the stall, before he cleaned himself off and told a friend what had happened. That resident notified Chad staff.

The victim’s mother was at the family’s Kentucky home on Sunday evening when she got a call from Chad: Her son had been raped. Rebecca Blair, a Brentwood attorney hired by the family, says her best estimate is that it took anywhere from one to three hours for the family to find out about the assault. Chad records show that it took nearly two hours.

When the boy’s mother asked if anyone had called police, Blair says the Chad supervisor told her it was not protocol. They called DCS— not the police. Then she asked if her son had been taken to the hospital for medical treatment, but she received the same answer: It was not Chad protocol.

The woman insisted that her son be transported to a hospital, and eventually, her pleas wore Chad staff down. Still, it took her nearly an hour to convince them. And by the time the boy arrived at Gateway Medical Center in Clarksville for examination, several hours had lapsed since the attack. And it wasn’t until after midnight that someone at the hospital called police to report the incident.

According to a Chad incident report, the boy returned to the facility a little after 3 a.m., and was transported to Nashville General Hospital and then to Our Kids, a Nashville treatment center for children who’ve been abused. It wasn’t until 9:45 the next morning that the boy made his way back to Chad.

The boy’s family removed him from the facility immediately and placed him at another treatment center closer to home. The suspect, who had come to Chad from Pennsylvania, has since been charged in the rape, taken into custody by Tennessee authorities and transferred back home, Blair says.

The family can hardly understand how such a thing could happen to their son in the first place. “They’re devastated,” Blair says. “And they’re just struggling to cope with this on a day-by-day basis.”

But according to one former Chad staffer, the fear of rape is common among residents. “They were afraid they were going to get hurt sexually by other residents...because they weren’t monitored closely enough, and it only takes a second for a young kid to get raped or for several to gang up on another kid,” Marshall says.

Chad is often understaffed on nights and weekends, Marshall says. Even during the daytime hours, she says Chad operated just at the minimum required staffing levels for the 85 or so residents who lived at Chad during the time she worked there. “You know, you’d call and beg and plead for people to come in and help, and nobody would,”she says.

Residents often told Marshall that they would find counselors sleeping on the job during the night shift. Some residents would use that as leverage. “The older boys would have cigarettes because the counselors at night would give them to them because they would fall asleep and the kids would catch them and they were going to tell on them if they didn’t give them some type of favors,” Marshall says.

Before any Google search of the Chad Youth Enhancement Center returned a multitude of reports on the death of Omega Leach, it wasn’t uncommon for families to research the facility and not find any red flags. “Even kind of knowing the key words to look for, I could find very little information about how this program functioned,” Conant Rees says.

The stress involved in making such a choice only complicates the process. Usually a child is either ordered to treatment by a judge or placed there by his family. And when parents decide to send their kid away from home and into facilities like Chad—centers that are, essentially, the last step before a psychiatric ward or jail—it’s a desperate measure. “Families are often exhausted and have used up their resources and don’t see any other options,” Conant Rees says.

She advises families to visit a facility’s campus before enrolling their child, to get that kind of gut reaction about what really happens behind closed doors. But when the family of the Kentucky boy visited the facility before admitting their son, no one told them that one resident had already died there. “They were shocked and very upset and alarmed that none of that had been brought to their attention when they were selecting this place as a treatment facility for their son,” Blair says.The family had even toured the facility and talked to Chad personnel “extensively before he was admitted.”

Of course, if the Kentucky family were to download Chad’s brochure from the KidLink Network website, a self-proclaimed leading referral source, they probably would’ve been all the more assured. KidLink is owned and operated by a subsidiary of UHS. And just like its UHS parent site, KidLink proudly states its mission: “Finding hope for youth and adolescents who are considered hopeless by others is something we do every day, because for us, giving up on a troubled child is simply not an option.”

Even if families take a closer look at Chad’s accreditation, they’ll find gold seals of approval and stellar marks.

The Joint Commission, a nonprofit group that regulates and certifies more than 15,000 U.S. health care programs, has awarded Chad its highest level of accreditation. And even after the two deaths at Chad, Tennessee’s Department of Mental Health and Developmental Disabilities (DMHDD), which is now the only state agency responsible for licensing Chad, still has not yanked the center’s license.

Mouthpieces for both the Joint Commission and DMHDD give the Scene similar explanations for why a handful of kids are still being treated at the facility today: Chad is trying to make things better.

Joint Commission spokeswoman Elizabeth Zhani says that after the death of Leach, Chad has worked within the commission’s requirements to develop an action plan for improvement. As long as Chad follows those requirements, its gold seal of approval won’t be stripped. “Organizations, when they take these steps, they learn from this,” Zhani says. “We don’t want to create a culture of fear where people are hiding things. We want to create a culture where people are learning from these incidents.”

Robinson-Coffee also seems to think that Chad is learning from its mistakes. She says it’s not the intent of DMHDD to shut it down. She’d much rather see the facility come back into compliance.“I think because Chad has kind of been in the media for so long, there just kind of seems to be a consensus that...there have been a number of incidents, but really in fact, they’ve been in compliance,” she says. “This has been a tragic incident, and they’ve been in the spotlight because of this incident. There are other minor incidents, but again, you have to put it in context of the type of facility they’re running and the population they’re dealing with.”

UHS feels that Chad might be getting an unfair shake in the media as well. In the first interview that the company’s Nashville office has grantedsince Leach’s death,Turner says,“We feel real strongly that thefacility and the company is committed to do the right things with kids.” He says UHS is interested in getting the story told about Chad, at least “the part about our facility treating really the most severely at-risk kids is a real statement about that facility…. We’ve got a successful history doing that, both at Chad and other places too.”

By those “other places,” Turner may be referring to the Compass Intervention Center in Memphis, another UHS-owned residential facility that is now treating an estimated 80 kids who are about the same age as Chad residents and who are generally treated for many of the same problems.

State files on Compass are disturbing. A 2006 report made by a DCS licensing consultant has one resident describing Chad as “better than Compass in Memphis” because “lots of kids get slammed down there.” Much like with Chad, stacks of reports detail resident complaints ranging from injuries sustained in restraint holds—Compass also uses the Handle With Care method—to allegations of staffers making sexual comments to residents. One girl reports that a male employee has asked her “to open her legs.” Other residents report being denied water or being threatened by a staffer who said she would “box [residents] like a grown woman.” One mother alleges that Compass staff laughed at her son and encouraged other residents to make fun of him because the boy had been placed in a private room because of excessive masturbation.

Robinson-Coffee says just as many issues from other facilities come across her desk. “I guess you can probably say it has to do with staffing and the proper training, and that’s something that we need to basically make sure that they’re doing properly,” she says. “But it’s kind of a tough situation all around. It really is.”

It’s an especially tough situation for parents such as Pruett, who don’t know if they will ever be able to move on from what happened to their children at Chad. And explanations from Tennessee’s regulatory bodies haven’t soothed uneasy minds. “Why can’t they just go and have these doors shut and locked up?” Pruett says. “If I were to commit that in my home, where do you think I would be? DCS would take that child out of my home...but [Chad] can do it and get a slap on the hand? I don’t understand why the doors are still open.”

FBI will look into boot camp death

THE ASSOCIATED PRESS

November 9, 2007

KANSAS CITY — FBI officials said Thursday that the agency is launching a preliminary investigation into the death of a student at a Missouri boot camp for troubled teens.

The Government Accountability Office had asked the FBI to look into potential criminal wrongdoing in the 2004 death of 15-year-old Roberto Reyes.

Jeff Lanza, a spokesman for the FBI's Kansas City office, said the agency will gather evidence for the next 30 to 90 days to determine whether a full investigation is needed.

During the preliminary investigation, Lanza said, the FBI will conduct interviews and review pertinent records in the case.

Reyes died after spending less than two weeks at the Thayer Learning Center in Kidder, Mo., about 50 miles north of Kansas City. His parents had sent him to Thayer after the California teenager's grades dropped and he repeatedly ran away from home.

His death was blamed on a probable spider bite, but GAO officials said records and interviews showed he had been ill for days and abused for insubordination.

Rhonda Smiley, a Kansas City attorney for Thayer and its owner, Willa Bundy, said she had not been informed of any action by the FBI.

"I'm confident that their preliminary investigation will end up with the same conclusion that all of the prior investigations have reached, that there is no abuse," Smiley said.

After Reyes' death, his parents sued the camp and several staff members, eventually settling the case for slightly more than $1 million. No criminal charges were filed.

The case received renewed attention after a congressional hearing last month on residential treatment programs for children. GAO officials testified that they believe there was evidence showing that Reyes was abused before he died.

No criminal charges have ever been filed against Thayer.

A state investigative team reported that it appeared those responsible for Reyes' safety did not recognize his medical distress or provide adequate treatment.

Former teen center worker arrested for sex crimes

Melissa Blasius

12 News Phoenix

November 20, 2007

A former employee at a residential treatment center for kids has been arrested and accused of having sex with a teen client. Phoenix officers picked up 33-year-old Kennedy Seroni Friday on a warrant in the case from summer 2006.

Seroni and another employee at Devereux Arizona were accused by a 15-year-old who was treated at the center. Police say Seroni made incriminating statements early in the case, but they waited for a formal charges from the County Attorney.

The teen's father tells 12 News the girl was being treated for substance abuse and behavioral issues including misappropriated sexual advances toward men. He says the employees preyed upon a vulnerable child who had been placed in the center by the court system.

A Devereux spokeswoman declined to talk about the case, citing confidentiality. She says all employees attend training about boundaries and sexual incident prevention. They also undergo background checks. According to Devereux, the background check processes has been enhanced since summer 2006, and employees are no longer allowed to be alone with clients of the opposite sex.

Juvenile Disservices
State Appoints Administrator With Troubled Background to Head Newly Reopened Youth Facility

By Jeffrey Anderson

Baltimore City Paper

November 28, 2007

When Christopher Perkins, 38, was tapped this summer to become superintendent of the newly renovated Victor Cullen Academy for youth offenders, he promised a “culture of transparency” and an end to the coercive and often violent culture that has plagued Maryland’s juvenile detention system for decades.

Closed in 2002 and reopened in July after a $16 million overhaul, the Frederick County facility is the state’s first new residential facility for teenage offenders in more than 10 years. Perkins, a veteran administrator who relocated from Montana, brought with him a reputation for ambition and competence--just what Gov. Martin O’Malley was looking for. But some 2,000 miles away a legal dispute is unfolding in Montana that could shed light on allegations that Perkins--known in Big Sky Country as “the Colonel”--is an abusive juvenile-facility director who favors military-style discipline and a code of silence.

Next month, a judge in Lewis and Clark County in Montana will decide whether to unseal an investigative report by the state’s Department of Public Health and Human Services regarding the Swan Valley Youth Academy, a facility that Perkins headed until December 2005. A complaint filed by the Montana Advocacy Program (MAP), a nonprofit protection and advocacy corporation specializing in civil rights for disabled people, prompted the investigation. The complaint charges that, on Perkins’ watch, staff at Swan Valley abused children and committed “actions which constituted criminal behavior.” The state’s investigative report, according to MAP attorney Andree Larose, is in addition to a state-licensing survey by the same agency that is already public, and which led to Perkins’ departure and the Swan Valley facility’s closure in 2006.

“In my opinion, you’re going to want to see that report,” says Larose, explaining that her group is asking the court to balance the public’s right to know over various confidentiality privileges. “Even before the report, I felt there were credible allegations that were serious enough to warrant criminal investigation by the State Attorney General’s Office.”

Swan Valley Youth Academy is notorious in Montana. In 2005, MAP provided local authorities with information about specific allegations that Perkins physically assaulted a juvenile and promoted a violent employee named Jeff Wagner to a position of leadership after he, too, allegedly abused children.

In a letter to Lake County Attorney Robert Long dated Oct. 27, 2005, Larose described chilling allegations such as staff slamming children to the floor and forcing them to do excessive physical activity until they vomited. During the intake process, staff allegedly abused the teens--many of them already victims of abuse in their homes--with taunts such as “fucking pussy,” “faggot,” and “fatso,” telling them that they and their parents are losers.

The goal of such alleged abuse, according to MAP, is to break the kids down so they will submit to authority. In one instance, Larose’s letter states, after Wagner, a 200-pound ex-Marine, allegedly slammed a 125-pound teenager against a wall, “Colonel Perkins responded [to staff concerns] that this was how intake was done at Swan Valley.”

When contacted for this story, Perkins referred calls to the Department of Juvenile Services. In a brief interview on Tuesday, DJS Secretary Donald DeVore said he was unaware of either Montana report, and that the 22-member advisory board at Victor Cullen is “delighted with the job Perkins is doing.” The facility will house no more than 48 intermediate-level juvenile offenders, DeVore adds--“no rapists or murderers”--which is a change from its previous status as 174-resident military-style academy.

As superintendent of Victor Cullen, Perkins also gained an appointment by O’Malley to DJS’s Delinquency Prevention and Diversion Services Task Force. O’Malley’s appointments secretary, Jeanne Hitchcock, says the vetting process for Perkins was routine. DJS would be responsible for reviewing prior employment of potential appointees, she says, adding, “If they did that.” A DJS spokesperson would not confirm the vetting process, however. After DJS recommends an appointee, Hitchcock looks for potential conflicts of interest, proof of Maryland residency, and any “red flags,” including involvement in civil lawsuits or criminal matters. Potential appointees are asked to disclose any such matters on an “honor basis,” she adds.

The letter from Larose to the Lake County Attorney’s Office, which is redacted to protect the names of children and certain staff, casts a shadow on Perkins’ appointment and raises questions about the DJS hiring process. It describes one staff member telling another that he could not wait for a particular teenager to arrive, and that he was “going to break his fucking face.” Staff allegedly placed bets as to who could make the newest child residents puke first, the letter states.

Among the more serious charges are that staff at Swan Valley placed kids in seclusion for long periods of time and doctored seclusion logs. In early 2004, the letter states, Perkins slammed a child against a wall for not standing in the chow line, and in August 2004 he removed an abuse report from a child’s file after the child was forced to stand at attention for three hours on a hot day. “Colonel Perkins told [a staff member] that they needed to break down this kid,” Larose’s letter states, in asking for a criminal investigation.

Instead, Montana’s Department of Public Health and Human Services took action in response to Larose’s advocacy efforts. The department’s Quality Assurance Division investigated alleged licensing violations, and the Child and Family Services Division investigated allegations of child abuse. The licensing report, made public in 2006, found 19 violations, including that staff at Swan Valley harmed youth during the intake process, imposed inappropriate seclusion and restraints on children, failed to report abuse and an attempted suicide to state authorities, and in general failed to “ensure proper care, treatment and safety of the residents.”

Throughout the licensing report, an individual identified as “Staff #20” is described as an authority figure who required subordinates to alter restraint reports, failed to report serious incidents to authorities, and told state regulators that the program’s philosophy is to “break the kid down to build them up.” If the Montana judge unseals the investigative report by the Child and Family Services Division, the public could soon learn the identity of Staff #20 and the state’s official findings on allegations of abuse at Swan Valley on Perkins’ watch.

As it was, the licensing report led to a firestorm in Montana. In December 2005, Perkins was placed on administrative leave, according to then-acting director Mark Mizner-Welch, and though licensing authorities accepted Swan Valley’s plan of correction, by February 2006 the facility was nearly empty and staring at a $500,000 loss over the next six months. It closed for financial reasons, Mizner-Welch says, denying that child abuse occurred at Swan Valley.

“Licensing officials cleared us and we were moving forward, but Montana is a close-knit place, and the media frankly killed us,” he says. Asked whether Maryland officials ever contacted him or anyone at Swan Valley before hiring Perkins, Mizner-Welch replied no. “Did Maryland do its homework? I don’t know,” he says. “A Google search would’ve turned up a whole bunch of news stories.” Asked for a reaction to Perkins’ hiring, he chuckles and says, “I’m not surprised. He’s ambitious and professionally competent.”

Swan Valley was owned by Colorodo-based Cornerstone Programs Corp. Former Maryland official Joseph Newman founded the company in the late 1990s. Before that, Newman, deputy secretary of DJS from 1992 to ’94, operated a for-profit juvenile-detention services company called Rebound, which has a checkered past as well. According to a Dallas Morning News story last July, Colorado officials closed a Rebound facility in 1998 after a 13-year-old inmate committed suicide and state authorities found widespread problems with physical and sexual abuse. A Human Rights Watch report later found that the facility, the High Plains Youth Center, “fell short of reasonable, even minimal performance.” In 1997, the story states, Florida officials severed a contract with the Cypress Creek Juvenile Detention Facility, also owned by Rebound, for repeated problems including arrests of inmates for inciting a riot.

Rebound also ran Maryland’s Charles H. Hickey School in the early 1990s, a juvenile-detention facility recently known for the escape of 10 inmates last January, after former governor Robert Ehrlich closed much of the facility in 2005. Newman did not return calls for comment.

DJS Secretary DeVore says Victor Cullen is operating on a more modern therapeutic model than its predecessors--one that “has received rave reviews.” He says the facility is expected to be a leading example for facilities statewide. Perkins will play a key role, DeVore says, noting that “his work has been exemplary.”

One former Swan Valley staff member who does not place much faith in Perkins, or Newman for that matter, is a retired Air Force chaplain named Curtis Wallace. In a June 3, 2004, memo to Newman, Wallace, then a youth counselor at Swan Valley, warned that staff concerns about the abuse of children were met with threats of retaliation. “I hope that the evidence you have collected will be enough to make an informed decision on [Jeff] Wagner and [Chris] Perkins’ ability to work with youth in the future,” the memo said. “In my strongest opinion, [they] worked in tandem to create an environment exceedingly hostile to anyone who dared to question their methodology or challenge their abusive practices.”

Wallace told City Paper this week that he never observed any action or concern on Newman’s part in response to the 2004 memo. He found Newman’s tacit approval of Perkins and the leadership he displayed at Swan Valley disturbing. “These kids come from broken homes with authority issues,” Wallace says. “If you want someone handling them who is dictatorial in nature and who has a reputation for getting physical, Perkins is your man.”

Yet a completely different portrait of Perkins emerged in a Sun article last July, heralding the reopening of Victor Cullen as a bellwether for juvenile-detention facilities across the state. “We have to prove that we know what we’re doing, and that we can fundamentally offer an improved program for youth,” Perkins told a Sun reporter. “We’re dealing with kids whose lives are in the balance.”