After slamming his fists into the wall until his knuckles dripped with blood, the raging teenage boy turned to a staff member and shoved him. The teen had recently been admitted to Youth Development Institute, a residential program for children with emotional and behavioral disorders in Phoenix, Arizona. Even the smallest incidents triggered his anger.

Years ago, the response would have been swift and physical: The boy would have been forced to the ground and restrained until he grew calm, which sometimes could take up to 45 minutes.

But this time, Sean Hennessey, a direct care staff coordinator, stepped in front of another staff member, sending him out of the room before the conflict could escalate. Hennessey stood at the door with his head down, avoiding eye contact, and calmly spoke to the boy. When tears rolled down the boy’s face minutes later, Hennessey moved in and offered a reassuring side hug.

“It’s exhilarating when you’ve avoided a restraint,” Hennessey told ProPublica, recalling the incident. “Pinning a kid to the ground until they stop fighting and start crying, it’s barbaric if you think about it.”

Eight years ago, restraints occurred multiple times a day at Youth Development Institute. When children violently acted out, staff would hold them or even strap them down, and sometimes inject them with sedatives. Trish and David Cocoros, the directors of the program, said they hated relying on restraints, but assumed that if they stopped using them, more staff members and kids would get hurt.

Then, in 2012, the program changed course after an industry expert visited and discussed alternatives to restraints such as the approach Hennessey used. Now, the program averages less than one restraint a month.

Youth Development Institute is part of a growing group of residential programs nationwide attempting to improve their work with children in key ways. Eliminating restraints is just one example. Many programs are shortening children’s stays, involving families more, and offering more rigorous classes.

But best practices like these are almost entirely self-imposed.

There are few federal requirements for residential programs involving children, and a patchwork of state regulation has left significant gaps: There is little to no monitoring of how well schools are teaching kids overall, no required national tracking of abuse and neglect allegations, and not even a comprehensive database of all programs.

Efforts to bolster federal standards have drawn fire from some providers and industry groups, which have lobbied lawmakers. Legislation to modestly increase federal oversight has languished for years.

As a result, for years, some programs have continued to thrive despite having long records of mistreating residents that has even, at times, led to injuries and deaths. (Read ProPublica’s recent story about one for-profit company, AdvoServ, that has used its deep pockets and influence to bully weak regulators and evade accountability.)

Because of the wide latitude they’re given, some programs still use extreme methods on children – including forced labor or exercise, electric shock and restraint devices that include shackles and a wrap that resembles a full-body straight jacket. Our recent story also detailed how AdvoServ workers at one campus used mechanical restraints 28,000 times in less than five years. (AdvoServ told us workers only use restraints as a last resort, “when there is imminent danger.”)

At programs across the country, at least 145 children have died from avoidable causes at residential facilities over the past 35 years, a ProPublica analysis of news reports found. At least 62 children died after being restrained, most often because of asphyxiation.

The job of monitoring the wellbeing of children at the programs is spread across so many state and local agencies that kids can fall through the cracks.

State education agencies, for instance, rarely take strong action. A ProPublica survey found that about half of the education departments didn’t have the power to sanction such schools even if they discovered public school students were being mistreated. School officials in just seven of the 44 states that responded to the survey said they had levied penalties on or closed such a program in the last decade.

“State agencies can certainly step up measures to hold all residential treatment programs accountable to high health and safety standards, but the reality is that most have not despite a rash of abuse allegations occurring in programs on their turf,” Rep. Adam Schiff, D-Calif., told ProPublica in an email. Schiff reintroduced a bill earlier this year that would require the tracking of abuse allegations lodged against such programs.

Trish and David Cocoros, directors of Youth Development Institute in Phoenix, Arizona, are part of a growing group of kids' residential treatment facilities working to strengthen best practices in the face of lax national oversight. (Annie Waldman/ProPublica)

Youth residential centers originated in the 1940s to fill a gap in the therapeutic spectrum: They are less restrictive than psychiatric hospitals and are often a last resort for overwhelmed families. They provide housing, treatment and, often, schooling to kids with a range of issues, from emotional disorders to substance abuse problems to profound disabilities like severe autism. They use a diverse array of approaches and include so-called “wilderness” programs, boot camps and other behavior modification centers.

Public schools funnel roughly 18,000 kids per year into residential programs. Federal law entitles all children with disabilities to free public schooling but school districts sometimes pay private providers to educate students with severe impairments that local classrooms can’t handle. Some of the programs provide 24-hour care and take children from across the country.

Many of the programs are pricey, with total costs for some children soaring past $350,000 per year. A host of other agencies, from child welfare to Medicaid, typically pay the rest of the bill for children’s stays, each with their own standards for the programs.

Despite the public funding, there is little data on residential schools. One federal database collects state data on abuse incidents, but submission is voluntary. There is no required federal tracking of abuse allegations–and there is not even a nationwide list of all residential programs. One often-cited government survey, which is more than a decade old, estimates that there are at least 3,600 facilities across the country, housing more than 50,000 children annually.

Ira Burnim, legal director for the Bazelon Center for Mental Health, believes that the current data gives an incomplete picture. “Our lack of information and data is very troubling,” said Burnim. “To a certain extent, the residential treatment centers are out of sight, out of mind.”

Lawmakers have repeatedly called for changes amid reports of chronic abuse and neglect. A government report in 2008 found gaps in state regulation increased the risk of abuse and neglect at some youth residential programs.

Some state agencies didn’t visit programs often enough to make sure kids were safe and well-cared for, the report found. In other states, some programs, such as private boarding schools and religious treatment centers, are exempt from licensing and do not have direct regulation. The report also found state agencies did not routinely share negative findings on programs, or even inform other agencies when a program had its license revoked.

A few industry groups support greater oversight and transparency.

“Even if it means more regulation and paperwork, we have an obligation to support what would be best for the children,” said Kari Sisson, executive director of the American Association of Children’s Residential Centers.

To help reinforce standards, some states and federal agencies require programs to obtain accreditation from professional standards groups, which generally have more requirements than state agencies.

But the accrediting agencies have few tools to enforce compliance.

“They do a lot of things well and they have a lot of good measures,” said Robert Friedman, a clinical psychologist at the University of South Florida. “But they are not there that often.”

Unrestrained

While evidence of abuse of the disabled has piled up for decades, one for-profit company has used its deep pockets and influence to bully weak regulators and evade accountability. Read the story.

What Happened to Adam

It took one mother seven years to learn that the for-profit school she trusted with her son had strapped him down again and again, one time after not picking up his Legos. Read the story.

With few enforcement powers, some federal officials have focused on encouraging best practices. Dr. Gary Blau, the chief of the child, adolescent and family branch of the federal Substance Abuse and Mental Health Services Administration, has led a campaign to promote changes at children’s residential centers, such as eliminating the use of restraints.

In 2006, Blau organized the first “Building Bridges” summit to bring residential program directors and community care providers together to discuss how to improve the standards of therapeutic care for youth.

Although many facilities, like Youth Development Institute, were ready and willing to incorporate best practices, others were resistant to any kind of culture change.

“There were residential facilities that had built fortresses around themselves,” Blau said. “They kept kids in and kept families out.”

Since that first meeting, nearly 130 organizations have committed to the standards set by the Building Bridges initiative.

Blau recognizes that there’s only so much that persuasion can accomplish. “There’s still a lot more work to be done,” Blau said. For facilities that are resistant to change, “that’s where I would look to state licensing and say that we need to include these principles in our licensing requirements.”

Aside from facilities, several states have also begun to formally adopt the standards as their own. Massachusetts, for example, has embedded the Building Bridges’ guidelines into their licensing regulations, including limiting restraints.

“The data made it impossible to walk away from,” said Janice LeBel, the director of system transformation at Massachusetts’ Department of Mental Health. When LeBel compared the psychiatric care of children and adults, the rate at which restraints were used was at least 4 times higher in youth facilities. “There was a moral imperative to do something about it.”

Under LeBel’s watch, the state has reduced the use of restraints in children’s psychiatric facilities by 89 percent. They are now implementing the reduction strategies across children’s residential facilities and schools. But for reductions to happen across the country, LeBel said, national standards should be stronger.

“There is great value to having local oversight, but it’s important for there to be federal standards that drive service advancement,” she told ProPublica.

Industry groups and providers have at times aggressively sought to fend off federal regulation of their programs and worked to undermine stricter rules.

“Lobbying against regulations is traditionally the posture of the providers,” said Burnim of Bazelon Law Center. “They are not fans of regulation, and where they are supportive of regulation, it’s in the service of getting resources.”

The National Association of Therapeutic Schools and Programs, also known as NATSAP, represents over 150 residential treatment programs and was one of the more prominent groups lobbying Congress on earlier versions of Schiff’s bill. Between 2008 and 2009, NATSAP spent $220,000 lobbying Congress, according to disclosure reports.

“We are all for regulation, it just has to be the right kind,” said Clifford Brownstein, the executive director of NATSAP, which requires that its members be licensed and accredited. “We have found that, for a variety of reasons, issues can be dealt with best more locally.”

While NATSAP has not actively lobbied since 2010, another member-based organization, the National Association for Children’s Behavioral Health, or NACBH, has spent at least $100,000 since 2013 lobbying Congress on mental health bills, including legislation on residential program oversight, according to congressional disclosure reports.

Joy Midman, executive director of NACBH, believes that “the field has been swiped with one broad brush.”

Midman, who emphasized that the disclosed dollars spent by NACBH only show what bills her organization has paid firms to monitor and does not necessarily indicate lobbying, described the recent legislation as a “work-in-progress.”

Additional reporting by Heather Vogell and Meral Agish.

Update, March 28, 2017: AdvoServ has a new leadership team and changed its name to Bellwether Behavioral Health earlier this year.