Arizona's troubled teens: At risk and overlooked

http://www.azcentral.com/news/juvenile-centers/

By Craig Harris and Rob O'Dell The Republic | azcentral.com Sun Feb 17, 2013 12:03 AM

Some of Arizona's most severely troubled youths have reportedly been sexually and physically abused in residential treatment centers amid lax oversight by the state agencies that license, monitor, fund and assign children to the facilities, an Arizona Republic investigation has found.

Many of Arizona's 11 Level 1 juvenile treatment centers have had ongoing problems managing their clients and staff, leading to frequent runaways, physical abuse and, in at least 15 cases, reported sexual abuse of teens by adult staff, a review of three years of state-agency incident reports and police records shows.

The Arizona Department of Health Services, which licenses the facilities, and the state Supreme Court's Administrative Office of the Courts, which contracts for their services, are aware of most of the incidents but have not demanded the facilities improve or have not taken enforcement actions regarding the incidents.

Regulators say many of the incidents — including the staff sexual-abuse allegations — have not been substantiated or did not result in criminal prosecutions.

While the ADHS and AOC collect data from facilities on health and safety incidents, including runaways, suicide attempts, fights, sexual activity, alleged sexual abuse or physical mistreatment, they rarely analyze the information.

Neither agency measures the effectiveness of the facilities' treatment of children nor do they track their recidivism rates.

The agencies do require the treatment centers to abide by strict administrative procedures, such as filing paperwork regarding a change in leadership, verifying employees' work credentials, and displaying patient rights in English and Spanish. The state has assessed small fines against centers that don't comply.

But virtually no strings have been attached to the more than $78 million in state funds spent during the past three fiscal years at nine facilities, which can receive up to $300 a day per patient.

Parents, guardians, the court system, state Child Protective Services and Native American tribes place children, most of whom are teenagers, in the facilities for acute specialized care for deep-seated emotional and behavioral problems including anger, drug addiction, mental illness, sexual abuse, sexual addiction and eating disorders.

The facilities' "Level 1" designation means they provide 24-hour nursing care, around-the-clock supervision and an on-campus school. They also can function as lockdown centers, much like juvenile detention. The 11 facilities collectively can house up to 510 children at one time.

Arizona regulators questioned about The Republic's findings said they plan to stay the course, that nothing is fundamentally wrong with the state's system of residential treatment centers or their oversight. Officials at AOC and ADHS also defended the centers when questioned about the incidents of mistreatment of patients and the number of runaways.

They also downplayed the significance of the numbers of incident reports reviewed by The Republic given the types of clients the centers serve. In many cases, they also minimized their severity.

"It is not surprising that a concentrated population of kids, who are predisposed to violence toward others, acting out sexually or injuring themselves, generate the number of self-reported incidents received by the AOC," said Jennifer Liewer, a spokeswoman for the Supreme Court.

Supporters of residential treatment centers acknowledge there will be some behavioral problems — everything from runaways to fights among clients — in their facilities, but they do not consider the number of reports excessive.

They say these problems are unavoidable, but the centers are necessary because they provide a haven and desperately needed counseling for hard-to-treat children, including many with mental disorders, who cannot function in traditional homes. And, successful treatment at the facilities can keep children from being sent to a psychiatric hospital, detention facility or, eventually, prison.

"You have to look at the population that is in there," said Emily Jenkins, president and chief executive of the Arizona Council of Human Service Providers, a 76-member statewide group that advocates for residential treatment centers. "There are kids in there who are a danger to themselves or others."

But Ira Burnim, legal director of the Bazelon Center for Mental Health Law in Washington, D.C, said children are being mistreated in a system that is ineffective. Arizona, Burnim said, is spending heavily on facilities that cannot prove to regulators that they work.

"They are writing off these kids by saying, 'We can't imagine a different result in how these facilities operate or how these kids live,'" he said.

Anne C. Ronan, an attorney for the Arizona Center for Law in the Public Interest, said residential treatment centers are "inherently not safe," adding that children are mistreated in them because society is generally unconcerned about their welfare.

"The system as a whole thinks of them as hopeless," Ronan said. "When you put a whole lot of people together that have the same problems, it's like a juvenile-justice facility."

Records ignored

Arizona requires facilities to report to state regulators any incidents requiring medical attention or intervention at the sites.

But The Republic examined local police records and compared them with reports to two different state agencies and found some facilities under-report serious incidents such as staff sexual involvement with patients, assaults and runaways. They also regularly missed state-imposed reporting deadlines, yet have not been penalized.

The information reported to the state, though public, is not readily available for citizens to inspect. Officials at both state agencies said it would be unfair to publish the information online because the state does not have the resources to substantiate or refute the incidents.

Officials at ADHS said their policy is to destroy incident reports after one year because of the large volume of reports. If kept longer, the data could be used to scrutinize facilities over longer periods.

The Republic obtained three years of electronic ADHS reports containing brief descriptions of the incidents, but only because the agency had not followed its policy of destroying them.

The health department acknowledged that it would have destroyed two years' worth of electronic incident reports had reporters not requested them. The Republic also obtained three years' worth of incident reports from the state court system.

The Republic created a searchable database of the reported incidents and beginning Tuesday will publish it at azcentral.com. The Republic's investigation is the first comprehensive examination of incident reports the facilities file with Arizona's two regulators.

Some jurisdictions outside Arizona keep detailed records of incidents and recidivism rates to gauge long-term patient outcomes. But ADHS says it destroys records after a year because it receives too many records to store for longer periods.

One national expert said it should be easy for an agency to handle large volumes of records by taking advantage of electronic storage capabilities. Westley Clark, director of the Center for Substance Abuse Treatment within the U.S. Department of Health and Human Services, said it is in the public interest for regulators to err on the side of preserving electronic records for longer periods, providing data to measure the successes or failures of individual facilities.

"Obviously, if we want to know if a facility has a reoccurring problem, a longer view gives us that information," Clark said.

One youth advocate called the ADHS record-retention policy senseless.

"I can't imagine the justification for destroying information after a year," Burnim said. "The reason you do the reports is not only to respond to immediate problems, but also to track trends over time in the system as a whole."

Sexual allegations

The Republic's review of three years of reports to ADHS, AOC and police found at least 15 allegations of staff members at three facilities being involved sexually with juveniles.

The reports do not indicate whether the allegations were substantiated, or if one individual was accused of multiple offenses. But The Republic found at least six employees were terminated or resigned at two facilities after incidents were alleged. Police declined to pursue charges when the reliability of an accuser was questioned or the accuser refused to assist authorities. In one case, they recommended charges, but prosecutors balked.

Two of the employees worked at Mingus Mountain Estate Residential Center in Prescott Valley. Four worked at Parc Place in Chandler.

At Parc Place, one man was accused of seeking sexual favors in exchange for providing over-the-counter drugs to two teenage girls, including one who was addicted to drugs. He was accused of groping them and touching their genitals. The former employee denied wrongdoing but was fired the day after the allegations surfaced.

"It was horrible. I hated it," said [name withheld], one of the accusers at Parc Place who now is 18 and living in Tucson. "No one would ever want to go through what I went through."

At Mingus Mountain, a counselor was accused of initiating a relationship with a client by having her write sexual fantasies about him while "journaling," and having sex with her in the facility's attic. He was immediately suspended and fired 18 days later, though he denied wrongdoing in interviews with law enforcement.

Regulators did not determine whether the acts had occurred because, as one regulator said, "The threat was removed" with the employees' firing.

Arizona Health Services Director Will Humble downplayed the significance of the firing of staff alleged to have had sexual relations with clients.

"A person ends up getting fired and no one was even prosecuted, let alone found guilty," Humble said.

Officials at ADHS, however, were not aware until it was brought to their attention that multiple allegations of staff having sexual contact with patients had been made over three years at Parc Place.

Humble said patients can fabricate accusations, citing Parc Place's zero-tolerance policy toward staff sexual misconduct as a motive for clients to lie. He said clients know they can say, "If you don't give me the privileges I'm looking for, I can easily just say you did something you didn't do and you will be fired."

Jenkins agreed, noting treatment centers have strict reporting requirements and some reported allegations of misconduct simply are not true.

In general, Jenkins said, "there are kids who will not tell the truth. ... Some of the kids in the facility may be trying to manipulate a new situation."

But some states encourage more stringent examination of such complaints, regardless of their source. For example, Alaska is recognized by mental-health experts for its vigilance and strict monitoring of residential treatment centers. Alaska licensing regulators immediately investigate a center if a child there is in "immediate jeopardy" or dies.

Arizona and Alaska have similar standards, but Alaska differs in that it requires an on-site investigation within 24 hours if there is an allegation of sexual or physical abuse. Alaska also requires an investigation within 72 hours if there are allegations of abuse or neglect. Arizona does not have such rules.

Troubling episodes

The Republic found in the records more than 75 allegations of physical abuse by staff, dozens of reports of inappropriate sexual contact between peers, hundreds of fights, and runaways so frequent that they occurred at a rate of one every three days at The New Foundation in Scottsdale. Most of the incidents occurred at five of the 11 facilities.

The Republic examined several thousand pages of documents and more than 2,000 electronic records describing "reportable" incidents from October 2009 to October 2012, along with 9-1-1 calls for service and reports from seven law enforcement agencies.

Facilities licensed by ADHS are required to report incidents to the agency. Those that contract with the courts also are required to report to AOC. The Republic found several facilities reported incidents to one agency and not the other even though they are required to report to both.

Initial reports to ADHS are supposed to be vetted to determine if the situation is life-threatening. If so, regulators are to go immediately to the facility to investigate. In any case, a written report on every incident must be submitted within five days for review by state regulators.

Incidents that ADHS officials believe merit additional investigation are elevated to a formal complaint, meaning they are classified differently but not necessarily given more scrutiny.

The Republic found that no more than 10 percent of the original incident reports were elevated by ADHS to complaints. ADHS officials acknowledged most written incident reports to ADHS are not thoroughly reviewed. They cited administrative staffing shortages.

Incidents reported to AOC must be followed by a written report within three days. When asked for documentation for all enforcement actions taken in response to reports made over the past three years, the agency said: "To pull and redact the files for the 1400+ incidents reports would take months of staff time." AOC asked The Republic to pare its request to specific incidents. The Republic requested a sample of 18 cases that mostly involved sexual abuse.

Those 18 records showed little follow-up by AOC, other than e-mails and, in Paige Warren's case, the drafting of a corrective action plan at Parc Place.

The plan required Parc Place employees to report concerns about staff members and rotate assignments. The staff member who had allegedly abused Warren had often asked to be placed at the end of the hallway, and several employees had been concerned about his behavior. The plan required staff members to only be in the doorway "vicinity" of patient rooms because the staffer was in the doorway when he allegedly "violated" a client's "boundaries."

The agencies contend they respond quickly to incidents that are life-threatening or involve patient safety. Neither, however, produced documentation of any substantial enforcement actions taken in response to the reports.

Three years of data from both agencies showed:

Parc Place in Chandler reported nine allegations of adults having sexual contact with patients. The number exceeds the combined total of similar reports at the other 10 facilities, according to ADHS records.

Parc Place reported 100 allegations of peer-on-peer violence, including a riot on April 26 that involved at least 10 girls. The Chandler facility generated 72 percent of all peer-on-peer violence reports, according to ADHS records.

Mingus Mountain reported to ADHS four instances in which staff were alleged to have had sexual contact with patients. None of the cases was reported to AOC.

Three facilities reported nine cases of peer physical abuse resulting in serious injuries, including two broken eye sockets, a broken jaw, broken bones in the face, a broken nose and a client who reported being choked until she lost consciousness.

Devereux Foundation in Scottsdale submitted 31 reports of peer-on-peer sexual abuse — accounting for four out of every five such cases reported to ADHS.

Devereux Foundation also reported 64 allegations of adult staff members physically mistreating clients, who alleged being punched in the face, choked or slammed to the ground. Devereux had 83 percent of staff physical mistreatment cases reported to ADHS.

The New Foundation in Scottsdale reported 217 instances of children running away, nearly 10 times as many as the facility with the second-highest number of runaways. The New Foundation placed nearly 200 additional calls to report runaways to the Scottsdale Police Department.

Youth Development Institute in Phoenix reported to ADHS 86 instances of self-inflicted injuries by patients and to the courts 128 cases of self-inflicted injuries. The number reported to ADHS was more than 15 times higher than any other facility.

Youth Development Institute reported to the courts 136 allegations of peer-on-peer physical abuse, but ADHS was told about only 11 of the cases. The facility attributed the discrepancy to different reporting requirements, though it is required to report to both.

Overall, nearly one in four reports submitted to ADHS and the courts were filed late. Reports to ADHS are due within five business days; those to AOC within three.

Centers defended

Chad Campbell, AOC's juvenile justice services division director, said many teens in Level 1 facilities "are very successful and have made great progress."

Barbara Lang, chief of the behavioral health licensing office for ADHS, agreed.

"Our residential treatment centers have some wonderful outcomes," Lang said. "RTCs serve a very, very important purpose to our state."

Neither Campbell nor Lang could provide The Republic with any documentation to back their assertions because the state has not established standards to measure the centers' success.

Facility operators also contend regulators provide rigorous oversight and require extensive documentation. They add that their clients make significant improvement while in their care because of specialized counseling and academic opportunities.

The facilities pointed to positive reviews from client families. All but one, however, referred to The Republic by these facilities declined to discuss their cases on the record.

Eric Kennedy, chief executive of Parc Place in Chandler, said children at his facility on average improve academically by two grade levels.

Geri Leary, chief executive of The New Foundation, said some children do leave the facility to blow off steam and then return. She added that kids there feel "respected and empowered," and are successful.

Residential treatment centers can be the last chance for some juveniles to turn their lives around, said Rick Carter, a lawyer representing Youth Development Institute.

"When these kids come to RTCs, most are lost," Carter said. "Anything you can do to save them is an accomplishment. There is no other place for them. Where would they go?"

Lane Barker, executive director for Devereux Arizona, said the center substantiated only 10 of the 64 staff physical abuse cases, and Devereux fired its staff members in four cases.

Devereux declined to identify which physical abuse cases were substantiated. Barker said the Devereux peer sexual abuse cases should not be classified that way because many were not serious cases of sexual abuse.

Mingus Mountain did not return repeated requests for comment.

Making it better

Several states and large urban counties throughout the country have found a less costly model that produces better results with fewer incidents of the kind The Republic found at Arizona facilities.

The most-acclaimed model, known as wraparound services, is a system of intensive treatment centered on keeping children in their homes and taking the help to them.

Only the most troubled are sent to institutions.

Milwaukee's program is the poster child.

It was conceived in the mid-1990s, when residential treatment centers were creating financial deficits and problems similar to those in Arizona, said Wraparound Milwaukee Director Bruce Kamradt.

"The outcomes were very poor for kids leaving these centers," Kamradt said. "Even if they were said to be successfully discharged, they would be back in the system within six months. We had a high rate of kids going AWOL and never completing (treatment)."

Since implementing its wraparound program, Milwaukee's tally of juveniles in treatment centers dropped from 375 to 80, while the number of psychiatric hospitalization days dropped from 5,000 to 500, Kamradt said.

Milwaukee has not increased funding for residential treatment centers since 1997.

Charley Huffine, medical director of the Seattle area's county child and adolescent program, said King County has used wraparound services to save money and cut the number of children in state hospitals from 100 to 18.

He said treatment centers in general are problematic because much of their staff is not certified to do mental-health work, yet they deal with troubled children who have severe behavior problems and lack impulse control.

Physical abuse and peer sexual abuse also are common, Huffine said.

"It's tough work — I don't care how well trained you are," Huffine said.

Burnim, the youth advocate from the Bazelon Center, suggested Arizona could better serve at-risk youths with more community services that allow them to live at home or in foster care.

"When you congregate all these kids in one place, it becomes a huge management problem," Burnim said. "These places have a tendency to get out of control."

Reach the reporters at craig.harris@arizonarepublic.com and rob.odell@arizonarepublic.com.

Last updated 12/16/13