United States Government Accountability Office

GAO

Testimony
Before the Committee on Education and
Labor, House of Representatives

For Release on Delivery
Expected at 10:30 a.m. EDT
Wednesday, October 10, 2007

RESIDENTIAL
TREATMENT PROGRAMS
Concerns Regarding Abuse
and Death in Certain
Programs for Troubled
Youth
Statement of Gregory D. Kutz, Managing Director
Forensic Audits and Special Investigations
Andy O’Connell, Assistant Director
Forensic Audits and Special Investigations

GAO-08-146T

October 10, 2007

RESIDENTIAL TREATMENT PROGRAMS
Accountability Integrity Reliability

Highlights

Concerns Regarding Abuse and Death in Certain
Programs for Troubled Youth

Highlights of GAO-08-146T, a testimony
before the Committee on Education and
Labor, House of Representatives

Why GAO Did This Study

What GAO Found

Residential treatment programs
provide a range of services,
including drug and alcohol
treatment, confidence building,
military-style discipline, and
psychological counseling for
troubled boys and girls with a
variety of addiction, behavioral,
and emotional problems. This
testimony concerns programs
across the country referring to
themselves as wilderness therapy
programs, boot camps, and
academies, among other names.

GAO found thousands of allegations of abuse, some of which involved death,
at residential treatment programs across the country and in American-owned
and American-operated facilities abroad between the years 1990 and 2007.
Allegations included reports of abuse and death recorded by state agencies
and the Department of Health and Human Services, allegations detailed in
pending civil and criminal trials with hundreds of plaintiffs, and claims of
abuse and death that were posted on the Internet. For example, during 2005
alone, 33 states reported 1,619 staff members involved in incidents of abuse in
residential programs. GAO could not identify a more concrete number of
allegations because it could not locate a single Web site, federal agency, or
other entity that collects comprehensive nationwide data.

Many cite positive outcomes
associated with specific types of
residential treatment. There are
also allegations regarding the abuse
and death of youth enrolled in
residential treatment programs.
Given concerns about these
allegations, particularly in
reference to private programs, the
Committee asked GAO to (1) verify
whether allegations of abuse and
death at residential treatment
programs are widespread and
(2) examine the facts and
circumstances surrounding
selected closed cases where a
teenager died while enrolled in a
private program.
To achieve these objectives, GAO
conducted numerous interviews
and examined documents from
closed cases dating as far back as
1990, including police reports,
autopsy reports, and state agency
oversight reviews and
investigations. GAO did not
attempt to evaluate the benefits of
residential treatment programs or
verify the facts regarding the
thousands of allegations it
reviewed.

GAO also examined, in greater detail, 10 closed civil or criminal cases from
1990 through 2004 where a teenager died while enrolled in a private program.
GAO found significant evidence of ineffective management in most of the 10
cases, with program leaders neglecting the needs of program participants and
staff. This ineffective management compounded the negative consequences of
(and sometimes directly resulted in) the hiring of untrained staff; a lack of
adequate nourishment; and reckless or negligent operating practices,
including a lack of adequate equipment. These factors played a significant role
in the deaths GAO examined. See the table below for detailed information
related to three of the case studies.
Examples of Case Studies GAO Examined
Date of
Cause of
Sex/age
death
death
Case details
Female, 15 May 1990
Dehydration
ƒ Showed signs of illness for 2 days, such as blurred
vision, vomiting water, and frequent stumbling
ƒ Program staff thought she was faking her illness to
get out of the program
ƒ Collapsed and died while hiking
ƒ Lay dead in the road for 18 hours
ƒ Program brochure advertised staff as “highly trained
survival experts”
Male, 15
Sept. 2000 Internal
ƒ Head-injury victim with behavioral challenges who
bleeding
refused to return to campsite
ƒ Restrained by staff and held face down in the dirt for
45 minutes
ƒ Died of a severed artery in the neck
ƒ Death ruled a homicide
Male, 14
July 2002
Hyperthermia ƒ Experienced difficulty while hiking and sat down,
(high body
breathing heavily and moaning
temperature)
ƒ Fainted and lay motionless
ƒ One staff member hid behind a tree for 10 minutes to
see whether the victim was “faking it”
ƒ Staff member returned and found no pulse
ƒ Died soon afterwards
Source: Records including police reports, legal documents, and state investigative documents.

To view the full product, including the scope
and methodology, click on GAO-08-146T.
For more information, contact Gregory D.
Kutz at (202) 512-6722 or kutzg@gao.gov.

United States Government Accountability Office

Mr. Chairman and Members of the Committee:
Thank you for the opportunity to discuss residential treatment programs
for troubled youth. In the context of this testimony, we are using the term
residential treatment program to refer to entities across the country and
abroad calling themselves wilderness therapy programs, boarding schools,
academies, behavioral modification facilities, and boot camps, among
other names. While some of these programs are funded publicly by state
and local government agencies, others are privately owned and operated.
Private residential treatment programs typically market their services to
the parents of troubled teenagers—boys and girls with a variety of
addiction, behavioral, and emotional problems—and provide a range of
services, including drug and alcohol treatment, confidence building,
military-style discipline, and psychological counseling for illnesses such as
depression and attention deficit disorder.
Many cite positive outcomes associated with specific types of residential
treatment. There are also allegations regarding the abuse and death of
youth enrolled in residential treatment programs. Given concerns about
these allegations, particularly in reference to private programs, you asked
us to (1) verify whether allegations of abuse and death at residential
treatment programs are widespread and (2) examine the facts and
circumstances surrounding selected closed cases where a teenager died
while enrolled in a private program.
To verify whether allegations of abuse and death at residential treatment
programs are widespread, we gathered available information about
allegations made over the last 17 years by performing interviews with
relevant experts, reviewing relevant studies and documents, conducting
Internet searches for Web sites making allegations, reviewing data from
the National Child Abuse and Neglect Data System (NCANDS),1 and
reviewing relevant state and federal court documents. We were unable to
disaggregate information on public and private programs; consequently,
the information we present includes allegations against both types.
To select our case studies, we identified numerous closed civil and
criminal cases in which a court was asked to decide whether a private

1

According to the Administration for Children and Families (part of the U.S. Department of
Health and Human Services), NCANDS is a voluntary national data collection and analysis
system created in response to the requirements of the Child Abuse Prevention and
Treatment Act.

Page 1

GAO-08-146T

residential treatment program was responsible for the death of an enrolled
teenager. When identifying our cases, we specifically excluded teenager
deaths at public programs such as state-sponsored foster programs,
juvenile justice programs for delinquent youth, or programs that
exclusively treat psychological disorders or substance abuse in a hospital
setting. We focused on deaths between the years 1990 and 2004 to
illustrate the long-standing issues presented by private residential
treatment programs. We limited our cases to closed cases and, thus,
ongoing cases from the last several years were not included in our work.
We selected these 10 cases based on several factors including victim age,
program location, type of program the victim attended, and date of death.
We then examined, in more detail, the facts and circumstances of the
death and any related abuse of the victim. To validate the facts and
circumstances of each case, and to the extent possible, we conducted
interviews with related parties, including current and former program staff
and officials, attorneys and law enforcement officials involved in the
cases, and the parents of the victims. Further, we reviewed available
documentation to support the facts of each case including (but not limited
to) marketing materials, police reports, autopsy reports, and state agency
oversight reviews and investigations. In addition, we conducted site visits
at nine residential treatment programs to obtain a firsthand perspective on
how residential treatment programs operate. Five of these nine programs
were related to the still-operational programs discussed in our cases—
either because they were the same program or represented a permutation
of the original program operating under a different name or in a new
location. Where we obtained financial information about the programs,
we converted this information to 2007 dollars so that the information was
comparable.
It is important to emphasize that residential treatment programs are
intended to help youth with serious problems—in some cases, these
problems constitute life-threatening addictions and diseases. We did not
attempt to evaluate the benefits of residential treatment programs in
dealing with these serious problems. Moreover, it is not possible to
generalize the results of our investigation as applying to all residential
treatment programs, whether privately or publicly funded. We found it
difficult to obtain an overall picture of the extent of the residential
treatment program industry. For example, while states often regulate
publicly funded programs, a number of states do not license or otherwise
regulate private programs. Because programs determine how to describe
themselves, especially in their marketing materials, there is no standard
definition for “wilderness therapy program,” “boot camp,” or other terms
Page 2

GAO-08-146T

used to describe the types of programs and facilities considered to be part
of this industry. GAO is completing a comprehensive review of state and
federal oversight of residential treatment programs for youth with
behavioral and emotional challenges and expects to report next year.
We performed our work from June through September of 2007 in
accordance with the quality standards for investigations set forth by the
President’s Council on Integrity and Efficiency.

Summary

We found thousands of allegations of abuse, some of which involved
death, at residential treatment programs across the country and in
American-owned and American-operated facilities abroad between the
years 1990 and 2007. Allegations included reports of abuse and death
recorded by state agencies and the Department of Health and Human
Services, allegations detailed in pending civil and criminal cases with
hundreds of plaintiffs, and claims of abuse and death that were posted on
the Internet. For example, according to the most recent NCANDS data,
during 2005 alone 33 states reported 1,619 staff members involved in
incidents of abuse in residential programs. Because there are no specific
reporting requirements or definitions for private programs in particular,
we could not determine what percentage of the thousands of allegations
we found are related to such programs.
We also examined, in greater detail, 10 closed cases where a teenager died
while enrolled in a private program. We found significant evidence of
ineffective management in most of these 10 cases, with program leaders
neglecting the needs of program participants and staff. This ineffective
management compounded the negative consequences of (and sometimes
directly resulted in) the hiring of untrained staff; a lack of adequate
nourishment; and reckless or negligent operating practices, including a
lack of adequate equipment. These factors played a significant role in most
of the deaths we examined. For example:
•

In May 1990, a 15-year-old female was enrolled in a 9-week wilderness
program. Although the program brochure claimed that counselors were
“highly trained survival experts,” they did not recognize the signs of
dehydration when she began complaining of blurred vision, stumbling,
and vomiting water 3 days into a hike. According to police documents,
on the fifth day and after nearly 2 days of serious symptoms, the dying
teen finally collapsed and became unresponsive, at which point
counselors attempted to signal for help using a fire because they were

Page 3

GAO-08-146T

not equipped with radios. Police documents state that the victim lay
dead in a dirt road for 18 hours before rescuers arrived.

Background

•

In another example, we learned that, in July 2001, a 14-year-old male
enrolled in a boot camp became so dehydrated that he began to eat dirt
from the desert floor. Witnesses said that when he eventually fell
unconscious and appeared to have a seizure, the program director told
staff members to put the victim in the flatbed of a pickup truck and
drive him to a hotel. When they could not revive him at the hotel, they
put him back in the flatbed of the truck, returned to the camp, and
placed the teen’s limp body onto his sleeping bag. The program director
assured his staff that “everything will be okay” but the victim died soon
afterwards.

•

In December 2001, on Christmas Day, a 16-year-old female was
climbing in an extremely dangerous area unsupervised by program
staff. According to documents we reviewed, the girl slipped, fell about
50 feet into a crevasse, and died of massive brain trauma about 3 weeks
later. An investigation revealed numerous licensing and safety
violations with the program, including an improperly low staff-to-youth
ratio, failure of staff to scout the hiking location prior to the hike, and
no first aid kit (it was left at the base camp).

Since the early 1990s, hundreds of residential treatment programs and
facilities have been established in the United States by state agencies and
private companies. Many of these programs are intended to provide a lessrestrictive alternative to incarceration or hospitalization for youth who
may require intervention to address emotional or behavioral challenges.
As mentioned earlier, it is difficult to obtain an overall picture of the
extent of this industry. According to a 2006 report by the Substance Abuse
and Mental Health Services Administration, state officials identified 71
different types of residential treatment programs for youth with mental
illness across the country.2 A wide range of government or private entities,
including government agencies and faith-based organizations, can operate
these programs. Each residential treatment program may focus on a
specific client type, such as those with substance abuse disorders or

2

For addition information, see H. T. Ireys, L. Achman, and A. Takyi. State Regulation of
Residential Facilities for Children with Mental Illness. DHHS Pub. No. (SMA) 06-4167
(Rockville, Md.: Center for Mental Health Services, Substance Abuse and Mental Health
Services Administration, 2006).

Page 4

GAO-08-146T

suicidal tendencies. In addition, the programs provide a range of services,
either on-site or through links with community programs, including
educational, medical, psychiatric, and clinical/mental health services.
Regarding oversight of residential treatment programs, states have taken a
variety of approaches ranging from statutory regulations that require
licensing to no oversight. States differ in how they license and monitor the
various types of programs in terms of both the agencies involved and the
types of requirements. For example, some states have centralized licensing
and monitoring within a single agency, while other states have
decentralized these functions among three or more different agencies.
There are currently no federal laws that define and regulate residential
treatment programs. However, three federal agencies—the Departments of
Health and Human Services, Justice, and Education—administer programs
that can provide funds to states to support eligible youth who have been
placed in some residential treatment programs. For example, the
Department of Health and Human Services, through its Administration for
Children and Families, administers programs that provide funding to states
for a wide range of child welfare services, including foster care, as well as
improved handling, investigation, and prosecution of youth maltreatment
cases.3
In addition to the lack of a standard, commonly recognized definition for
residential treatment programs, there are no standard definitions for
specific types of programs—wilderness therapy programs, boot camps,
and boarding schools, for instance. For our purposes, we define these
programs based on the characteristics we identified during our review of
the 10 case studies. For example, in the context of our report, we defined
wilderness therapy program to mean a program that places youth in
different natural environments, including forests, mountains, and deserts.
Figure 1 shows images we took near the wilderness therapy programs we
visited.

3

Under Titles IV-B and IV-E of the Social Security Act and the Child Abuse and Neglect
Prevention and Treatment Act.

Page 5

GAO-08-146T

Figure 1: Environments Where Wilderness Therapy Programs Operate

Source: GAO.

Note: These images show the surroundings that youth enrolled in a wilderness treatment program
might encounter. Clockwise from the upper left, these images show (1) West Virginia woodlands,
(2) an Oregon river, and (3) a Utah mountain range.

According to wilderness therapy program material, these settings are
intended to remove the “distractions” and “temptations” of modern life
from teens, forcing them to focus on themselves and their relationships.
Included as part of a wilderness training program, participants keep
journals that often include entries related to why they are in the program
and their experiences and goals while in the wilderness. These journals,
which program staff read, are part of the individual and group therapy
provided in the field. As part of the wilderness experience, these programs

Page 6

GAO-08-146T

also teach basic survival skills, such as setting up a tent and camp, starting
a fire, and cooking food. Figure 2 is photo montage of living arrangements
for youth enrolled in the wilderness programs we visited.
Figure 2: Living Arrangements at Wilderness Therapy Programs GAO Visited

Source: GAO.

Note: The top two images show living arrangements at two wilderness therapy programs—a “time
out” shelter (upper left) and an enrolled youth’s campsite (upper right). The bottom two images show
the girls’ tent (lower left) and the shelter for group therapy and meetings (lower right) for the middle
phase of a residential treatment program.

Page 7

GAO-08-146T

Some wilderness therapy programs may include a boot camp element.
However, many boot camps (which can also be called behavioral
modification facilities) exist independently of wilderness training. In the
context of our report, a boot camp is a residential treatment program in
which strict discipline and regime are dominant principles. Some militarystyle boot camp programs also emphasize uniformity and austere living
conditions. Figure 3 is a photo montage illustrating a boot camp which
minimizes creature comfort and emphasizes organization and discipline.

Page 8

GAO-08-146T

Figure 3: Interior of a Boot Camp Facility That GAO Visited

Source: GAO.

Note: These images show the interior of a boot camp facility. Clockwise from the upper left, the
images show (1) the overall layout of “the boot camp” room in the facility, where male enrollees spend
the majority of their indoor time and sleep on the floor; (2) the limited supplies and personal items of
enrollees, including a rolled sleeping bag and mat; (3) bathroom facilities; and (4) a room with bunk
beds for youth in the advanced phase of the program.

A third type of residential treatment program is known as a boarding
school. Although these programs may combine wilderness or boot camp
elements, boarding schools (also called academies) are generally

Page 9

GAO-08-146T

advertised as providing academic education beyond the survival skills a
wilderness therapy program might teach. This academic education is
sometimes approved by the state in which the program operates and may
also be transferable as elective credits toward high school. These
programs often enroll youth whose parents force them to attend against
their will. The schools can include fences and other security measures to
ensure that youth do not leave without permission. Figure 4 shows some
of the features boarding schools may employ to keep youth in the
facilities.

Page 10

GAO-08-146T

Figure 4: Security Features Employed at a Boarding School GAO Visited

Source: GAO.

Note: These images show the exterior of a boarding school. Clockwise from the upper left, the
images show (1) a close-up of the video surveillance equipment and motion detectors in place on the
outside of the school; (2) tall exterior fencing and motion detector; and (3) an angle of the facility
exterior that clearly displays security features, including video monitoring, lighting, fencing, and wire
mesh over the windows.

A variety of ancillary services related to residential treatment programs
are available for an additional fee in some programs. These services
include:

Page 11

GAO-08-146T

•

Referral services and educational consultants to assist parents in
selecting a program.

•

Transport services to pick up a youth and bring him or her to the
program. Parents frequently use a transport service if their child is
unwilling to attend the program.

•

Additional individual, group, or family counseling or therapy sessions
as part of treatment. These services may be located on the premises or
nearby.

•

Financial services, such as loans, to assist parents in covering the
expense of residential treatment programs.

These services are marketed toward parents and, with the exception of
financial services, are not regulated by the federal government.

Widespread
Allegations of Abuse
and Death at
Residential Treatment
Programs

We found thousands of allegations of abuse, some of which involved
death, at public and private residential treatment programs across the
country between the years 1990 and 2007. We are unable to identify a more
concrete number of allegations because we could not locate a single Web
site, federal agency, or other entity that collects comprehensive
nationwide data related to this issue. Although the NCANDS database,
operated by the Department of Health and Human Services, collects some
data from states, data submission is voluntary and not all states with
residential treatment programs contribute information. According to the
most recent NCANDS data, during 2005 alone 33 states reported 1,619 staff
members involved in incidents of abuse in residential programs. Because
of limited data collection and reporting, we could not determine the
numbers of incidents of abuse and death associated with private
programs.
It is important to emphasize that allegations should not be confused with
proof of actual abuse. However, in terms of meeting our objective, the
thousands of allegations we found came from a number of sources besides
NCANDS. For example:
•

We identified claims of abuse and death in pending and closed civil or
criminal proceedings with dozens of plaintiffs alleging abuse. For
instance, according to one pending civil lawsuit filed as recently as July
2007, dozens of parents allege that their children were subjected to
over 30 separate types of abuse.

Page 12

GAO-08-146T

•

We found attorneys around the country who represent youth and
groups of youth who allege that abuse took place while these youth
were enrolled in residential treatment programs. For example, an
attorney based in New Jersey with whom we spoke has counseled
dozens of youth who alleged they were abused in residential treatment
programs in past cases, as has another attorney, a retired prosecutor,
who advocates for abuse victims.

•

We found that allegations are posted on various Web sites advocating
for the shutdown of certain programs. Past participants in wilderness
programs and other youth residential treatment programs have
individually or collectively set up sites claiming abuse and death. The
Internet contains an unknown number of such Web sites. One site on
the Internet, for example, identifies over 100 youth who it claims died
in various programs. In other instances, parents of victims who have
died or were abused in these programs have similarly set up an
unknown number of Web sites. Conversely, there are also an unknown
number of sites that promote and advocate the benefits of various
programs.

Because there are no specific reporting requirements or definitions for
private programs in particular, we could not determine what percentage of
the thousands of allegations we found are related to such programs. There
is likely a small percentage of overlapping allegations given our inability to
reconcile information from the sources we used.

Cases of Death at
Selected Residential
Treatment Programs

We selected 10 closed cases from private programs to examine in greater
detail. Specifically, these cases were focused on the death of a teenager in
a private residential treatment program that occurred between 1990 and
2004. We found significant evidence of ineffective management in most of
these 10 cases, with many examples of how program leaders neglected the
needs of program participants and staff. In some cases, program leaders
gave their staff bad advice when they were alerted to the health problems
of a teen. In other cases, program leaders appeared to be so concerned
with boosting enrollment that they told parents their programs could
provide services that they were not qualified to offer and could not
provide. Several cases reveal program leaders who claimed to have
credentials in therapy or medicine that they did not have, leading parents
to trust them with teens who had serious mental or physical disabilities
requiring proper treatment. These ineffective management techniques
compounded the negative consequences of (and sometimes directly

Page 13

GAO-08-146T

resulted in) the hiring of untrained staff; a lack of adequate nourishment;
and reckless or negligent operating practices, including a lack of adequate
equipment. These specific factors played a significant role in most of the
deaths we examined.
•

Untrained staff. A common theme of many of the cases we examined
is that staff misinterpreted legitimate medical emergencies. Rather than
recognizing the signs of dehydration, heat stroke, or illness, staff
assumed that a dying teen was in fact attempting to use trickery to get
out of the program. This resulted in the death of teenagers from
common, treatable illnesses. In some cases, teens who fell ill from lesscommon ailments exhibited their symptoms for many days, dying
slowly while untrained staff continued to believe the teen was “faking
it.” Unfortunately, in almost all of our cases, staff only realized that a
teen was in distress when it was already too late.

•

Lack of adequate nourishment. In many cases, program philosophy
(e.g., “tough love”) was taken to such an extreme that teenagers were
undernourished. One program fed teenagers an apple for breakfast, a
carrot for lunch, and a bowl of beans for dinner while requiring
extensive physical activity in harsh conditions. Another program forced
teenagers to fast for 2 days. Teenagers were also given equal rations of
food regardless of their height, weight, or other dietary needs. In this
program, an ill teenager lost 20 percent of his body weight over the
course of about a month. Unbeknownst to staff, the teenager was
simultaneously suffering from a perforated ulcer.

•

Reckless or negligent operating practices. In at least two cases,
program staff set out to lead hikes in unfamiliar territory that they had
not scouted in advance. Important items such as radios and first aid
kits were left behind. In another case, program operators did not take
into account the need for an adjustment period between a teenager’s
comfortable home life and the wilderness; this endangered the safety of
one teenager, who suddenly found herself in an unfamiliar
environment. State licensing initiatives attempt, in part, to minimize the
risk that some programs may endanger teenagers through reckless and
negligent practices; however, not all programs we examined were
covered by operating licenses. Furthermore, some licensed programs
deviated from the terms of their licenses, leading states, after the death
of a teen, to take action against programs that had flouted health and
safety guidelines.

See table 1 for a summary of the cases we examined.

Page 14

GAO-08-146T

Table 1: Summary of Victim Information
Case

Program
Victim information attended

Date of
death

Cause of death

1

Female, 15,
California resident

Utah wilderness May 1990
therapy program
(death occurred
in Arizona)

Dehydration

2

Female, 16, Florida
resident

Utah wilderness June 1990
therapy program

Heat stroke

3

Male, 16, Arizona
resident

Utah wilderness March 1994
therapy program

Acute infection
resulting from
perforated ulcer

4

Male, 15, Oregon
resident

Oregon
Sept. 2000
wilderness
therapy program

Severed artery

5

Male, 14,
Massachusetts
resident

Feb. 2001
West Virginia
residential
school and
wilderness
therapy program

Suicide (hanging)

Page 15

Case details
Died while hiking on fifth day of program
• Exhibited signs of illness for 2 days, such as
throwing up water, falling down, and
complaining of blurred vision
• Collapsed due to dehydration
• Lay dead for 18 hours on dirt road
• Program brochure given to parents had
advertised program staff as “highly trained
survival experts”
• Died on federal land
• Died while hiking on third day of program
• Program had not considered child’s adjustment
from a coastal, sea-level residence to a high
desert wilderness area
• Died of “exertional heatstroke” while hiking
• Program owner acquitted of criminal charges
but placed on state list of suspected child
abusers
• Exhibited signs of physical distress for nearly 3
weeks, such as severe abdominal pain,
significant weight loss (20 percent of body
weight), loss of bodily functions, and weakness
• Collapsed and became unresponsive
• Air lifted to hospital and pronounced dead on
arrival
• Died on federal land
• Refused to return to campsite but did not
behave violently
• Restrained by staff and held face down to the
ground for almost 45 minutes
• Died of severed artery in neck
• Death ruled a homicide
• Grand jury declined to issue an indictment
• Died on federal land
• Attempted suicide twice before enrolling in
program
• On the fifth day of program cut arm several
times with camp-issued pocket knife
• Staff did not take the knife away
• Hung himself near his tent the next day
• Program had no suicide prevention plan
•

GAO-08-146T

Program
Victim information attended

Date of
death

Cause of death

6

Male, 14, Arizona
resident

July 2001

Dehydration

7

Female, 16, Virginia Utah wilderness Jan. 2002
resident
therapy program

Case

Arizona boot
camp

Massive head
trauma

Case details
• On seventh day was punished for asking to go
home
• Forced to sit in 113-degree desert heat
• Was delirious and dehydrated
• Taken to motel room, placed in shower tub, left
unattended
• Staff returned victim to camp in the flatbed of a
pickup truck and placed his limp body onto his
sleeping bag
• Staff later found him unresponsive and he died
at the hospital
•
•
•
•
•

8

Female, 15,
California resident

Oregon
May 2002
wilderness
therapy program
(also operated in
Nevada at time
of death)

Dehydration/ heat
stroke

•
•

•
•
•

•

9

Male, 14, Texas
resident

Utah wilderness July 2002
therapy program

Hyperthermia
(excessive body
temperature)

•
•
•
•
•
•

Page 16

Fell while hiking on Christmas Day
Staff had not scouted extremely dangerous
area beforehand
Staff had no medical equipment, against its
licensing agreement
Took about one hour for first paramedics to
arrive
Died on federal land
Died while hiking on first day of program
Told others she had taken methamphetamines
before the hike, but was not screened for drug
before hike
Experienced signs of distress for several hours
while hiking
Collapsed and stopped breathing
Died of heat stroke complicated by the
methamphetamines and prescription
medication
Died on federal land
On a 3-mile hike in desert heat
Complained of thirst and refused to continue
hike
Left in the sun for an hour and stopped
breathing
Staff member hid behind a tree for 10 minutes
thinking the victim was “faking” illness
Help arrived over an hour after death
Died on federal land

GAO-08-146T

Case
10

Program
Victim information attended

Date of
death

Male, 15, California
resident

Nov. 2004

Missouri boot
camp and
boarding school

Cause of death
Complications of
rhabdomyolysis
due to a probable
spider bite

Case details
• Displayed signs of distress for several days
• Program’s medical officer told staff victim was
“faking it”
• Became lifeless and could hardly move
• Punished for being too weak to exercise and
forced to wear a 20-pound sandbag around his
neck
• Autopsy reported death was caused by
complications of rhabdomyolysis due to a
probable spider bite, but also found numerous
bruises all over the victim’s body

Source: Records including police reports, legal documents, and state investigative documents.

Case One

The victim was a 15-year-old female. Her parents told us that she was a
date-rape victim who suffered from depression, and that in 1990 she
enrolled in a 9-week wilderness program in Utah to build confidence and
improve her self-esteem. The victim and her parents found out about the
program through a friend who claimed to know the owner. The parents of
the victim spoke with the owner of the program several times and
reviewed brochures from the owner. The brochure stated that the
program’s counselors were “highly trained survival experts” and that “the
professional experience and expertise” of its staff was “unparalleled.” The
fees and tuition for the program cost a little over $20,600 (or about $327
per day). The victim and her parents ultimately decided that this program
would meet their needs and pursued enrollment.
The victim’s parents said they trusted the brochures, the program owner,
and the program staff. However, the parents were not informed that the
program was completely new and that their daughter would be going on
the program’s first wilderness trek. Program staff were not familiar with
the area, relied upon maps and a compass to navigate the difficult terrain,
and became lost. As a result, they crossed into the state of Arizona and
wandered onto Bureau of Land Management (BLM) land. According to a
lawsuit filed by her parents, the victim complained of general nausea, was
not eating, and began vomiting water on about the third day of the 5-day
hike. Staff ignored her complaints and thought she was “faking it” to get
out of the program. Police documents indicate that the two staff members
leading the hike stated that they did not realize the victim was slowly
dehydrating, despite the fact that she was vomiting water and had not
eaten any food.

Page 17

GAO-08-146T

On the fifth day of the hike, the victim fell several times and was described
by the other hikers as being “in distress.” It does not appear that staff took
any action to help her. At about 5:45 p.m. on the fifth day, the victim
collapsed in the road and stopped breathing. According to police records,
staff did not call for help because they were not equipped with radios—
instead, they performed CPR and attempted to signal for help using a
signal fire. CPR did not revive the victim; she died by the side of the road
and her body was covered with a tarp. The following afternoon, a BLM
helicopter airlifted her body to a nearby city for autopsy. The death
certificate for the victim states that she died of dehydration due to
exposure. Although local police investigated the death, no charges were
filed. Utah officials wanted to pursue the case, but they did not have
grounds to do so because the victim died in Arizona. The parents of the
victim filed a civil suit and settled out of court for an undisclosed sum.
Soon after the victim’s death and 6 months after opening, the founder
closed the program and moved to Nevada, where she operated in that state
until her program was ordered to close by authorities there. In a hearing
granting a preliminary judgment that enjoined the operator of the program,
the judge said that he would not shelter this program, which was in effect
hiding from the controls of the adjoining state. He chastised the program
owner for running a money-making operation while trying to escape the
oversight of the state, writing, “[The owner] wishes to conduct a
wilderness survival program for children for profit, without state
regulation” and she “hide[s] the children from the investigating state
authorities and appear[s] uncooperative towards them.” He expressed
further concerns, including a statement that participants in the program
did not appear to be receiving “adequate care and protection” and that
qualified and competent counselors were not in charge of the program.
The judge also noted that one of the adult counselors was “an ex-felon and
a fugitive.” After this program closed, the program founder returned to
Utah and joined yet another program where another death occurred 5
years later (this death is detailed in case seven). We found that the founder
of this residential treatment program had a history in the industry—prior
to opening the program discussed in this case, she worked as an
administrator in the program covered in another case (case two). Today,
the program founder is still working in the industry as a consultant,
providing advice to parents who may not know of her history.

Case Two

The victim was a 16-year-old female who had just celebrated her birthday.
According to her mother, in 1990 the victim was enrolled in a 9-week
wilderness therapy program because she suffered from depression and
Page 18

GAO-08-146T

struggled with drug abuse. The victim’s mother obtained brochures from
the program owner and discussed the program with him and other
program staff. According to the mother, the program owner answered all
her questions and “really sold the program.” She told us:
“I understood there would be highly trained
and qualified people with [my daughter] who
could handle any emergency… they boasted
of a 13-year flawless safety record, [and] I
thought to myself ‘why should I worry? Why
would anything happen to her?’”
Believing that the program would help her daughter, the victim’s mother
and stepfather secured a personal loan to pay the $25,600 in tuition for the
program (or about $400 per day). She also paid about $4,415 to have a
transport service come to the family home and take her daughter to the
program. The victim’s mother and stepfather hired the service because
they were afraid their daughter would run away when told that she was
being enrolled in the program. According to the victim’s mother, two
people came to the family home at 4 a.m. to take her daughter to the
program’s location in the Utah desert, where a group hike was already
under way.
Three days into the program, the victim collapsed and died while hiking.
According to the program brochure, the first 5 days of the program are
“days and nights of physical and mental stress with forced march, night
hikes, and limited food and water. Youth are stripped mentally and
physically of material facades and all manipulatory tools.” After the victim
collapsed, one of the counselors on the hike administered CPR until an
emergency helicopter and nurse arrived to take the victim to a hospital,
where she was pronounced dead. According to the victim’s mother, her
daughter died of “exertional heatstroke.” The program had not made any
accommodation or allowed for any adjustment for the fact that her
daughter had traveled from a coastal, sea-level residence in Florida to the
high desert wilderness of Utah. The mother of the victim also said that
program staff did not have salt tablets or other supplies that are commonly
used to offset the affects of heat.
Shortly after the victim died, the 9-week wilderness program closed. A
state hearing brought to light complaints of child abuse in the program and
the owner of the program was charged with negligent homicide. He was
acquitted of criminal charges. However, the state child protective services
agency concluded that child abuse had occurred and placed the owner on

Page 19

GAO-08-146T

Utah’s registry of child abusers, preventing him from working in the state
at a licensed child treatment facility. Two other program staff agreed to
cooperate with the prosecution to avoid standing trial; these staff were
given probation and prohibited from being involved with similar programs
for up to 5 years. In 1994, the divorced parents of the victim split a
$260,000 settlement resulting from a civil suit against the owner.
After this program closed, its owner opened and operated a number of
domestic and foreign residential treatment programs over the next several
years. Although he was listed on the Utah registry of suspected child
abusers, the program owner opened and operated these programs
elsewhere—many of which were ultimately shut down by state officials
and foreign governments because of alleged and proven child abuse. At
least one of these programs is still operating abroad and is marketed on
the Internet, along with 10 other programs considered to be part of the
same network. As discussed above, the program owner in our first case
originally worked in this program as an administrator before it closed.

Case Three

The victim was a 16-year-old male. According to his parents, in 1994 they
enrolled him in a 9-week wilderness therapy program in Utah because of
minor drug use, academic underachievement, and association with a new
peer group that was having a negative impact on him. The parents learned
of the program from an acquaintance and got a program brochure that
“looked great” in their opinion. They thought the program was well-suited
for their son because it was an outdoor program focusing on small groups
of youth who were about the same age. They spoke with the program
owner and his wife, who flew to Phoenix, Arizona, to talk with them. To be
able to afford the program’s cost of about $18,500 (or $263 per day), the
victim’s parents told us they took out a second mortgage on their house.
They also paid nearly $2,000 to have their son transported to the campsite
in the program owner’s private plane. At the time they enrolled their son,
the parents were unaware that this program was started by two former
employees of a program where a teenager had died (this program is
discussed in our second case).
According to the victim’s father, his son became sick around the 11th day
of the program. According to court and other documents, the victim began
exhibiting signs of physical distress and suffered from severe abdominal
pain, weakness, weight loss, and loss of bodily functions. Although the
victim collapsed several times during daily hikes, accounts we reviewed
indicate that staff ignored the victim’s pleas for help. He was forced to
continue on for 20 days in this condition. After his final collapse 31 days
Page 20

GAO-08-146T

into the program, staff could not detect any respiration or pulse. Only at
this time did staff radio program headquarters and request help, although
they were expected to report any illnesses or disciplinary incidents and
had signed an agreement when employed stating that they were
responsible for “the safety and welfare of fellow staff members and
students.” The victim was airlifted to a nearby hospital and was
pronounced dead upon arrival. The 5-foot 10-inch victim, already a thin
boy, had dropped from 131 to 108 pounds—a loss of nearly 20 percent of
his body weight during his month-long enrollment.4
The victim’s father told us that when he was notified of his son’s death, he
could only think that “some terrible accident” had occurred. But according
to the autopsy report, the victim died of acute peritonitis—an infection
related to a perforated ulcer. This condition would have been treatable
provided there had been early medical attention. The father told us that
the mortician, against his usual policy, showed him the condition of his
son’s body because it was “something that needed to be investigated.” The
victim’s father told us he “buckled at the knees” when he saw the body of
his son—emaciated and covered with cuts, bruises, abrasions, blisters, and
a full-body rash; what he saw was unrecognizable as his son except for a
childhood scar above the eye.
In the wake of the death, the state revoked the program’s operating
license. According to the state’s licensing director, the program closed 3
months later because the attorney general’s office had initiated an
investigation into child abuse in the program, although no abuse was
found after examining the 30 to 40 youth who were also enrolled in the
program when the victim died. The state attorney general’s office and a
local county prosecutor filed criminal charges against the program owners
and several staff members. After a change of venue, one defendant went to
trial and was convicted of “abuse or neglect of a disabled child” in this
case. Five other defendants pleaded guilty to a number of other charges—
five guilty pleas on negligent homicide and two on failure to comply with a
license. The defendants in the case were sentenced to probation and
community service. The parents of the victim subsequently filed a civil suit
that was settled out of court for an undisclosed amount.

4

The program consisted of four phases. At the start of the second phase, students were
required to fast for 2 days. During this phase, students slept under tarpaulins and, at the
end of their fast, they were each given a supply of food and told that they were responsible
for cooking and rationing it themselves. This food supply was the same for all participants
and was supposed to last each of them for a week.

Page 21

GAO-08-146T

Case Four

The victim was a 15-year-old male. According to the victim’s mother, in
2000 she enrolled her son in a wilderness program in Oregon to build his
confidence and develop self-esteem in the wake of a childhood car
accident. The accident had resulted in her son sustaining a severe head
injury, among other injuries. After an extensive Internet search and
discussions with representatives of various wilderness programs and
camps for head-injury victims, the mother told us she selected a program
that she believed would meet her son’s needs. What “sold me on the
program,” she said, was the program owner’s repeated assurances over the
telephone that the program was “a perfect fit” for her son. She told us that
to pay for the $27,500 program, she withdrew money from her retirement
account. The program was between 60 to 90 days (about $305 to $450 per
day) depending on a youth’s progression through the program.
The victim’s mother said that she became suspicious about the program
when she dropped her son off. She said that the program director and
another staff person disregarded her statements about her son’s “likes and
dislikes,” despite believing that the program would take into account the
personal needs of her son. Later, she filed a lawsuit alleging that the staff
had no experience dealing with brain-injured children and others with
certain handicaps who were in the program. What she also did not know
was that the founder of the program was himself a former employee of
two other wilderness programs in another state where deaths had
occurred (we discuss these programs in cases two and three). The
program founder also employed staff who had been charged with child
abuse while employed at other wilderness programs.
According to her lawsuit, her son left the program headquarters on a group
hike with three counselors and three other students. Several days into the
multiday hike, while camping under permit on BLM land, the victim
refused to return to the campsite after being escorted by a counselor about
200 yards to relieve himself. Two counselors then attempted to lead him
back to the campsite. According to an account of the incident, when he
continued to refuse, they tried to force him to return and they all fell to the
ground together. The two counselors subsequently held the victim face
down in the dirt until he stopped struggling; by one account a counselor
sat on the victim for almost 45 minutes. When the counselors realized the
victim was no longer breathing, they telephoned for help and requested a
9-1-1 operator’s advice on administering CPR. The victim’s mother told us
that she found out about the situation when program staff called to tell her
that her son was being airlifted to a medical center. Shortly afterwards, a
nurse called and urged her to come to the hospital with her husband. They
were not able to make it in time—on the drive to the hospital, her son’s
Page 22

GAO-08-146T

doctor called, advised her to pull to the side of the road, and informed her
that her son had died. The victim’s mother told us that she was informed,
after the autopsy, that the main artery in her son’s neck had been torn. The
cause of death was listed as a homicide.
In September 2000, after the boy’s death, one of the counselors was
charged with criminally negligent homicide. A grand jury subsequently
declined to indict him. The victim’s mother told us that at the grand jury
hearing, she found out from parents of other youth in the program that
they had been charged different amounts of money for the same program,
and that program officials had told them what they wanted to hear about
the program’s ability to meet each of their children’s special needs. In
early 2001, the mother of the victim filed a $1.5 million wrongful death
lawsuit against the program, its parent company, and its president. The
lawsuit was settled in 2002 for an undisclosed amount.
Due in part to the victim’s death, in early 2002, Oregon implemented its
outdoor licensing requirements. The state’s Department of Justice
subsequently filed a complaint alleging numerous violations of the state’s
Unlawful Trade Practices Act and civil racketeering laws, including
charges that the program misrepresented its safety procedures and
criminally mistreated enrolled youth. In an incident unconnected to this
case, the program was also charged with child abuse related to frostbite.
As a result of these complaints, in February of 2002, the program entered
into agreement with the state’s attorney general to modify program
operations and pay a $5,000 fee. The program continued to work with the
State of Oregon throughout 2002 to comply with the agreement. In the
summer of 2002, BLM revoked the camping permit for the program due, in
part, to the victim’s death. The program closed in December of 2002.

Case Five

The victim was a 14-year-old male. According to his father, in 2001 the
victim was enrolled in a private West Virginia residential treatment center
and boarding school. He told us that his son had been diagnosed with
clinical depression, had attempted suicide twice, was on medication, and
was being treated by a psychiatrist. Because their son was having
difficulties in his school, the parents—in consultation with their son’s
psychiatrist—decided their son would benefit by attending a school that
was more sensitive to their son’s problems. To identify a suitable school,
the family hired an education consultant who said he was a member of an
educational consultants’ association and that he specialized in matching
troubled teens with appropriate treatment programs. The parents
discussed their son’s personality, medical history (including his previous
Page 23

GAO-08-146T

suicide attempts), and treatment needs with the consultant. According to
the father, the consultant “quickly” recommended the West Virginia
school. The program was licensed by the state and cost almost $23,000 (or
about $255 per day).
According to the parents and court documents, the victim committed
suicide 6 days into the program. On the day before he killed himself, while
participating in the first phase of the program (“survival training”), the
victim deliberately cut his left arm four times from wrist to elbow using a
pocket knife issued to him by the school. After cutting himself, the victim
approached a counselor and showed him what he had done, pleading with
the counselor to take the knife away before he hurt himself again.5 He also
asked the counselor to call his mother and tell her that he wanted to go
home. The counselor spoke with the victim, elicited a promise from him
not to hurt himself again, and gave the knife back. The next evening the
victim hung himself with a cord not far from his tent. Four hours passed
before the program chose to notify the family about the suicide. When the
owner of the program finally called the family to notify them, according to
the father, the owner said, “There was nothing we could do.”
In the aftermath of the suicide, the family learned that the program did not
have any procedures for addressing suicidal behavior even though it had
marketed itself as being able to provide appropriate therapy to its
students. Moreover, one of the program owners, whom the father
considered the head therapist, did not have any formal training to provide
therapy. The family also learned that the owner and another counselor had
visited their son’s campsite, as previously scheduled, the day he died.
During this visit, field staff told them about the self-inflicted injury and
statements the victim had made the night before. According to the father,
the owner then advised field staff that the victim was being manipulative
in an attempt to be sent home, and that the staff should ignore him to
discourage further manipulative behavior.
The owners and the program were indicted by a grand jury on criminal
charges of child neglect resulting in death. According to the transcript, the
judge who was assigned to the case pushed the parties not to choose a

5

Cutting is a common practice of superficially cutting oneself to draw attention and is often
associated with adolescent mental health and behavioral issues. It is not considered an
attempt to commit suicide, based on information in the American Psychiatric Association’s
2003 Practice Guidelines for the Assessment and Treatment of Patients with Suicidal
Behaviors.

Page 24

GAO-08-146T

bench trial to avoid a lengthy and complicated trial. The program owner
pleaded no contest to the charge of child neglect resulting in death with a
fine of $5,000 in exchange for dismissal of charges. The state conducted an
investigation into the circumstances and initially planned to close the
program. However, the program owners negotiated an agreement with the
state not to shut down the program in exchange for a change of ownership
and management. According to the victim’s father, the family of the victim
subsequently filed a civil suit and a settlement was reached for
$1.2 million, which included the owners admitting and accepting personal
responsibility for the suicide.
This program remains open and operating. Within the last 18 months, a
group of investors purchased the program and are planning to open and
operate other programs around the country, according to the program
administrators with whom we spoke. As part of our work we also learned
that the program has a U.S. Forest Service permit however, because it has
not filed all required usage reports nor paid required permit fees in almost
8 years, it is in violation of the terms of the permit. We estimate that the
program owes the U.S. Forest Service tens of thousands of dollars,
although we could not calculate the actual debt.

Case Six

The victim was a 14-year-old male. According to police documents, the
victim’s mother enrolled him in a military-style Arizona boot camp in 2001
to address behavioral problems. The mother told us that she “thought it
would be a good idea.” In addition, she told us that her son suffered from
some hearing loss, a learning disability, Attention Deficit Hyperactivity
Disorder (ADHD), and depression. To address these issues her son was
taking medication and attending therapy sessions. According to the
mother, her son’s therapist had recommended the program, which he
described as a “tough love” program and “what [her son] needed.” The
mother said she trusted the recommendation of her son’s therapist; in
addition, she spoke with other parents who had children in the program,
who also recommended the program to her. She initially enrolled her son
in a daytime Saturday program in the spring of 2001 so he could continue
attending regular school during the week. Because her son continued to
have behavioral problems, she then enrolled him in the program’s 5-week
summer camp, which she said cost between $4,600 and $5,700 (between
$131 and $162 per day). Her understanding was that strenuous program
activities took place in the evening and that during the day youth would be
in the shade.

Page 25

GAO-08-146T

Police documents indicate about 50 youth between the ages of 6 and 17
were enrolled in the summer program. According to police, youth were
forced to wear black clothing and to sleep in sleeping bags placed on
concrete pads that had been standing in direct sunlight during the day.
Both black clothing and concrete absorb heat. Moreover, according to
documents subsequently filed by the prosecutor, youth were fed an
insufficient diet of a single apple for breakfast, a single carrot for lunch,
and a bowl of beans for dinner. On the day the victim died, the
temperature was approximately 113 degrees Fahrenheit, according to the
investigating detective. His report stated that on that day, the program
owner asked whether any youth wanted to leave the program; he then
segregated those who wanted to leave the program, which included the
victim, and forced them to sit in the midday sun for “several hours” while
the other participants were allowed to sit in the shade. Witnesses said that
while sitting in the sun, the victim began “eating dirt because he was
hungry.” Witnesses also stated that the victim “had become delirious and
dehydrated… saw water everywhere, and had to ‘chase the Indians.’” Later
on the victim appeared to have a convulsive seizure, but the camp staff
present “felt he was faking,” according to the detective’s report. One staff
member reported that the victim had a pulse rate of 180, more than double
what is considered a reasonable resting heart rate for a teenager.6 The
program owner then directed two staff and three youth enrolled in the
program to take the victim to the owner’s room at a nearby motel to “cool
him down and clean up.” They placed the victim in the flatbed of a staff
member’s pickup truck and drove to the motel.
Over the next several hours, the following series of events occurred.
•

In the owner’s hotel room, the limp victim was stripped and placed into
the shower with the water running. The investigating detective told us
that the victim was left alone for 15 to 20 minutes for his “privacy.”
During this time, one of the two staff members telephoned the program
owner about the victim’s serious condition; the owner is said to have
told the staff person that “everything will be okay.” However, when
staff members returned to the bathroom they saw the victim facedown
in the water. The victim had defecated and vomited on himself.

•

After cleaning up the victim, a staff member removed him from the
shower and placed him on the hotel room floor. Another staff member

6

This is according to information from the U.S. National Library of Medicine, National
Institutes of Health.

Page 26

GAO-08-146T

began pressing the victim’s stomach with his hands, at which point,
according to the staff member’s personal account, mud began oozing
out of the victim’s mouth. The staff member then used one of his feet to
press even harder on the victim’s stomach, which resulted in the victim
vomiting even more mud and a rock about the size of quarter. At this
point, a staff member again called the owner to say the boy was not
responding; the owner instructed them to take the victim back to the
camp. They placed the victim in the flatbed of the pickup truck for the
drive back.
•

Staff placed the victim on his sleeping bag upon returning to camp. He
was reportedly breathing at this time, but then stopped breathing and
was again put in the back of the pickup truck to take him for help.
However, one staff member expressed his concern that the boy would
die unless they called 9-1-1 immediately. The county sheriff’s office
reported receiving a telephone call at approximately 9:43 p.m. that
evening saying a camp participant “had been eating dirt all day, had
refused water, and was now in an unconscious state and not
breathing.” This is the first recorded instance in which the program
owner or staff sought medical attention for the victim. Instructions on
how to perform CPR were given and emergency help was dispatched.

The victim was pronounced dead after being airlifted to a local medical
center. The medical examiner who conducted the autopsy expressed
concern that the victim had not been adequately hydrated and had not
received enough food while at the camp. His preliminary ruling on the
cause of death was that “of near drowning brought on by dehydration.”
After a criminal investigation was conducted, the court ultimately
concluded that there was “clear and convincing evidence” that program
staff were not trained to handle medical emergencies related to
dehydration and lack of nutrition. The founder (and chief executive
officer) of the program was convicted in 2005 of felony reckless
manslaughter and felony aggravated assault and sentenced to 6-year and 5year terms, respectively. He was also ordered to pay over $7,000 in
restitution to the family. In addition, program staff were convicted of
various charges, including trespassing, child abuse, and negligent
homicide but were put on probation. According to the detective, no staff
member at the camp was trained to administer medication or basic
medical treatment, including first aid. The mother filed a civil suit that was
settled for an undisclosed amount of money. The program closed in 2001.

Case Seven

The victim was a 16-year-old female. Because of defiant, violent behavior,
her parents enrolled her in a Utah wilderness and boarding school

Page 27

GAO-08-146T

program in 2001, which was a state-licensed program for youth 13 to 18
years old. The 5 month program cost around $29,000 (or about $193 per
day) and operated on both private and federal land. The parents also hired
a transport service at a cost of over $3,000 to take their daughter to the
program. We found that the director and another executive of this
wilderness program had both worked at the same program discussed in
our second case and the executive owned the program discussed in our
first case.
According to program documents and the statements of staff members, a
group hiking in this program would normally require three staff—one in
front leading the hike, one in the middle of the group, and one at the end
of the group. However, this standard structure had been relaxed on the
day the victim fell. It was Christmas Day, and only one staff member
accompanied four youth. While hiking in a steep and dangerous area that
staff had not previously scouted out, the victim ran ahead of the group
with two others, slipped on a steep rock face, and fell more than 50 feet
into a crevasse according to statements of the other two youth—one of
whom ran back to inform the program staff of the accident. The staff
radioed the base camp to report the accident, then called 9-1-1. One of the
staff members at the accident scene was an emergency medical technician
(EMT) and administered first aid. However, in violation of the program
licensing agreement, the first aid kit they were required to have with them
had been left at the base camp. An ambulance arrived about 1 hour after
the victim fell. First responders decided to have the victim airlifted to a
medical center, but the helicopter did not arrive until about 1-1/2 hours
after they made the decision to call for an airlift.
According to the coroner’s report, the victim died about 3 weeks later in a
hospital without ever regaining consciousness. She had suffered massive
head trauma, a broken arm, broken teeth, and a collapsed lung. As a result
of the death, the state planned to revoke the program’s outdoor youth
program license based on multiple violations. In addition to an
inappropriate staff-to-child ratio (four youth for one staff member, rather
than three to one), failure to prescreen the hiking area, and hiking without
a first aid kit, the state identified the following additional license
violations:
•

Program management did not have an emergency or accident plan in
place.

•

Two of the four staff members who escorted the nine youth in the
wilderness had little experience—one had 1 month of program

Page 28

GAO-08-146T

experience and the other had 9 days. Neither of them had completed
the required staff training.
•

The two most senior staff members on the trip had less than 6 months
of wilderness experience—but they remained at the camp while other
two inexperienced staff members led the hike.

A lawsuit filed by the family in November 2002 claims that the program did
not take reasonable measures to keep the youth in the program safe,
especially given the “hiking inexperience” of the youth and the
“insufficient number of staff.” Specifically, the suit claims that the
program’s executive director waited for an hour before calling assistance
after the victim fell. Additionally, the suit claims that staff only had one
radio and no medical equipment or emergency plan. The parents filed an
initial lawsuit for $6 million but eventually settled in 2003 for $200,000
before attorneys’ fees and health insurance reimbursement were taken
out.
The program closed in May 2002 due to fiscal insolvency. However, its
parent program—a boarding school licensed by the state—is still in
operation. We have not been able to determine whether the wilderness
director at the time of the victim’s death is still in the industry. However,
the other program executive remains in the industry, working as a referral
agent for parents seeking assistance in identifying programs for troubled
youth.

Case Eight

The victim, who died in 2002, was a 15-year-old female. The parents of the
victim told us that she suffered from depression, suicidal thoughts, and
bipolar disorder. She also reportedly had a history of drug use, including
methamphetamines, marijuana, and cocaine. Her parents explained that
they selected a program after researching several programs and consulting
with an educational advisor. Although the program was based in Oregon, it
operated a 3-week wilderness program in Nevada, which was closer to the
family home. The total cost of the program was over $9,200 (or about $438
per day), which included a nonrefundable deposit and over $300 for
equipment.
The parents of the victim drove their daughter several hundred miles to
enroll her in the program. Because of the distance involved, they stayed
overnight in a motel nearby. The next day, when the parents arrived home,
they found a phone message waiting for them—it was from the program,
saying that their daughter had been in an accident and that she was
Page 29

GAO-08-146T

receiving CPR. According to documents we reviewed, three staff members
led seven students on a hike on the first day of the program. The victim fell
several times while hiking. The last time she fell, she lost muscle control
and had difficulty breathing. The EMT on the expedition had recently
completed classroom certification and had no practical field experience.
While the staff called for help, the EMT and other staff began CPR and
administered epinephrine doses to keep her heart beating during the 3
hours it took a rescue helicopter to arrive. The victim was airlifted to a
nearby hospital where she was pronounced dead.
The victim’s death was ruled an accident by the coroner—heat stroke
complicated by drug-induced dehydration. According to other youth on
the hike, they were aware the victim had taken methamphetamines prior
to the hike. The victim had had a drug screening done 1 week before
entering the program; she tested positive for methamphetamine, which the
program director knew but the staff did not. However, the program did not
make a determination whether detoxification was necessary, which was
required by the state where the program was operating (Nevada),
according to a court document. The victim was also taking prescribed
psychotropic medications, which affected her body’s ability to regulate
heat and remain hydrated.
At the time the victim died, this private wilderness treatment program had
been in operation for about 15 years in Oregon. Although it claimed to be
accredited by the Joint Commission on Heath Care Organizations, this
accreditation covered only the base program—not the wilderness program
or its drug and alcohol component in which the victim participated.7
Moreover, even though the wilderness program attended by the victim had
been running for 2 years, it was not licensed to operate in Nevada. The
district attorney’s office declined to file criminal child abuse and neglect
charges against two program counselors, although those charges had been
recommended by investigating officers. The parents of the victim were
never told why criminal charges were never filed. They subsequently filed
a civil lawsuit and settled against the program for an undisclosed sum.
Two other deaths occurred in this program shortly after the first—one

7
According to its Web site, the Joint Commission on Health Care Organizations evaluates
and accredits nearly 15,000 health care organizations and programs in the United States. It
maintains state-of-the-art standards that focus on improving the quality and safety of care
provided by health care organizations. Its comprehensive accreditation process evaluates
an organization’s compliance with these standards and other accreditation requirements.

Page 30

GAO-08-146T

resulted from a previously unknown heart defect and the other from a
fallen tree.
Although the wilderness program had a federal permit to operate in
Nevada, it was not licensed by that state. After the death, that state
investigated and ordered the program closed. The parent company had
(and continues to maintain) state licenses in Oregon to operate as a drug
and alcohol youth treatment center, an outpatient mental health facility,
and an outdoor youth facility, as well as federal land permits from BLM
and the U.S. Forest Service. According to program officials, the program
has modified its procedures and policies—it no longer enrolls youth taking
the medication that affected the victim’s ability to regulate her body
temperature.

Case Nine

The victim was a 14-year-old male who died in July 2002. According to
documents we reviewed, the mother of the victim placed her son in this
Utah wilderness program to correct behavioral problems. The victim kept
a journal with him during his stay at the program. It stated that he had
ADHD and bipolar disorder. His enrollment form indicates that he also had
impulse control disorder and that he was taking three prescription
medications. His physical examination, performed about 1 month before
he entered the program, confirms that he was taking these medications.
We could not determine how much the program cost at the time.
According to documents we reviewed, the victim had been in the program
for about 8 days when, on a morning hike on BLM land, he began to show
signs of hyperthermia (excessively high body temperature). He sat down,
breathing heavily and moaning. Two staff members, including one who
was an EMT, initially attended to him, but they could not determine if he
was truly ill or simply “faking” a problem to get out of hiking. When the
victim became unresponsive and appeared to be unconscious, the staff
radioed the program director to consult with him. The director advised the
staff to move the victim into the shade. The director also suggested
checking to see whether the victim was feigning unconsciousness by
raising his hand and letting go to see whether it dropped onto his face.
They followed the director’s instructions. Apparently, because the victim’s
hand fell to his side rather than his face, the staff member who was an
EMT concluded that the victim was only pretending to be ill. While the
EMT left to check on other youth in the program, a staff member
reportedly hid behind a tree to see whether the victim would get up—
reasoning that if the victim were faking sickness, he would get up if he
thought nobody was watching. As the victim lay dying, the staff member
Page 31

GAO-08-146T

hid behind the tree for 10 minutes. He failed to see the victim move after
this amount of time, so he returned to where the victim lay. He could not
find a pulse on the victim. Finally realizing that he was dealing with a
medical emergency, the staff member summoned the EMT and they began
CPR. The program manager was contacted, and he called for emergency
help. Due to difficult terrain and confusion about the exact location of the
victim, it took over an hour for the first response team to reach the victim.
An attempt to airlift the victim was canceled because a rescue team
determined that the victim was already dead.
According to the coroner’s report, the victim died of hyperthermia. State
Department of Human Services officials initially found no indication that
the program had violated its licensing requirements, and the medical
examiner could not find any signs of abuse. Subsequently, the Department
of Human Services ruled that there were, in fact, licensing violations, and
the state charged the program manager and the program owner with child
abuse homicide (a second degree felony charge). The program manager
was found not guilty of the charges; additionally, it was found that he did
not violate the program’s license regarding water, nutrition, health care,
and other state licensing requirements. Moreover, the court concluded that
the State did not prove that the program owner engaged in reckless
behavior. Later that year, however, an administrative law judge affirmed
the Department of Human Services’ decision to revoke the program’s
license after the judge found that there was evidence of violations. The
owner complied with the judge and closed the program in late 2003. About
16 months later, the owner applied for and received a new license to start
a new program. According to the Utah director of licensing, as of
September 2007, there have been “no problems” with the new program. We
could not find conclusive information as to whether the parents of the
victim filed a civil case and, if so, what the outcome was.

Case Ten

The victim was a 15-year-old male. According to investigative reports
compiled after his death, the victim’s grades dropped during the 2003–2004
school year and he was withdrawing from his parents. His parents
threatened to send him to a boarding or juvenile detention facility if he did
not improve during summer school in 2004. The victim ran away from
home several times that summer, leading his frustrated parents to enroll
him in a boot camp program. When they told him about the enrollment, he
ran away again—the day before he was taken to the program in a remote
area of Missouri. The 5-month program describes itself as a boot camp and
boarding school. Because it is a private facility, the state in which it is

Page 32

GAO-08-146T

located does not require a license. According to Internet documents, the
program costs almost $23,000 (or about $164 per day).
Investigative documents we reviewed indicate that at the time the parents
enrolled the teenager, he did not have any issues in his medical history.
Staff logs indicate that the victim was considered to be a continuous
problem from the time he entered the program—he did not adhere to
program rules and was otherwise noncompliant. By the second day of the
boot camp phase of the program, staff noticed that the victim exhibited an
oozing bump on his arm. School records and state investigation reports
showed that the victim subsequently began to complain of muscle
soreness, stumbled frequently, and vomited. As days passed, students
noticed the victim was not acting normally, and reported that he defecated
involuntarily on more than one occasion, including in the shower. Staff
notes confirmed that the victim defecated and urinated on himself
numerous times. Although he was reported to have fallen frequently and
told staff he was feeling weak or ill, the staff interpreted this as being
rebellious. The victim was “taken down”—forced to the floor and held
there—on more than one occasion for misbehaving, according to
documents we reviewed. Staff also tied a 20-pound sandbag around the
victim’s neck when he was too sick to exercise, forcing him to carry it
around with him and not permitting him to sit down. Staff finally placed
him in the “sick bay” in the morning on the day that he died. By
midafternoon of that day, a staff member checking on him intermittently
found the victim without a pulse. He yelled for assistance from other staff
members, calling the school medical officer and the program owners. A
responding staff member began CPR. The program medical officer called
9-1-1 after she arrived in the sick bay. An ambulance arrived about 30
minutes after the 9-1-1 call and transported the victim to a nearby hospital,
where he was pronounced dead.
The victim died from complications of rhabdomyolysis due to a probable
spider bite, according to the medical examiner’s report.8 A multiagency
investigation was launched by state and local parties in the aftermath of
the death. The state social services’ abuse investigation determined that
staff did not recognize the victim’s medical distress or provide adequate
treatment for the victim’s bite. Although the investigation found evidence
of staff neglect and concluded that earlier medical treatment may have

8

According to the National Library of Medicine, rhabdomyolysis is the breakdown of
muscle fibers resulting in the release of muscle fiber contents into the bloodstream.

Page 33

GAO-08-146T

prevented the death of the victim, no criminal charges were filed against
the program, its owners, or any staff. The state also found indications that
documents submitted by the program during the investigation may have
been altered. The family of the victim filed a civil suit against the program
and several of its staff in 2005 and settled out of court for $1 million,
according to the judge.
This program is open and operating. The tuition is currently $4,500 per
month plus a $2,500 “start-up fee.” The program owner claims to have 25
years of experience working with children and teenagers. Members of her
family also operate a referral program and a transport service out of
program offices located separately from the actual program facility.
During the course of our review, we found that current and former
employees with this program filed abuse complaints with the local law
enforcement agency but that no criminal investigation has been
undertaken.

Mr. Chairman and Members of the Committee, this concludes my
statement. We would be pleased to answer any questions that you may
have at this time.

Contacts and
Acknowledgments

(192250)

For further information about this testimony, please contact Gregory D.
Kutz at (202) 512-6722 or kutzg@gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last page
of this testimony.

Page 34

GAO-08-146T

This is a work of the U.S. government and is not subject to copyright protection in the
United States. It may be reproduced and distributed in its entirety without further
permission from GAO. However, because this work may contain copyrighted images or
other material, permission from the copyright holder may be necessary if you wish to
reproduce this material separately.

GAO’s Mission

The Government Accountability Office, the audit, evaluation, and
investigative arm of Congress, exists to support Congress in meeting its
constitutional responsibilities and to help improve the performance and
accountability of the federal government for the American people. GAO
examines the use of public funds; evaluates federal programs and policies;
and provides analyses, recommendations, and other assistance to help
Congress make informed oversight, policy, and funding decisions. GAO’s
commitment to good government is reflected in its core values of
accountability, integrity, and reliability.

Obtaining Copies of
GAO Reports and
Testimony

The fastest and easiest way to obtain copies of GAO documents at no cost
is through GAO’s Web site (www.gao.gov). Each weekday, GAO posts
newly released reports, testimony, and correspondence on its Web site. To
have GAO e-mail you a list of newly posted products every afternoon, go
to www.gao.gov and select “E-mail Updates.”

Order by Mail or Phone

The first copy of each printed report is free. Additional copies are $2 each.
A check or money order should be made out to the Superintendent of
Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent. Orders
should be sent to:
U.S. Government Accountability Office
441 G Street NW, Room LM
Washington, DC 20548
To order by Phone: Voice:
TDD:
Fax:

(202) 512-6000
(202) 512-2537
(202) 512-6061

Contact:

To Report Fraud,
Waste, and Abuse in
Federal Programs

Web site: www.gao.gov/fraudnet/fraudnet.htm
E-mail: fraudnet@gao.gov
Automated answering system: (800) 424-5454 or (202) 512-7470

Congressional
Relations

Gloria Jarmon, Managing Director, JarmonG@gao.gov, (202) 512-4400
U.S. Government Accountability Office, 441 G Street NW, Room 7125
Washington, DC 20548

Public Affairs

Susan Becker, Acting Manager, BeckerS@gao.gov, (202) 512-4800
U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, DC 20548

PRINTED ON

RECYCLED PAPER