As described in the list of examples above, physical, sexual, and psychological abuse are present at many RFs. The perpetuation of abuse, coupled with insufficient accountability for such behavior, leaves already vulnerable youths subject to re-traumatization and exacerbation of their behavioral and mental health symptoms. As the examples in this report indicate, abuse in RF’s is not limited to any one geographic region of the U.S. or to any one provider.
The abuse of children at RF’s has not been resolved. As mentioned above, as recently as January 2021, a class action complaint was filed against Devereux Advanced Behavioral Health.
P&A reports have significant consequences, so it is critical that they be correct. Procedures have been put into place at each P&A to ensure accuracy. For example, P&A staff have techniques to verify reports of abuse by children, youth, and staff in these facilities. To ensure accuracy in reporting, practiced investigators at ADAP, the Alabama P&A, take the following steps (among others):
- ADAP staff educate children and youth up front about steps used to protect their identities to encourage a sense of security and foster honesty in reporting
- When ADAP staff interview most or all of the children in a particular program, they look for consistencies and inconsistencies in the stories. They ask the same set of questions of all children to establish a consistent baseline. This type of questioning exposes patterns of problematic practices and identifies particular staff who may be engaging in abuse/neglect.
- ADAP staff verify, with proper permission, as much as possible through record reviews, follow up interviews and video surveillance data. For example, when a boy residing in a RF reported being slammed against a wall, ADAP staff initiated an investigation and viewed surveillance video for that day that corroborated his story. When children and youth reported being “football tackled” this technique was consistent with what was reflected on the video footage.
- Investigations are unannounced. ADAP staff interview individual children and youth who live on the same unit as quickly as possible to prevent them from communicating with each other.
- When camera footage is not available, ADAP staff conduct follow up interviews with witnesses and compare incident reports and other documentation to identify similarities in injuries or other aspects of the report.
“I don’t feel safe.”
Physical abuse, often masked as punishment or a control tactic, is not uncommon in RFs. Although some incidents begin as restraint and quickly escalate into physical abuse, children also report more direct examples of physical abuse as well, such as dragging, punching, and throwing or “slamming” them against walls or the floor.
Youth report physically fighting with and inflicting injury on each other in staff members’ absence, while staff members watch, and/or as a result of staff members allowing youths to fight each other. A boy at a RF in Alabama told ADAP that he had bruises after being hit by a peer and did not feel safe at the facility.
Another boy at the same facility said that he was kicked in the face and had to have stitches after a fight with a peer. Other boys described calling out to staff for help but staff was “too old” to respond. In another incident, in which one boy reportedly started beating another boy and staff declined to intervene, other residents reportedly had to pry the boy off his peer. In some instances, children are forced to share rooms with their abusers. In a North Carolina facility, staff placed a child in a room with another resident who had given him a black eye.
Children in RFs across the country report sexual assault at the hands of staff. An investigation by The Imprint and San Francisco Chronicle revealed that staff at Clarinda Academy had been accused of punching, kicking, choking, and sexually assaulting youth at the facility. A male Clarinda staff member reportedly raped a seventeen-year-old girl and pled guilty to sexual misconduct with a juvenile. In 2017, an employee at Three Springs was accused of, and subsequently pled guilty to, having sexual contact with a thirteen-year-old boy. In March 2014, a 29 year-old staff member at Sequel Red Rock Canyon School in Utah was convicted of forcible sexual abuse after abusing three male students at the facility. In January 2018, a 38 year-old staff member of Sequel Northern Illinois Academy pled guilty to three counts of criminal sexual assault on an adolescent over whom he held a position of trust and authority.
According to a year-long investigation by American Public Media Reports, there are at least twenty documented cases since 2010 in which government investigations concluded that Sequel staff engaged in sexual or romantic relationships with residents.
Children in RFs also report sexual violence committed by their peers. Some RFs specialize in treating youth who have been adjudicated as sex offenders. These youth need more supervision, not less. As described below, staff do little to prevent the violence and are slow to interrupt and stop it. At one RF, several boys reported that older boys sexually prey on the younger boys making comments such as: “you better keep that little one from over here or I’ll snatch ‘em up.” Another boy reported that he did not feel safe because boys were “doing sexual stuff” and that one boy “shows his stuff” and touches him inappropriately when the boys are in line. The boy further said that he had reported these incidents to multiple staff on multiple shifts but they do not believe him and thus, the activity continues.
“If your parents really wanted you, y’all would be home.”
Children at two RFs in Alabama report being subjected to a near-constant barrage of verbal abuse from staff. Staff curse, yell, make demeaning and derogatory comments, insult and make fun of the children. They threaten and intimidate them and even instigate arguments among residents and with staff. For instance, at a Sequel facility in Alabama, girls reported being called “f*ng fat,” “f*ng ugly,” “bitch,” stupid,” and “ignorant.” Multiple other girls reported that when they attempted suicide, they were told by staff that they should try again.
A photo box sits beside a bed of a youth living at a RF.
At another Alabama RF, boys similarly reported being called names, being taunted, and being threatened by facility staff. For instance, one boy reported that staff told him to “Get the f* out of my face!” and that caused him to have flashbacks to fights with his dad. Another boy reported that staff told him “you ain’t never gonna be nothing” and “you gonna go to jail.” Another boy said that there were lots of boys harming themselves, trying to commit suicide, trying to elope, fighting, and staff making residents angry on purpose so that staff could restrain them.
RFs may fail to provide appropriate trauma-informed care following incidents of self-harm and suicide attempts/ideations. For example, one boy at the Sequel facility in Alabama reported that he was one of many boys who had tried to kill himself, and that although he had tried to hang himself ten times, he was not able to see his therapist after the suicide attempts.
Restraint and Seclusion
Lakeside Academy, a for-profit RF in Michigan, made headlines in May 2020 when 16-year-old Cornelius Frederick was killed by staff during a restraint. Cornelius died of asphyxiation after two Sequel staff members sat on his chest and abdomen for nearly ten minutes while he cried that he could not breathe. A third Sequel staff member allegedly witnessed the abuse but did not intervene or seek help for Cornelius. According to a state report, staff restrained Cornelius simply because he threw a sandwich.
In June 2020, the three staff members were charged with causing Cornelius’s death. The two workers who restrained Cornelius were charged with the felony offense of involuntary manslaughter as well as with two counts of child abuse. The third staff member was charged with one count of involuntary manslaughter and one count of child abuse after failing to seek, obtain, or follow through with timely medical care after witnessing the restraint. The restraint was captured by video footage that, according to a lawsuit filed on behalf of Cornelius’s aunt, showed the staff “placing his/her weight directly on [Cornelius’s] chest for nearly 10 minutes as [he] lost consciousness.” According to the Office of the Medical Examiner in Kalamazoo, MI, Cornelius Frederick died within two days following cardiac arrest, and his death was determined to be a homicide resulting from “restraint asphyxia.”
Michigan Department of Health and Human Services (MDHHS) investigated his death and found ten licensing violations at Sequel Lakeside. The MDHHS Division of Child Welfare Licensing subsequently began the process of revoking the facility’s license. In June of 2020, the Governor of Michigan ordered MDHHS to ensure that Sequel is not providing services at any facility licensed by the department.
Facilities use a variety of physical holds or physical restraints. The majority of crisis intervention programs provide training on physical holds in one or more of the following areas: (a) protection and release, (b) physical escorts, (c) standing restraints, (d) seated restraints, and (e) prone (face-down) floor restraints. Providers often use euphemisms to describe restraint and seclusion practices, such as “therapeutic holds” and “reflection rooms.”
Federal regulations, called the Conditions of Participation (CoP), specify the manner in which Medicaid funds may be used in PRTFs that receive Medicaid. The CoP’s identify three general types of restraint:
- “Mechanical restraint” is “any device attached or adjacent to the resident’s body that he or she cannot easily remove that restricts freedom of movement or normal access to his or her body.”
- “Personal restraint” is “the application of physical force without the use of any device, for the purpose of preventing free movement of a resident’s body. The term personal restraint does not include briefly holding without undue force a resident in order to calm or comfort him or her, or holding a resident’s hand to safely escort them from one area to another.”
- “Drug used as a restraint” is “any drug that (1) [i]s administered to manage a resident’s behavior in a way that reduces the safety risk to the resident or others; (2) [h]as the temporary effect of restricting the resident’s freedom of movement; and (3) [i]s not a standard treatment for the resident’s medical or psychiatric condition.”
- “Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior.”
The CoP permit restraints only as an intervention of last resort, and only in an emergency safety situation to prevent a resident from harming themself or others. The CoP explicitly prohibit any form of restraint used as a means of coercion, discipline, convenience, or retaliation. Further, restraints must be “performed in a manner that is safe, proportionate, and appropriate to the severity of the behavior, and the resident’s chronological and developmental age; size; gender; physical, medical, and psychiatric condition; and personal history (including any history of physical or sexual abuse)” and must not result in harm or injury to the resident.
The decision to use restraint or seclusion must be an individualized determination made based on the context and facts at the moment to ensure the safety of the resident or others and must cease once safety can be ensured. Additionally, states may have their own laws which regulate the use of certain types of interventions. In some cases, state laws may be more limiting than federal law.
Due to their specific Medicaid/funding restrictions PRTFs, which are a specific type of RF, must abide by the CoP. However, data obtained from Serious Occurrence Reports, which PRTFs are required to complete in some circumstances, and on-site monitoring visits by P&A investigators demonstrate that some PRTFs fail to follow these requirements and are overly reliant on restrictive and dangerous interventions such as restraints and seclusion.
P&As report that providers justify the use of seclusion and restraint as necessary, therapeutic techniques that ultimately reduce undesirable behaviors. However, there is no validated research to support such claims; rather, study after study demonstrates the detrimental effects of using seclusion and restraints.
Physical harm is common during restraint. As discussed below, restraint is rarely, if ever, a non-violent event in which the risk of injury is minimal. For example, North Carolina regulators cited a PRTF for violations of the CoP when a staff member’s attempt to implement a restraint resulted in the fracture of a child’s orbital bone.
At another PRTF, the regulators documented:
|A door at an RF with damage.
“[LPN], Nurse: 7/16/2020: Nurse, [LPN] reported that on 7/13/2020 around 8:30pm, she observed [Client #1] hitting the wall and as a result [Staff #1] and [Staff #2] attempted to place [Client #1] in a therapeutic hold; to prevent [Client #1] from harming herself. The therapeutic hold was improperly performed; as [Client #1] hit and kicked staff ([Staff #1 and Staff #2]) to avoid being placed in a restraint. The therapeutic hold failed as [Staff #1], [Staff #2] and [Client #1] fell to the floor; after they fell, [Client #1] grabbed and pulled [Staff #1’s] hair. While on the floor [Client #1] continued to kick and yelled out, she was unable to breathe and for [Staff #1] to remove her knee from her face. Nurse, [LPN] began to assist by placing her hand in [Client #1’s] hand to release [Staff #1’s] hair from [Client #1’s] hand as she continuously asked [Staff #1] to remove her knee from [Client #1’s] neck. [LPN] then was able to remove [Staff #1’s] hair from [Client #1’s] hand and [Staff #1] was able to remove herself from [Client #1]”
After the incident, Client #1 was assessed and had injuries that included reddened areas on the left side of the upper body, neck and chin and swelling, swelling/redness to right 2nd, 3rd and 4th finger, discomfort to left thumb and bruising/discoloration on left upper arm.
Trauma is perhaps the most common of the adverse effects of seclusion or restraint. Trauma is “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” During the traumatic event, youth may experience terror or helplessness; they may vomit, have a racing heart, or lose control of their bladder. The event can be frightening, as one or more adults hold the youth against his will, or drag her into a seclusion room. The situation may become further complicated as the youth, already operating at a high level of arousal, reverts to the “fight or flight” instinct and may be unable to calm themselves or process verbal directives from staff. This may result in new, ineffective and dangerous control behaviors by the staff when the youth does not comply, respond, or otherwise behave as desired by staff.
As is found in P&A monitoring described in this report, facilities continue to rely on restraint to manage and modify behavior in residential settings. A study from 2005 estimated the cost of one episode of restraint to be $302 – $354 based on a time/motion/task analysis. These funds could be better spent hiring and retaining qualified behavior specialists to provide treatment to the children placed in RFs, instead of relying on traumatizing, dangerous interventions that cause injury to children and staff.
Prone restraint is a physical restraint during which an individual is forcefully moved from standing to lying face down on the ground. Two or more staff will then secure the arms and legs of the individual and hold him or her face down until calm. Staff initiating prone restraint are told to avoid putting pressure on the individual’s back as this can “inhibit breathing due to postural asphyxia, a form of asphyxia that occurs when one’s position prevents them from breathing adequately.” The use of prone restraint in particular has been discredited over the last decade as incidents of severe injury or death have occurred with prone restraint. Such incidents have been documented recently in several high-profile cases, such as those of Cornelius Frederick and George Floyd.
Due to the dangers associated with this type of restraint, more than 30 states have already banned the use of prone restraints in public schools; yet many states have yet to extend protections to children and youth in facilities. For example, in 2011, the Tennessee legislature signed into law the Tennessee Special Education Behavioral Supports Act which aims to reduce restraint and isolation in public schools through encouraging the utilization of functional behavior assessments and behavior intervention plans to mitigate complex challenging behaviors. However, this law does not apply to special education- eligible children in residential facilities, even if they attend a school licensed by Tennessee’s Department of Education.
State Examples of Restraint and Seclusion
During an extensive monitoring visit over multiple days at a for-profit RF in Alabama, the P&A received numerous reports of violent and illegal restraints. One boy described his head being caught on a nail in the wall during a restraint; another said he was picked up and slammed on his stomach onto the concrete. A boy who had visible gashes to his head said that facility staff had slammed him against a wall the previous night. Another boy reported being “football tackled” by staff after kicking a door.
At another for-profit RF in Alabama, girls reported similar incidents to the P&A. One girl reported that male staff repeatedly enter girls’ bedrooms (where there are no cameras) and put them in violent “containments.” Another girl reported that when she refused to sleep in the hallway, she was forcibly dragged out of her room, thrown on the floor and then up against a wall, and suffered injuries to her head. A third girl reported that facility staff forced her against a wall for making a comment to a staff member. The girl attempted to defend herself but the “staff member picked her up, slammed her onto the ground, and placed his weight on her by putting his knee into her back, causing significant pain and trouble breathing.” The staff member “did not relent until forced off her back by other staff.” The incidents reported by these children are physically abusive.
A recertification survey completed in December 2019 by the Illinois Department of Public Health revealed that Northern Illinois Academy (NIA) in Chicago, a Sequel facility, was, among other findings, not in compliance with the CoP regarding restraint use. As a result, the Washington County Department of Children, Youth, and Families reported a halt on referrals to Sequel facilities stating “the deficiencies are so serious that they constitute an immediate threat to patient health and safety.” As of September 2020, Washington still had three children placed in Sequel Northern Illinois Academy.” Washington placed the children and youth ignoring the warnings.
Equip for Equality (EFE, the Illinois P&A) filed a late 2020 complaint to the State about on-going concerns at Northern Illinois Academy and the State asked EFE to conduct a complete review of the facility, which EFE commenced in early 2021. At that time, there were a total of 72 children/youth there, of whom about 10 were from out-of-state. EFE completed a comprehensive report that included concerning findings about youth safety, restraint, seclusion, and quality of treatment. This report was central to Illinois’ decision to remove all state and locally funded youth from the facility and subsequently Northern Illinois Academy was completely closed by early August 2021.
Disability Rights Washington and Iowa, the P&As in those states, conducted joint monitoring visits to the Clarinda Academy in Iowa, and DRWA completed a subsequent systemic investigation. Children at Clarinda, a for-profit RF, reported excessive and inappropriate physical restraint on a daily basis. Several children reported that staff “just drop you.” Another child reported being grabbed and forced to sit on the ground in a forward folded position so that the child’s head hit the ground and the child’s glasses broke.
Prior to Cornelius Frederick’s death, Sequel had come under scrutiny for improperly using restraint and had previously stated that it would integrate training on proper restraint methods, such as Ukeru. Yet, despite Sequel’s promises of proper training, its staff have violated the Ukeru guidelines. For example, during the restraint that led to Cornelius’s death, one staff member got off the boy to retrieve a Ukeru pad, and then propped it against a nearby table while the boy asphyxiated under body weight restraint.
Disability Rights Ohio (DRO), after receiving disturbing reports of physical abuse by staff, peer-on-peer bullying, and bullying by staff, conducted a nine-month investigation at a for-profit PRTF. Children at the facility reported that “[t]hey (staff) put their elbows in our jaws and tell us to stop talking . . . Our arms are up in such a way that they can get broken or our shoulders pop out of place . . . Staff throw kids against walls.” Facility leadership informed DRO that staff were going to be trained on safer, trauma-informed crisis management. When DRO visited the facility five months later, staff expressed confusion about training and said “it’s not being used yet.”
Alternatives to Restraint
Restraints are not the only way, nor are they the best way, to improve youth behavior and ensure safety. According to the Center for Clinical Standards and Quality, there are a number of less intrusive and low/cost-free strategies and approaches that can be implemented to mitigate the need for emergency intervention. Preventative, or antecedent-based, interventions focus on arranging the child’s environment to reduce the likely occurrence of a challenging behavior. Antecedent-based interventions can include creating structured routines and schedules, modifying the setting to reduce identified triggers, embedding personal interests in tasks to increase engagement, avoiding demands that may elicit challenging behaviors, and offering choice. Additionally, residential programs that have had success in reducing the use of restraint and isolation also employ additional strategies such as implementation of training curricula to promote change in practice such as models of care, crisis prevention, or dispute resolution; creation of a stronger system of staff supervision; and use of compensation or incentives to encourage staff to obtain additional training.
The safety of children and youth is jeopardized when staff do not report data in compliance with legal requirements. As described below, staff may fail to document and report the use of restraint or seclusion as they are required to do or may fail to document all of the required information, such as the time the intervention began and ended, or key details of the emergency situation that led to the use of seclusion or restraint. This information is key to an effective post restraint review, one that prevents the need for future restraints, and evaluates the need for policy and training reform.
Disability Rights North Carolina, the P&A for that state, found that for-profit RFs fail to submit the required Serious Occurrence Reports (SORs) to the P&A and/or state regulatory agency. A 48-bed for-profit PRTF in North Carolina was cited three times in a six-month period for failing to submit SORs to DRNC. The North Carolina State Survey Agency identified nearly 900 instances of seclusion or restraint at the PRTF over the course of one year (870 in the one-year period and 1000 in one year and a quarter).
Overuse and Misuse of Psychiatric Medication
P&As have found instances of overuse and misuse of psychiatric medication during monitoring visits at both youth residential facilities and also at for-profit psychiatric hospitals that treat children. As described below, these are not “one off” circumstances and have the potential to cause great harm to children.
The American Academy of Child and Adolescent Psychiatry’s guidelines to providers describing best practices for prescribing psychiatric medication to children and adolescents recommends that psychotropic medications and polypharmacy for children and youth be used only in limited circumstances. Although the Food and Drug Administration (FDA) has approved some psychotropic medications for use in youths, many psychotropic medications prescribed to children are not approved for use in young age groups. Psychotropic medications also pose unique health risks to children because young people lack the liver and kidney capacity required to metabolize psychotropic medications.
The long-term effects of psychotropic medication use in youth are largely unknown, and the limited studies that have been conducted tend to connect psychotropic medication use in youth to increased health problems into adulthood.
|A mattress sits in the corner of a large room at an RF
Antipsychotics, a dangerous class of psychotropic drugs, are particularly harmful to youth. The cardiovascular metabolic effects and central nervous system depression associated with antipsychotics can cause life-threatening conditions in youths. For example, a 2018 study linked administration of a high dosage of antipsychotic drugs to a significantly increased risk of sudden unexplained death for children and youth. Data also suggest that youth experience the known adverse effects of antipsychotics more than adults.
Medications prescribed and used for “off-label” purposes have not specifically been approved by the FDA to treat the particular conditions for which they may be prescribed; they have not undergone the same clinical trial procedures as medications approved for specific purposes. The side effects and overall safety of off-label drugs are therefore less certain. The immediate and long-term risks associated with uncertainty about a drug’s safety are heightened for children and youth, as data on use of these drugs in youth are largely lacking as compared to data for adults. Yet, off-label drug use represents approximately 50-75% of all pediatric medication use, including for psychotropic medications.
Polypharmacy, or the use of multiple medications on one patient, is associated with adverse effects and poor health outcomes because of an increased risk of dangerous drug interactions and other harmful side effects. The potential dangers of polypharmacy are heightened by off-label drug use. Children at for-profit RFs have reported instances in which staff administer the same polypharmacy medication regimen to all residents, regardless of individual mental or behavioral health conditions and needs.
Youth are at a higher risk for adverse effects of polypharmacy than adults, and youth under age 10 are particularly vulnerable. Despite the adverse health risks, polypharmacy use in children has increased dramatically over the last three decades.
Careful screening, assessment, and individual care planning for each patient constitute the foundation of effective treatment of mental and behavioral health challenges. The safe administration of psychotropic medication to children requires medical oversight, treatment planning and health monitoring, before, during, and after the time period in which medications are used. Oversight of children’s health enhances continuity of care, increases placement stability, decreases the incidence of adverse drug reactions and polypharmacy interactions, and can decrease the need for psychiatric hospitalization.
Regular lab testing is a fundamental component of medical oversight. Lab tests can reveal the effects a medication may be having on the body, including changes in hormones, weight, electrolytes, and organ function. Because the risks of adverse side effects from psychotropic medication increase with polypharmacy, and polypharmacy can result in dangerous or deadly drug interactions, it is vital that physicians have current information about a patient’s medication regimen and treatment history.
Seroquel is an atypical antipsychotic approved by the FDA to treat schizophrenia, bipolar disorder, and depression. After Seroquel’s initial FDA approvals, manufacturer AstraZeneca illegally marketed off-label use of the medication, targeting physicians who did not treat the conditions for which Seroquel was clinically approved. Instead, AstraZeneca targeted marketing efforts at physicians who treat the elderly, primary care physicians, and adolescent and pediatric physicians in long-term care facilities, and in prisons. The company, without clinical evidence, promoted Seroquel’s use in treating aggression, anger management, anxiety, insomnia, attention deficit hyperactivity disorder, and other conditions. In its marketing efforts, the company also engaged doctors to promote Seroquel, conduct studies on unapproved uses of Seroquel, and to serve as authors on studies promoting Seroquel in which the “authoring” doctors were not involved.
Although declared illegal by the Unites States government, Seroquel continues to be commonly prescribed for multiple off-label uses, including the treatment of insomnia. In recent years, the medical community has grown increasingly concerned about the off-label prescription of antipsychotics, and Seroquel in particular, due to limited evidence supporting its off-label use and its potentially damaging side effects.
Use of Seroquel as an emergency intervention indicates the use of the medication as a control rather than clinical measure, as the clinical benefits of Seroquel take weeks to months to be effective. Facilities administer Seroquel to children to control their sleep patterns, their energy levels, or in response to specific behavioral incidents.
Disability Rights Tennessee (DRT), observed the practice of increasing children’s Seroquel dosage in an RF as an “emergency psychotropic intervention,” despite Seroquel’s lack of immediate impact. In one facility, staff increased a child’s Seroquel dosage from 50 mg to 300 mg as an emergency intervention.
Disability Rights North Carolina (DRNC) has identified similar problematic uses of Seroquel by for-profit youth RFs. DRNC found in reviewing state records that staff had administered Seroquel numerous times to a child who did not have any diagnoses that would indicate use of antipsychotics. In this instance, the RF only administered Seroquel to the child while she was physically restrained, indicating the medication’s use as a chemical restraint rather than as treatment. “As needed” prescriptions (often called in medical records as PRN for “pro re nata,” meaning “whenever necessary.”) can lead to a failure to properly document the administration of Seroquel and other such medications to children. For example, the same North Carolina facility was also cited for ordering multiple dosages (50mg and 150mg) of Seroquel on the same day without any documentation of the medication’s administration. In fact, the use of medication for the purposes of restraint and/or behavioral control is so ubiquitous that children and youth have a name for it: “Booty Juice.”
In 2019, Oregon and Montana state agencies investigated Montana’s Acadia facility and uncovered significant and multiple incidents involving chemical restraint. Oregon has placed children at the facility.
For years, one facility in Alabama employed a practice called “Group Ignorance” (GI). Group ignorance, in essence, is shunning—a practice sure to diminish a child’s sense of dignity and self-worth. According to the facility’s resident handbook, girls on GI cannot “interact with peers and [are] required to remain 10 feet from all residents at all times.” Girls are allowed to interact with peers only during participation in billable services such as basic living skills instruction and therapist-led group therapy. Girls are not allowed to engage in “small talk” with staff, and even therapeutic discussions with staff “must be minimal—only enough to support/encourage the resident.” While in the common area, girls must sit in a chair facing the wall. Residents who interact with another girl on GI risk being placed on GI themselves. Girls at that facility reported to ADAP that they had been on GI for months at a time. One girl, with a history of self-harm, reported to ADAP staff that she attempted suicide in a facility bathroom as a result of her extreme emotional distress from being on GI.
Many RFs also use convoluted point/level systems that residents must work their way through and complete before being eligible to leave. Each youth accumulates points with good behavior, moving up levels that become progressively less restrictive, or loses points with behavioral violations, moving down levels that become more restrictive. These systems are punitive in nature and facility staff often arbitrarily withhold or threaten to withhold points/treats/outings as a means of coercion and punishment.
Two surveillance cameras in a common room of an RF
There are several problems with this technique as applied to children and youth with certain disabilities. First, children and youth are placed at these facilities for mental health treatment needs which ostensibly cannot be met in the community. Many of their behaviors are manifestations of their disabilities and are not within their control without treatment. As such, it is discriminatory to apply a point and level system to the behaviors that are the basis for the referral. In fact, some for-profit RFs hold themselves out as providing specialized treatment for children with complex mental health treatment needs; they exist to serve precisely this population of children. In addition, point and level systems are often highly subjective and unevenly applied in practice, so a youth may apply substantial effort toward a goal that is ever shifting.
Education is a critical component of the child’s placement at a RF, to ensure that children depart from the facility without stunted educational growth and are fully prepared for integration back into a community school.
P&As report very limited education resources in some facilities. For example, residents complain about receiving the same educational instruction and assignments regardless of age or grade level. Some youths report that they are unable to obtain academic credit for education completed at RFs, putting them at a significant disadvantage upon return to their communities.
Although they receive hundreds of dollars per child per day, some for-profit RFs pay facility employees as little as $11-$15 per hour, and often provide no employment benefits. Staff members who provide mental health services—the fundamental purpose of the RFs—may be manifestly unqualified for their positions. Michigan and Kansas have cited for-profit RFs for maintaining multiple staff members, including people hired as nurses, who lack qualifications for their assigned duties. In one for-profit RF, a counselor was originally hired as a cook and lacked documentation of any training that qualified them to provide counseling services.
In one for-profit facility, children rarely saw a therapist or psychiatrist and were often forced, in violation of their rights, to jointly attend the few therapy sessions that were offered.
Some facilities have staff-to-resident ratios that do not comport with state policies. In recent years, there have been instances of children and youth dying by suicide or self-harm in facilities that were understaffed at the time. As mentioned, there have been reports of youth-on-youth assault that are the result of minimal staff intervention.
Inadequate staffing levels have led to multiple instances of youth eloping from (leaving the facility without the knowledge of staff) RFs; however, the justification for placement of some children and youth into RFs in the first place is their repeated elopement from home or foster care placement. According to a database of emergency calls from Sequel facilities, there were more than 1,000 reports of residents eloping from Sequel treatment centers since 2010.
P&As discovered for-profit RFs in Alabama and North Carolina that do not maintain adequate living conditions for their residents. Youth were found to lack adequate access to clean water and proper sanitation and have limited recreational space. ADAP investigated one such for-profit RF. There residents on one unit reported that they could only access drinking water in the bathroom with staff permission and that some reported that they were inadequately fed. ADAP investigators also documented decrepit facility structures, and received reports of insects and vermin present throughout the facilities.
ADAP investigators noted blood and feces on the walls and floors of the residence halls during a monitoring visit, and the very same blood and feces on the next visit which remained uncleaned and unaddressed despite ADAP’s clear prior report to facility staff and administrators. Additionally, youth were forced to sleep on concrete slabs and almost exclusively sit on the floor, as the limited seating options in the facility were reserved for staff use.
Complaints about food adequacy (as separate from food quality or taste) were reported during monitoring visits. Rather than gaining weight, as would be developmentally typical for the growing bodies of adolescents, children at for-profit RFs report losing weight. One example: at Canyon Hills Treatment Facility, a for-profit RF in North Carolina, at least one-third of residents lost weight after they were admitted for treatment. The staff member in charge of purchasing food at Canyon Hills reported that the food budget had to be reduced. In response to insufficient food portions, reported by both residents and nurses at the facility, one resident circulated a unanimously-signed petition for larger portions and better food. After residents gave the petition to staff, Canyon Hills reduced their food portions as punishment. A nurse reportedly told one resident that the facility intentionally gives patients “a little bit of food” because “your stomach will shrink and then you will not be hungry.” North Carolina threatened to shut down Canyon Hills in recent years due to numerous reports of abuse, but the facility remains open as of September 2021.
Some for-profit RFs have not adequately followed COVID-19 precautions, resulting in a large proportion of residents and many staff testing positive for the virus in those facilities. For example, in a for-profit RF in New Jersey, every resident and 86% of staff tested positive for COVID-19 at one point in 2020. Sequel had at least two other major COVID-19 outbreaks in 2020, with 41 residents and 13 staff testing positive at a Michigan facility and 123 people testing positive at an Arizona facility.
Sequel’s website indicates that all Sequel facilities are following COVID-19 precautions, such as enhanced cleaning and sanitation protocols, using mandatory screening tools for residents and employees, and limiting access to/from residential programs for visitors and residents. Sequel states that many of these precautions have been in place since January 2020, and the company has continued to admit residents throughout the pandemic. However, a Michigan investigation revealed that at least one Sequel facility did not follow Sequel’s written emergency procedure for COVID-19 screening, including not screening the Michigan Health Department investigators themselves upon their arrival to the facility.
 See Class Action Complaint & Demand for Jury Trial, Jines et al. v. The Devereux Found. et al., No. 2:21-cv-00346 (E.D. Pa. Jan. 26, 2021).
 This statement was repeated over and over by boys at a Sequel PRTF in Alabama. See Monitoring Report for Sequel Youth and Family Services of Courtland, Ala. Disabilities Advoc. Program, pp. 2-3, and app. 1 (July 2, 2020) (hereinafter “ADAP”).
 See July 6, 2020 Letter of Concern from ADAP, Children’s Rights, and Southern Poverty Law Center to the Commissioners of the Alabama Department of Human Resources, Alabama Department of Mental Health, Alabama Medicaid Agency, and Alabama Department of Public Health, p. 4, https://adap.ua.edu/uploads/5/7/8/9/57892141/letter_to_state_re_sequel.pdf (hereinafter “ADAP Letter of Concern”).
 See ADAP, note 74, at app. 1, p. 1-4.
 ADAP, note 74, at app. 1, p. 1.
 Id. at app.1, p.3.
 Fred Clasen-Kelly, Kids in NC psych center abused, fed so little ‘your stomach will shrink,’ report says, Charlotte Observer (Nov. 13, 2018), https://www.charlotteobserver.com/news/local/article221541035.html.
 Located in Iowa, Clarinda closed its doors in early 2021.
 Joaquin Palomino, Sara Tiano & Cynthia Dizikes, After abuse probe, another Sequel-run program that housed California youth will close, Laredo Morning Times, Feb. 8, 2021 (available at https://www.lmtonline.com/bayarea/article/After-abuse-probe-another-Sequel-run-program-15934785.php).
 Hannah Rappleye, Eric Salzman and Kate Snow, ‘They Told Me It Was Going To Be A Good Place’: Allegations Of Abuse At Home For At-Risk Kids, NBC News (Mar. 26, 2019), https://www.nbcnews.com/news/us-news/they-told-me-it-was-going-be-good-place-allegations-n987176.
 An Alabama PRTF owned by Sequel.
 Ashley Remkus, Former Three Springs Worker Sentenced For Sexual Contact With 13-Year-Old, AL.COM (Aug. 20, 2020), https://www.al.com/news/2020/08/former-three-springs-worker-sentenced-for-sexual-contact-with-13-year-old.html.
 Mori Kessler, Former youth worker sentenced in sex abuse case, St. George News, Jun. 2014 (available at https://www.stgeorgeutah.com/news/archive/2014/06/05/mgk-former-youth-worker-sentenced-sex-abuse-case/#.YWB4-UZKj0r); see also Multi-Million Fines Insufficient to Curb Abuse in For-Profit Behavioral Health Industry, Citizens Commission on Human Rights, Florida.
 Hannah Leone, Aurora residential facility employee charged with sex assault of minor staying at center, The Beacon-News, Jan. 9, 2018 (available at https://www.chicagotribune.com/suburbs/aurora-beacon-news/ct-abn-sex-assault-residential-facility-st-0109-20180109-story.html); see also Man gets 10 years for sexual assault of resident at juvenile health facility, FOX 32 Chicago, Feb. 22, 2019 (available at https://www.fox32chicago.com/news/man-gets-10-years-for-sexual-assault-of-resident-at-juvenile-health-facility); see also Multi-Million Fines Insufficient to Curb Abuse in For-Profit Behavioral Health Industry, Citizens Commission on Human Rights, Florida.
 Lauren Dake and Curtis Gilbert, The Bad Place, APM REP. (Sept. 28, 2020), https://www.apmreports.org/story/2020/09/28/for-profit-sequel-facilities-children-abused
 See: Residential Treatment Programs for Youth | Youth Residential Treatment Centers (available at https://www.sequelyouthservices.com/residential-treatment-programs-for-youth/) (“Sequel’s staff-secure residential academies offer a broad continuum of specialized treatment options including: long-term residential treatment for chronic delinquent males and females, short-term residential treatment for males and females, sexual offender treatment for males, therapeutic group homes, alternative day schools, and shelter care.”)
 ADAP, note 74, app.1, p.3.
 This remark was made by staff to girls at a Sequel Facility in Alabama and is illustrative of emotionally hurtful comments regularly made by staff at the facility. See ADAP Letter of Concern, note 15, at 6.
 See generally ADAP, note 74; see also generally ADAP Letter of Concern, note 15.
 See ADAP Letter of Concern, note 15, at 6.
 See ADAP, note 74, at 3, and app. 1.
 Id., at app. 1, p.4
 Id. at app.1, p. 2.
 ADAP, note 74 at app. 1, p. 2.
 See ADAP, note 74, at 3, and app.1, at 2; see also ADAP Letter of Concern, note 15, at 6.
 ADAP, note 74, at app. 1, at 2.
 See Christine Hauser & Michael Levenson, Three Charged in Death of Michigan Teenager Restrained at Youth Academy, The N.Y. Times, Jun. 24, 2020 (available at https://www.nytimes.com/2020/06/24/us/cornelius-frederick-lawsuit-lakeside-academy.html); see also 3 Charged with Manslaughter for Death of Teen at Kalamazoo Youth Home, 13 On Your Side (June 24, 2020 6:24PM), https://www.wzzm13.com/article/news/local/kalamazoo/three-charged-with-manslaughter-for-the-homicide-of-cornelius-fredericks-at-kalamazoo-youth-home/69-a80c97ae-d39f-4745-95ce-7e3067b10cc5.
 See id.
 Dustin Dwyer, ‘It’s still not right.’ An investigation into Lakeside Academy, NPR Michigan (Sept. 24, 2020) https://www.michiganradio.org/post/its-still-not-right-investigation-lakeside-academy.
 3 Charged with Manslaughter for Death of Teen at Kalamazoo Youth Home, 13 On Your Side (June 24, 2020 6:24PM), https://www.wzzm13.com/article/news/local/kalamazoo/three-charged-with-manslaughter-for-the-homicide-of-cornelius-fredericks-at-kalamazoo-youth-home/69-a80c97ae-d39f-4745-95ce-7e3067b10cc5.
 Christine Hauser & Michael Levenson, Three Charged in Death of Michigan Teenager Restrained at Youth Academy, The N.Y. Times, Jun. 24, 2020 (available at https://www.nytimes.com/2020/06/24/us/cornelius-frederick-lawsuit-lakeside-academy.html).
 State of Michigan, June 20, 2020, https://www.michigan.gov/whitmer/0,9309,7-387-90499_90640-532682–,00.html
 Couvillon, M., Peterson, R., Joseph, R., Schauermann, B., & Stegall, J. (2010). A review of crisis intervention training programs for school. TEACHING exceptional Children, 42(5), 6-17. Retrieved from https://journals.sagepub.com/doi/10.1177/004005991004200501.
 Medicaid, a federal medical insurance program, funds a high percentage of RF placements.
 42 C.F.R. § 483.352.
 42 C.F.R. § 482.13(e)(1)(ii); See also 42 C.F.R. § 483.352.
 42 C.F.R. § 483.356.
 42 C.F.R. § 483.356(a)(1).
 42 C.F.R. § 483.356(b).
 42 C.F.R. § 483.356(a)(3).
 42 C.F.R. § 483.356(a)(2). Federal regulation prohibits standing orders for the use of restraint and seclusion; 42 C.F.R. § 483.356(a)(3)(i) – (ii).
 42 C.F.R. § 483.374. Facility reporting requirements.
 PRTFs are a unique type of RF. See glossary above.
 42 C.F.R. § 483.374(b).
 “The foundation of any discussion about the use of restraint and seclusion is that every effort should be made to structure environments and provide supports so that restraint and seclusion are not necessary. As many reports have documented, the use of restraint and seclusion can, in some cases, have very serious consequences, including, most tragically, death. There is no evidence that using restraint or seclusion is effective in reducing the occurrence of the problem behaviors that frequently precipitate the use of such techniques.” U.S. Department of Education Restraint and Seclusion: Resource Document, p. 2, May 2012 (https://sites.ed.gov/idea/files/restraints-and-seclusion-resources.pdf)
 NC Div. of Health Serv. Regulation, Survey of Jackson Springs Treatment Center (June 23, 2020) (https://info.ncdhhs.gov/dhsr/mhlcs/sods/2020/20200706-080669.pdf).
 NC Div. of Health Serv. Regulation., Statement of Deficiencies and Plan of Correction, p. 10-11 (Aug. 14, 2020); (https://info.ncdhhs.gov/dhsr/mhlcs/sods/2020/20200825-060869.pdf)
 See e.g., SAMSHA, Trauma and Violence (08/02/2019) available at: https://www.samhsa.gov/trauma-violence/seclusion (“Studies have shown that the use of seclusion and restraint can result in psychological harm, physical injuries, and death to both the people subjected to and the staff applying these techniques. . . . Restraints can be harmful and often re-traumatizing for people, especially those who have trauma histories. Beyond the physical risks of injury and death, it has been found that people who experience seclusion and restraint remain in care longer and are more likely to be readmitted for care.”
 See, e.g., Streeck-Fischer & van der Kolk, Down Will Come Baby, Cradle and All: Diagnostic and therapeutic implications of chronic stress on child development, 34 Australian and New Zealand Journal of Psychiatry, 903-917 (2000); DeBellis, Woolley & Hooper, Neuropsychological Findings in Pediatric Maltreatment: Relationship of PTSD, Dissociative Symptoms, and Abuse/Neglect Indices to Neurocognitive Outcomes, 18 Children Maltreatment 3, 171-183 (2013), available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3769175/ (last accessed July 23, 2021).
 Haimowitz & Huckshorn, Restraint and seclusion: A risk management guide (2006), available at https://nasmhpd.org/sites/default/files/R-S%20RISK%20MGMT%2010-10-06%282%29.pdf (last accessed July 23, 2021); Jones & Timbers, An analysis of the restraint event and its behavioral effects on clients and staff, 11 Reclaiming Children and Youth, 37-41 (2002); Magee & Ellis, The detrimental effects of physical restraint as a consequence for inappropriate classroom behavior, 34 Journal of Applied Behavioral Analysis, 501-504 (2001).
 Substance Abuse and Mental Health Services Administration. The Business Case for Preventing and Reducing Restraint and Seclusion Use. HHS Publication No. (SMA) 11-4632. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011 (retrieved from https://edsource.org/wp-content/iframe/seclusion-restraint/Businesscaseagainstrestraint.pdf). The Business Against Restraint. retrieved from: (https://edsource.org/wp-content/iframe/seclusion-restraint/Businesscaseagainstrestraint.pdf).
 Alliance Against Seclusion and Restraint (2021). Retrieved from https://endseclusion.org/2021/02/01/prone-restraint-is-neither-safe-nor-is-it-therapeutic/.
 See e.g., https://www.samhsa.gov/trauma-violence/seclusion (“Studies have shown that the use of seclusion and restraint can result in psychological harm, physical injuries, and death to both the people subjected to and the staff applying these techniques. . . . Restraints can be harmful and often re-traumatizing for people, especially those who have trauma histories. Beyond the physical risks of injury and death, it has been found that people who experience seclusion and restraint remain in care longer and are more likely to be readmitted for care.p.16).
 See, e.g., Christine Hauser & Michael Levenson, Three Charged in Death of Michigan Teenager Restrained at Youth Academy, The N.Y. Times, Jun. 24, 2020 (available at https://www.nytimes.com/2020/06/24/us/cornelius-frederick-lawsuit-lakeside-academy.html); Jacob Sullum, George Floyd’s Prolonged Prone Restraint Was ‘Totally Unnecessary,’ a Police Lieutenant Testifies, Reason, Apr. 5, 2021 (available at https://reason.com/2021/04/05/george-floyds-prolonged-prone-restraint-was-totally-unnecessary-a-police-lieutenant-testifies/).
 Dunlap, C., & Fox, L. (2011). Preventing the Use of Restraint and Seclusion with Young Children: The Role of Effective, Positive Practices. Retrieved from: https://challengingbehavior.cbcs.usf.edu/docs/IssueBrief_preventing-restraint-seclusion.pdf.
 TN Code 49-10-1302 (2016).
 See ADAP, note 74, at 2-3, and app. 1.
 ADAP, note 74, at 2, and app. 1.
 July 6, 2020 Letter of Concern from ADAP, Children’s Rights, and Southern Poverty Law Center to the Commissioners of the Alabama Department of Human Resources, Alabama Department of Mental Health, Alabama Medicaid Agency, and Alabama Department of Public Health, pp. 3-4, https://adap.ua.edu/uploads/5/7/8/9/57892141/letter_to_state_re_sequel.pdf (hereinafter “ADAP Letter of Concern”).
 Id. at p. 4.
 Letter from Gregg Brandush, Division Director, CMS-Chicago, Survey & Operations Group to Anthony Penn, Executive Director of Northern Illinois Academy (Jan. 24, 2020)(available at https://beta.documentcloud.org/documents/20421834-washington-state-medicaid-termination-sequel).
 Curtis Gilbert, Washington becomes latest state to ditch Sequel, Am. Pub. Media Reports, Dec. 9, 2020 (available at https://www.apmreports.org/story/2020/12/09/washington-becomes-the-latest-state-to-ditch-sequel).
 IL Dept. of Educ., Administration to Transition Students Out of Northern Illinois Academy Following Findings of State-Commissioned Equip for Equality Report (May 14, 2021); 23312-Administration_to_Transition_Students_Out_of_Northern_Illinois_Academy.pdf.
 At the time of the monitoring in February 2018, Washington placed a number of children in its foster care services at out-of-state facilities, including Clarinda Academy in Iowa. Disability Rts. Washington, Washington’s Out-of State Youth Plead: Let Us Come Home, Report and Recommendations, October 2018, pp. 2-4.
 See id. at p. 26.
 Gilbert & Drake, note 7.
 According to its website: “Ukeru is… the only restraint-free program that combines hands-on training, theoretical concepts, practical tools, and specialized equipment to safely manage—and diffuse—crises” See: ukerusystems.com.
 Gilbert & Drake, note 7.
 Christine Hauser & Michael Levenson, Three Charged in Death of Michigan Teenager Restrained at Youth Academy, NYT (Jun. 24, 2020), https://www.nytimes.com/2020/06/24/us/cornelius-frederick-lawsuit-lakeside-academy.html.
 See Disability Rts. Ohio, Investigative Report on Sequel Pomegranate. Sequel Pomegranate’s license has since been revoked.
 Id. at 3.
 Disability Rts. Ohio, Investigative Report on Sequel Pomegranate, p. 8.
 Center for Clinical Standards and Quality, CMS Guidance for Infection Control in Communities Serving Individuals with Behavioral Health, Psychiatric and Cognitive Impairment Issues, Center for Medicare & Medicaid Services (Dec. 17, 2020), https://www.cms.gov/files/document/qso-21-07-psych-hospital-prtf-icf-iid.pdf.
 Neitzel, J. (2009). Steps for implementation: Antecedent-based interventions. Chapel Hill, NC: The National Professional Development Center on Autism Spectrum.
 National Association of State Mental Health Program Directors (NASMHPD). (2009). Training curriculum for creation of violence-free, coercion-free treatment settings and the reduction of seclusion and restraint, 7th edition. Alexandria, VA: National Association of State Mental Health Program Directors, Office of Technical Assistance.
 Examples found in numerous surveys in 2021: NC Div. of Health Serv. Regulation., Statement of Deficiencies and Plan of Correction, p. 3(August 14,2020); NC DHSR MHLCS: Statement of Deficiency (ncdhhs.gov).; NC Div. of Health Serv. Regulation., Statement of Deficiencies and Plan of Correction, p. 3 (Jan. 8. 2021) NC DHSR MHLCS: Statement of Deficiency (ncdhhs.gov); NC Div. of Health Serv. Regulation., Statement of Deficiencies and Plan of Correction, p. 3 (May 10, 2021) NC DHSR MHLCS: Statement of Deficiency (ncdhhs.gov); NC Div. of Health Serv. Regulation., Statement of Deficiencies and Plan of Correction, p. 3 (Feb. 22, 2021)NC DHSR MHLCS: Statement of Deficiency (ncdhhs.gov); NC Div. of Health Serv. Regulation., Statement of Deficiencies and Plan of Correction, p. 3 (Mar.29, 2021 NC DHSR MHLCS: Statement of Deficiency (ncdhhs.gov);NC Div. of Health Serv. Regulation., Statement of Deficiencies and Plan of Correction, p. 3 (April 9, 2021);NC DHSR MHLCS: Statement of Deficiency (ncdhhs.gov);
2020 surveys: NC Div. of Health Serv. Regulation., Statement of Deficiencies and Plan of Correction, p. 3 (Oct 23, 2020) NC DHSR MHLCS: Statement of Deficiency (ncdhhs.gov).; NC Div. of Health Serv. Regulation., Statement of Deficiencies and Plan of Correction, p. 3 (November 18, 2020); NC DHSR MHLCS: Statement of Deficiency (ncdhhs.gov); NC Div. of Health Serv. Regulation., Statement of Deficiencies and Plan of Correction, p. 3 (April, 14, 2020; NC DHSR MHLCS: Statement of Deficiency (ncdhhs.gov).
 NOVA Inc. owned and operated 3 licenses for PRTFs: Oakwood Cottage, Maplewood Cottage, and Pinewood Cottage. Here are the links to the most recent NC DHSR surveys documenting failure to provide SORs to Disability Rights NC: NC Div. of Health Serv. Regulation., Statement of Deficiencies and Plan of Correction, (May 18, 2021) NC DHSR MHLCS: Statement of Deficiency (ncdhhs.gov). NC Div. of Health Serv. Regulation., Statement of Deficiencies and Plan of Correction, (April 19, 2021) NC DHSR MHLCS: Statement of Deficiency (ncdhhs.gov).
 The records were provided to DRNC by the facility in 2020 and 2021 Quarterly Client Rights Committee meetings.
 Charlotte Huffman & Mark Smith, Patients say sedative known as ‘booty juice’ injected against their will, WFAA, (April 19, 2018), Patients say sedative known as ‘booty juice’ injected against their will | wfaa.com (Texas).
 Am. Acad. of Child & Adolescent Psychiatry, Psychiatric Medication for Children and Adolescents Part I – How Medications Are Used,”(Jul. 2017), https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Psychiatric-Medication-For-Children-And-Adolescents-Part-I-How-Medications-Are-Used-021.aspx.
 Johanna Butler, Jennifer Reck & Maureen Hensley-Quinn, Evidence-Based Policymaking Is an Iterative Process: A Case Study of Antipsychotic Use among Children in the Foster Care System, Nat’l Acad. For St. Health Pol’y, 1, 2 (2019), https://www.nashp.org/wp-content/uploads/2019/02/Antipsychotic-Meds-Foster-Kids-Brief.pdf.
 Julie M. Zito et al., Off-label psychopharmacologic prescribing for children: History supports close clinical monitoring, Child & Adolescent Psychiatry & mental health, 1, 1, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2566553/pdf/1753-2000-2-24.pdf.
 Patient-Centered Outcomes Res. Inst., note 188.
 Patient-Centered Outcomes Res. Inst., note 188, at 2-3.
 Patient-Centered Outcomes Res. Inst., note188, at 2-3.
 See Patient-Centered Outcomes Res. Inst., note 188, at 3.
 See Zito et al., note 178.
 Zito et al., note 178 , at 3.
 Zito et al., note 178 , at 3.
 Zito et al., note 178 , at 1.
 Masnoon et al., What is polypharmacy? A systematic review of definitions, BMC Geriatric 17, 230 (2017). https://doi.org/10.1186/s12877-017-0621-2.
 Patient-Centered Outcomes Res. Inst., “Research Summary: Ensuring that Youth in Out of Home Care are only Prescribed Psychotropic Medication when it is in their Best Interests,” 4, https://www.pcori.org/sites/default/files/2019.07.14-PCORI-research-summary-memo.pdf.
 See Zito et al., note 178.
 Patient-Centered Outcomes Res. Inst., note 188, at 3.
 Example: A survey which documents multiple residents being administered Thorazine despite different diagnoses and exhibited behaviors. NC DHSR MHLCS: Statement of Deficiency (ncdhhs.gov)
 See Patient-Centered Outcomes Res. Inst., note 188, at 4.
 See Patient-Centered Outcomes Res. Inst., note 188, at 4.
 Va. Commission on Youth, Collection of Evidence-based Practices for Children and Adolescents with Mental Health Treatment Needs, 1, 18, http://vcoy.virginia.gov/pdf/Collection_HouseDoc7041513withcover.pdf.
 See Patient-Centered Outcomes Res. Inst., note 188, at 7.
 Off. of Inspector Gen., Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication, U.S. Dep’t of Health & Hum. Serv.’s, 1, 2, https://oig.hhs.gov/oei/reports/oei-07-15-00380.pdf.
 Patient-Centered Outcomes Res. Inst., note 188, at 5.
 Zito et al., note, at 7.
 Patient-Centered Outcomes Res. Inst., note188, at 5.
 NAMI, “Quetipapine (Seroquel), https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications/Types-of-Medication/Quetiapine-(Seroquel).
 US DOJ, “Pharmaceutical Giant AstraZeneca to Pay $520 Million for Off-label Drug Marketing,” Office of Public Affairs (Apr. 27, 2010), https://www.justice.gov/opa/pr/pharmaceutical-giant-astrazeneca-pay-520-million-label-drug-marketing.
 AstraZeneca paid $520 million to the U.S. government under the False Claims Act. The government found that AstraZeneca violated the federal Anti-Kickback Statute in compensating doctors for promoting unauthorized uses of Seroquel. US DOJ, “Pharmaceutical Giant AstraZeneca to Pay $520 Million for Off-label Drug Marketing,” Office of Public Affairs (Apr. 27, 2010), https://www.justice.gov/opa/pr/pharmaceutical-giant-astrazeneca-pay-520-million-label-drug-marketing.
 Id.; Jonathan Brett, “Concerns about quetiapine,” AUSTRALIAN PRESCRIBER 95-97 (Jun. 2015), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4653966/.
 Brett; Sharon Kirkey, “Sleeping with Seroquel: Drug safety expert urges doctors to stop prescribing antipsychotic for insomnia,” NAT’L POST (Jun. 15, 2017), https://nationalpost.com/health/seroquel-for-insomnia.
 NAMI, “Quetipapine (Seroquel), https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications/Types-of-Medication/Quetiapine-(Seroquel).
 Disability Rights Tennessee, Steppenstone Investigation Report (Mar. 15, 2021), at 2.
 NC DHHS, “Statement of Deficiencies and Plan of Corrections,” DIVISION OF HEALTH SERVICE REGULATION, https://info.ncdhhs.gov/dhsr/mhlcs/sods/2019/20191108-130438.pdf.?
 Charlotte Huffman and Mark Smith, “Patients say sedative known as ‘booty juice’ injected against their will,” WFAA.COM (April 19, 2018), https://www.wfaa.com/article/news/patients-say-sedative-known-as-booty-juice-injected-against-their-will/287-543222886.
 See series: Ted McDermott, “Acadia Montana: Use of injected medication, tolerated for years in state, draws Oregon outrage,” MONTANA STANDARD (April 21, 2019), https://mtstandard.com/news/local/acadia-montana-use-of-injected-medication-tolerated-for-years-in/article_d94f659c-d479-5a6d-979a-305c2d1b9bdf.html.
 See ADAP Letter of Concern, note 15, at 7. Only after ADAP’s Letter of Concern, was this practice allegedly discontinued at the facility.
 Id. at attachment B.
 Id. at 7.
 See Wanda K. Mohr, et al., Beyond Point and Level Systems: Moving Toward Child-Centered Programming, 79 American Journal of Orthopsychiatry 8, 8 (2009), http://uofthenet.org/alliant/Ablon/InPatient-Mohr.pdf.
 Id. at 9.
 See id. at 11-12.
 See Sequel website: Residential Treatment Programs for Youth | Youth Residential Treatment Centers (sequelyouthservices.com), https://www.sequelyouthservices.com/residential-treatment-programs-for-youth/.
 See Peter Tompkins-Rosenblatt & Karen VanderVen, Perspectives on Point and Level Systems in Residential Care: A Responsive Dialogue, 22(3) Residential Treatment for Children & Youth 1, 8 (2005).
 ADAP, note 74, at 4 and app. 1, pp. 5-6.
 See id.
 See, e.g., Global Partner Acquisition Corp., Definitive Additional Materials Exhibit 99.1 (Schedule 14A) 19 (May 2017), https://www.sec.gov/Archives/edgar/data/0001643953/000121390017005620/ex99.htm; Global Partner Acquisition Corp., Definitive Additional Materials Exhibit 99.1 (Schedule 14A) 4 (Jan. 11, 2017), https://www.sec.gov/Archives/edgar/data/1643953/000121390017000449/f8k011317ex99i_global.htm
 Gilbert & Drake, note 7.
 Mich. Dep’t of Health & Hum. Servs., Special Investigation Report for Lakeside, p. 6-7 (June 17, 2020) (hereinafter “Lakeside Report”); Kan. Dep’t for Child. & Fams., Notice of Survey Findings, p. 1-2 (Jan. 30, 2018) (concluding also that staff had “frightening” indifference to a child’s pain).
 Foster, note 23.
 ADAP, note 74, at 16-17.
 MI DHHS Report, CI390201235_SIR_2020C0207030_6_18_2020__Redacted_694555_7.pdf (michigan.gov) at 8.
 Ninette Sosa, A CLOSER LOOK: Piney Ridge Treatment Center understaffed, sources say, KNWA (Sept. 30, 2020), https://www.nwahomepage.com/news/a-closer-look/a-closer-look-piney-ridge-treatment-center-understaffed-sources-say/. (Discusses understaffing only)
 ADAP, note 74, at app. 1, p. 3-4.
 Gilbert & Drake, note7 (detailing a database compiled by reporters that contains more than 8,600 total emergency calls in 18 states).
 See ADAP, note 74.
 Id. at 4.
 Id. at 5.
 ADAP, note 74, at 4.
 Clasen-Kelly, note 81. See also, NC DHSR MHLCS: Statement of Deficiency (ncdhhs.gov) On page 13 of 69, the survey documents the admission weights and the weight of each child on the survey date, which indicates the amount of weight lost per child.
 Clasen-Kelly, note 81.
 See: NC DHSR MHLCS: Statement of Deficiency (ncdhhs.gov), page 13 of 69.
 Clasen-Kelly, note 81.
 ABC 11, State threatens to shut Raeford children’s psychiatric facility amid abuse, neglect allegations, (Nov. 15, 2018), http://abc11.com/childrens-treatment-center-abuse-allegations-neglect-hoke-county-facility/4696593/; Canyon Hills Treatment Facility, http://www.canyonhillstreatmentfacility.com/ (showing hours of operation and statements by the facility that reflect it is currently offering services).
 Gilbert & Drake, note 7.
 Gilbert & Drake, note 7.
 Sequel Youth & Fam. Services, “Covid-19,” https://www.sequelyouthservices.com/covid-19/.
 Sequel Youth & Fam. Services, “Covid-19,” https://www.sequelyouthservices.com/covid-19/.
 Sequel Youth & Fam. Services, “COVID-19 Announcement,” https://www.sequelyouthservices.com/covid-19-announcement/.
 Mich. Dep’t of Health & Hum. Servs., Special Investigation Report for Lakeside, (June 17, 2020) (hereinafter “Lakeside Report”).