Appelgate, along with her parents, and other students who attended similar alternative, for-profit behavior modification programs in Montana testified about their experiences to help pass a new law that aims to bolster protections for teens in programs that are part of what is commonly referred to as the “troubled teen industry.”

The the state Department of Public Health and Human Services’ oversight of such programs by requiring weekly, unmonitored video calls between program attendees and their parents, more inspections, and a 24-hour child abuse hotline for program residents.

“If we knew then what we know today, my wife and I would never have made the decision to send our daughter to a residential treatment boarding school in Montana,” said Richard Gochnauer, Appelgate’s father.

Like other states, Montana has struggled to fund and regulate options for behavioral health care for adolescents. Those are not only private, for-profit programs in the state, where allegations of abuse and neglect went unchecked for years, but also Medicaid-funded treatment programs in other states where Montana kids are sent, some of which have also faced allegations of abuse.

Advocates for teens have called for national oversight of alternative treatment programs. Celebrity Paris Hilton is among those working to introduce federal legislation to better regulate programs nationwide on the basis of her experience in Montana as a teen. Until federal regulations exist, some states, including Utah, California, and Oregon, have aimed to regulate the industry within their borders. In many other states, though, little to no oversight exists.

“One of the things that has been really tough as we shine light on these programs is that the bad actors in the industry condition and prime parents to not believe their own children, and children aren’t able to tell their parents what’s going on,” said state Rep. , a Democrat who sponsored the Montana measure. “So, I wanted to ensure that kids have a way of reporting abuse.”

The new Montana law, which takes effect in October, adds protections for youths attending private, for-profit alternative therapeutic programs in the state. It increases the number of unannounced inspections by state officials to two a year, and requires that at least half the kids be interviewed at each inspection, in addition to their weekly unmonitored video calls. It also allows the state health department to review and approve each program’s policies.

Megan Stokes, executive director of the , said her group supported the measures included in Montana’s new law, such as increased inspections. However, she said she also would like the state to remove its exemption for faith-based programs from those rules.

“It’s a loophole a program could go into and then they’re unlicensed,” Stokes said. “There’s no oversight, and that’s a concern.”

The measure had gotten a boost by the appearance of Hilton, the hotel chain scion who visited Montana and met with senators to impart that a lack of open communication in programs stifles reports of abuse and neglect. Hilton alleged that she experienced abuse, including being strangled by staffers, while attending a program in Montana.

“It really gave my colleagues in the legislature a real picture of what happens in these programs, because if these programs can be so secretive that they can violently assault a Hilton, what are they doing to foster kids and everyday people?” Smith said.

This law is meant to bolster program oversight, which the state health department took over following in 2019 that exposed long-standing problems. Previously, the programs were overseen by a board composed mostly of program owners that dismissed 58 complaints submitted to the board over a decade.

Smith was deputy director of the health department when oversight was transferred in 2019. Within a month of the department taking on the new regulatory duties, it removed 27 children from Ranch for Kids near Eureka and permanently revoked the program’s state license based on allegations of children being hit, kicked, and spat on.

In 2021, Reflections Academy for Girls voluntarily closed after the state found the program had mishandled the case of a 17-year-old girl who died by suicide. According to reports, state inspectors found that staffers did nothing to supervise the girl after she told employees she felt suicidal on the day of her death, instead dismissing her statements as manipulation. She was found dead in a bathroom several hours later.

In the time since oversight was transferred, 11 of the 19 programs that existed under the previous board have closed, changed licensure, or moved to other states, according to program licensing records. Now are licensed in Montana, according to the department’s website.

Corey Hickman, executive director at Chrysalis, said that he supports the new law and that it won’t be very consequential for his program. He said the structure for weekly calls to parents is already in place, though he said he’ll need to figure out the logistics to have a phone available for students to call an abuse hotline.

He said he was uncertain about the events during Appelgate’s time at Chrysalis, given he and the current owners took over the program nearly a decade after her attendance. Hickman said rules governing access to medical care were added once the health department assumed licensing.

“I’ll be the first one to own it’s never perfect,” Hickman said. “And we always have to be better and more client-centered.”

Other programs did not respond to requests for comment about the law for this article.

Appelgate, now 37 and the CEO of , a group that advocates for reform and transparency in the troubled teen industry, said it would have helped to have unmonitored calls during her time at Chrysalis. Yet she said she worried the state may not have the capacity to enforce the new law.

“Even if it’s not monitored and a child is experiencing what they believe to be abuse and say, ‘I need to use the phone unmonitored,’ that is enough for retaliation,” Appelgate said.

Jen Shaw, a former teacher who worked at Clearview Girls Academy, a private residential treatment program, said she thinks Montana’s new law will help the state hold more programs accountable. The measure includes “basic health and safety standards with actual oversight so that more kids don’t die,” Shaw said, referring to the .

Smith said other aspects of the industry still need improvement, including addressing deceptive marketing practices, a lack of adequate educational services within some programs, and inconsistent professional qualifications required for staff members.

The high demand for treatment of children with behavioral and substance abuse problems and the limited care options in Montana have led state health officials to spend Medicaid funds to send kids to residential programs in other states with less stringent oversight. Some of those programs have been accused of abuse and mistreatment.

Shipping those kids out of state for treatment comes with a high price tag for taxpayers, and often the children’s issues are not resolved or grow worse. To reduce the need to send kids out of state, Shaw said, Montana will need to focus on community-based care within its borders.

For years, Montana’s medical professionals have struggled because of reimbursement rates that don’t cover all their costs for providing care to patients covered by Medicaid, the state-federal program that provides health coverage for low-income people. This legislative session, state lawmakers finally raised providers’ Medicaid reimbursements, which may keep more kids in state for treatment.

“This has been under-resourced for a very long time,” said Lauren Wilson, a pediatrician and the president of the Montana Chapter of the American Academy of Pediatrics. “This isn’t a huge windfall for any of these programs, but it will help them meet their costs, which is a start.”

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Some of those children have been sent to out-of-state programs that have been accused of abuse and mistreatment, according to documents from state agencies and media reports.

Shipping those kids out of state for treatment for behavioral and substance use disorders comes with a high price tag, and often the children’s issues are not resolved or are even worse, said , CEO of Yellowstone Boys and Girls Ranch. “When they return to us, they return with worse outcomes and for higher cost,” last fall.

In 2019, Montana increased its oversight of private alternative treatment programs for young people, abolishing an industry-controlled oversight board and making the programs subject to Montana Department of Public Health and Human Services’ regulations and inspections. By the end of 2020, 11 of the 19 programs operating in Montana had closed.

This month, approximately 90 children from Montana were attending facilities approved by Montana’s Medicaid program in 10 other states, according to state officials. The facilities were in Arkansas, Florida, Georgia, Iowa, Kansas, Mississippi, Oklahoma, Tennessee, Utah, and Wyoming.

By comparison, Medicaid paid for 171 Montana children to be treated at in-state psychiatric residential facilities and 407 kids to live in in-state therapeutic group homes during the state’s previous fiscal year, which ended June 30, according to health department officials.

Nearly all the out-of-state programs that have been approved by Montana’s Medicaid program and are currently housing kids from Montana have faced allegations of abuse or have histories of noncompliance with state regulations, according to state documents, inspection reports, and investigations by news organizations.

Jon Ebelt, a Montana health department spokesperson, confirmed that there have been reports of abuse or neglect of young people from Montana at out-of-state facilities during the past two years, although he did not specify which facilities or how many reports. In some cases, Montana has moved young people from out-of-state programs because of concerns about facilities, he added, without providing details.

The state where an allegation of abuse or neglect of a Montana child occurs is responsible for investigating it, Ebelt said.

Why Out of State?

The majority of children attending out-of-state Medicaid-funded treatment facilities are sent by their parents or guardians, although some are referred by the state health department’s Child and Family Services Division or by the state’s juvenile justice system as wards of the state, Ebelt said.

Kids are sent to programs out of state because of a lack of available beds at in-state facilities stemming from the state’s low rate of reimbursement and staffing shortages, said program administrators of Montana’s psychiatric residential treatment facilities and therapeutic group homes. In-state providers are reimbursed an average of $405 per day per child, while out-of-state providers are reimbursed an average of $615 per day per child.

For the fiscal year that ended June 30, Montana spent a total of $12.6 million for out-of-state psychiatric residential treatment facility stays and $4.7 million for out-of-state therapeutic group home stays, Ebelt said.

“It is always our preference to serve youth with serious emotional disturbances in or near their home communities,” Ebelt said. “However, sometimes, due to a variety of factors, including acuity of symptoms, need for specialized care, or in-state bed availability, youth are referred to out-of-state providers.”

Among the programs eligible for Montana Medicaid and that are currently housing kids from Montana is Provo Canyon School in Utah, where Paris Hilton and hundreds of other students , according to lawsuits, former students who have shared accusations about abuse at the program, news organizations’ investigations, and state documents. Those allegations led Utah to increase oversight of residential youth programs.

When reached for comment, Provo Canyon School sent a statement, last updated in August 2021, that says Provo does not “condone or promote any form of abuse” and that the program is “committed to providing high-quality care to youth with special, and often complex, emotional, behavioral and psychiatric needs.”

Montana is also sending kids to another Utah facility, Falcon Ridge Ranch, an employee of which was arrested and charged with multiple counts of sexual battery and distributing harmful material to minors in March 2021, according to the . The employee pleaded guilty to three misdemeanor counts of sexual battery in a plea agreement with prosecutors in January, said Cade Stubbs, the clerk of court for Utah’s 5th District Court. Falcon Ridge Ranch was owned by Sequel Youth and Family Services at the time, and is now owned by .

Minnesota, Oregon, and Maryland stopped sending children to Sequel programs after the May 2020 death of a 16-year-old student at a Michigan facility. Cornelius Frederick died after staff members restrained him at Sequel’s now-closed Lakeside Academy, according to by Michigan child welfare officials. California and Washington also severed ties with Sequel after an in September 2020 detailed abuse and noncompliance with state regulations at Sequel facilities across the country.

An by The Imprint and the San Francisco Chronicle found that of the hundreds of alleged violations or deficiencies at Sequel facilities that child welfare officials in California and other states have investigated, more than 75% resulted in confirmation by state authorities that violations had occurred.

Officials from Sequel did not respond to multiple requests for comment.

Regulatory Confusion

A January found that monitoring out-of-state youth treatment facilities is difficult because of “state challenges in collecting and reporting facility-level information.” It also found that different definitions of maltreatment, fear of retaliation, and the inability of the residents to communicate with others outside the program posed challenges for reporting maltreatment and data collection.

The report found that federal agencies have been inconsistent in addressing state and federal program noncompliance and recommended improved state oversight and stronger enforcement to hold facilities accountable.

Oregon state , a Democrat from Corvallis, experienced those regulatory problems firsthand when she was investigating reports that Oregon children had been mistreated at Sequel’s Northern Illinois Academy in 2019.

Gelser Blouin said she contacted Oregon’s abuse investigator and the state health department but found no agency officials able to investigate the matter. Gelser Blouin then contacted officials in Illinois she thought might have the authority to investigate Northern Illinois Academy, with the same result.

“Nobody thought they had the authority to investigate,” Gelser Blouin said. “They just kept saying, ‘Well they’re accredited by the Joint Commission.’ So I called the Joint Commission, and the Joint Commission told me that they are not a ‘Betty Crocker seal of approval’ for child safety.”

is a private organization that accredits health care organizations and programs in the United States and is funded primarily by the fees it charges facilities for accreditation. In some states, accreditation from the Joint Commission can relieve treatment facilities of oversight from most other organizations.

At Gelser Blouin’s request, the federal Centers for Medicare & Medicaid Services initiated an unannounced survey of Northern Illinois Academy. CMS surveyors declared all the kids at Northern Illinois Academy at immediate risk of serious injury or death.

One month earlier, in November 2019, the Joint Commission had reaccredited all Sequel facilities, including Northern Illinois Academy, in a pilot systemwide accreditation.

Northern Illinois Academy closed last year after a state-funded report by a disability-rights organization documented allegations of abuse and neglect, .

Oregon and California Lead With Bans

Oregon and California are the only states that have passed legislation to prevent young people from being placed in facilities that are not overseen by a youth’s home state.

California banned the practice of sending foster children charged with crimes to out-of-state programs in July 2021. That same month, Oregon, driven largely by the work of Gelser Blouin, became the first and only state to require any out-of-state facility housing Oregon children to comply with Oregon regulations and be licensed by the Oregon Department of Human Services.

Gelser Blouin is now working with other youth rights advocates, including Paris Hilton, to champion a federal bill called the Accountability for Congregate Care Act. It would establish standard regulations and common definitions for abuse and treatment across the states and identify the rights of children in institutional settings.

The bill would also create a federal database to track placements of young people, critical incident reports, and complaints, among other information. Currently, complaints against programs are funneled through various state agencies and accrediting bodies.

In Montana, for example, Ebelt said complaints about out-of-state programs housing Montana’s young people can be filed in various ways “due to the various people and entities who interact with or have oversight of out-of-state programs.”

The bill would also define different types of programs, which Caroline Lorson, an advocate working on the federal legislation, said is at the heart of the need for change.

“They all have different requirements, they all have different standards, and they all have different agencies that interact with them, and that’s why they’ve been hard to regulate,” Lorson said.

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Trish Leon, aunt of the 12-year-old, Logan, contacted various state agencies, the Utah governor’s office, elected officials and youth rights nonprofits — but soon discovered the law’s limits. Secluding a student from others is still allowed under the new rules, for example, but program operators must now report to regulators when they do so. Leon’s complaints about what happened to her nephew while he was at Provo Canyon School were dismissed as unsubstantiated or hit dead ends. 

Leon said the dismissals show the state law isn’t enough to hold accountable an industry that makes billions of dollars treating kids with behavioral or substance use problems.

“If we’re still doing the same thing, there’s never going to be a change,” Leon said.

For groups pressing for more accountability for these programs, Leon’s story shows that the new law doesn’t go far enough. Further, they say, oversight is often weak and enforcement of the new law has been lax.

No federal laws govern these private, for-profit residential treatment programs, boot camps, and wilderness programs. Efforts to pass federal legislation that would regulate them failed for more than a decade, even after a 2007 detailed allegations of abuse and neglect, along with deaths and deceptive marketing practices at programs across the country.

That’s left regulation largely to the states, with mixed results. A handful of states besides Utah have passed laws to bolster protections for young people in these programs. Among them is Montana, whose 2019 law led to the closure of several programs; California, whose 2016 law required residential treatment programs to operate on a nonprofit basis to ensure that financial incentives do not affect the quality of care; and Oregon, whose various laws have aimed to crack down on the so-called troubled teen industry, including a 2021 law that regulates “secure transport” companies hired to forcibly take kids to wilderness or residential programs. But in many other states, there is little to no oversight.

The Paris Hilton Effect

Utah is the troubled teen industry’s epicenter, offering a wide variety of these programs. Its new law, which took effect in March 2021, marks the state’s first attempt in 15 years to bring more regulation to the industry. 

Utah’s law was championed by advocates and celebrity heiress Paris Hilton, who testified before the Utah Legislature that she experienced abuse while attending Provo Canyon School as a teenager. Hilton’s revelation and an investigation by ushered in calls for change from former program attendees who shared similar experiences.

bans chemical sedation and mechanical restraints unless authorized by the Utah Office of Licensing. It also increases the number of inspections per year for each program and requires programs to report use of physical restraints and incidents of seclusion to the licensing office, although it does not ban or significantly restrict the practices. The law does require programs to provide participants with access to unmonitored communication with their families, which Logan’s family said they were denied while he was at Provo Canyon School.

Critics said tighter limits are needed on residential programs’ use of seclusion, restraint, and medication, in addition to more regulation of the use of degrading disciplinary practices and aversive behavioral interventions such as food deprivation.

Pivot to Congress

A new push to pass a federal law is now brewing, with a measure called the Accountability for Congregate Care Act. It would create a commission under the Department of Justice to research and establish best practices for youth congregate care settings and would allow the federal agency to take action or require states to take action when there is abuse. It also would enable the department to consult with states on the closure of facilities that do not meet standards, establish a “bill of rights” for young people in congregate care facilities and define the terms “treatment” and “institutional abuse.”

These residential programs are an “industry that is based on selling treatment even though many of them are not licensed to provide treatment,” said state Sen. Sara Gelser Blouin of Oregon, who sponsored legislation to increase oversight in her state. “That is a change that needs to happen at the federal level.”

In Logan’s case, relatives said in interviews and in formal complaints — copies of which were provided to KHN — that the 12-year-old was placed in seclusion, called “stabilization” by Provo Canyon School officials. During stabilization, Logan was sent to a room, made to stare at a wall all day, and prohibited from talking with other students because of “maladaptive behaviors,” according to Logan and his relatives. The antipsychotic medication he received was prescribed by a psychiatrist under contract with Provo Canyon School against his mother’s wishes.

During his stay at Provo Canyon School, Logan was sent to stabilization multiple times — the longest stint lasted a week. After Logan’s aunt unsuccessfully filed her complaints against the program, she said, he left the Provo school for a different program and later returned to his mother, who had moved from their home in Washington state to Utah while he was in the program.

Provo Canyon School officials did not respond to questions about Leon’s complaints to government authorities but referred to a media statement from August that said the program “is committed to the safety of our students and staff” and “DOES NOT use ‘solitary confinement’ as a form of intervention.” 

Some States Seek Reform

Utah, California, Oregon, Montana, and Missouri have enacted laws aimed at increasing oversight of residential treatment programs for young people. But each law is tailored to its state, and child advocacy groups said enforcement has been uneven.

And when states identify problems, they sometimes appear to be reluctant to escalate the penalties for repeat offenders, the advocates said.

“We’ve seen facilities in many different states that have been cited again and again and again for noncompliance for dangerous practices, for children dying at their facilities, but if the state doesn’t revoke their license or shut them down, then it’s pointless,” said Caroline Lorson, an advocate helping draft the federal legislation.

In Montana, the 2019 state law created new regulations for programs and moved oversight from an industry-dominated board to the Montana Department of Public Health and Human Services. A month after the health department took over oversight of the programs, the state removed 27 children from a program called Ranch for Kids and revoked its license. By late 2020, 11 of Montana’s 19 programs had closed, some because of the new regulatory environment, according to Erica Johnston, head of the state health department’s economic security services.

But the problems haven’t gone away, and critics have questioned the enforcement of the new rules.

A program called Wood Creek Academy near Thompson Falls has undergone three state inspections since September 2020, two that resulted from complaints and one that was regularly scheduled. Inspectors found violations of the law, including that Wood Creek Academy staff members waited more than an hour to call 911 after two boys ran away and by separating them from other students for two days and making them sleep in tents in shorts and T-shirts in below-freezing temperatures.

The program wasn’t penalized for the violations but was required to submit plans detailing how it would prevent the violations from occurring again. Wood Creek Academy closed voluntarily in September.

At another program, Reflections Academy, a 17-year-old girl died by suicide in June. That prompted an inspection, which found that Reflections Academy staff members did not follow program policies for responding to the suicidal ideation of a participant and did not take the patient to the hospital or ensure she received a psychiatric evaluation that was recommended by a physician a day before the girl’s death.

Staff members failed to supervise the girl after she said she was suicidal and harmed herself the day before her death, saying they weren’t sure “how much of this is real or manipulation,” according to the state inspection report.

But the Montana health department did not revoke Reflections Academy’s provisional license. Instead, the department accepted a one-sentence plan of correction from Reflections that stated, “Moving forward, the program will follow the revised policies for child abuse and neglect reporting, child abuse and neglect, self-harm, and suicide policies.”

Reflections Academy program director Michele “Mickey” Manning voluntarily closed the program in October. She previously served as the principal of the now-shuttered Spring Creek Lodge, where a 16-year-old girl killed herself in 2004 after she was put in isolation nearly 30 times in six months, according to the notes and logs that staff members kept on students and were included in a lawsuit filed after the girl’s death.

Spring Creek Lodge closed after lawsuits, , and a drop in enrollment. Manning went on to serve as program administrator of Clearview Horizon until 2015, when she left to open Reflections Academy in 2016.

The 2019 Montana law . After the state health department implemented the 2019 law, Clearview Horizon, now called Clearview Girls Academy, began operating as a “Christian therapeutic boarding school” and is therefore exempt from state oversight.

Manning is named in several lawsuits in which over a dozen former students allege psychological and sexual abuse by staff members whom Manning employed at Clearview Horizon and Reflections Academy. In one lawsuit, 10 former Clearview students allege that the program and its staff employed psychologically harmful practices, including solitary confinement, social isolation, food deprivation, and corporal punishment, according to the complaint.

Manning did not respond to repeated requests for comment. She has previously said in response to a lawsuit against her that she complied with “all applicable standards of therapy and was not negligent,” according to legal documents.

Without federal legislation, advocates said, the few state laws that exist result in inconsistent regulations that allow program owners accused of abuse and mistreatment to hop across state lines and reopen, rebrand, and continue to profit from children.

A former Reflections Academy student, 20-year-old Molly McCready, said that was her concern about the program she attended from 2017 to 2019.

“It’s good that it closed, but another school could pop up somewhere else,” she said.

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