This is the first in a three-part series investigating North Carolina's psychiatric residential treatment facilities where children with complex behavioral needs are sent for care. Read Part 2 and Part 3 here.
When children with severe mood or behavior disorders require intense therapeutic care, they can end up in one of the state's two dozen psychiatric residential treatment facilities. Operators of these facilities, commonly known as PRTFs, say they stabilize children and provide trauma-informed care that lets them return to their communities on a track toward healing.
But a review of hundreds of inspection reports, as well as interviews with families and experts familiar with the inner workings of these facilities, tells a dramatically different story.
"The things that they described are analogous to anything that you would hear from people who have spent time in jail or prison or children in the juvenile justice system," said Joonu Coste, a lawyer whose work centers around children with disabilities and behavioral disorders. "These are not therapeutic environments. These are not evidence-based practices."
North Carolina ranks 42nd in the country with the highest prevalence and lowest access to mental health services for youth. Suicide is now the second leading cause of death for North Carolina youth ages 10 to 18.
"They heard [Former Staff #4] scream and then some of the clients saw [client #1] on the floor of his room and saw [FS #4] standing over [client #1] with his arms moving. The clients all stated that [staff #1] and [staff #2] both ran to the incident and were trying to verbally and physically remove [FS #4] from [client #1] by physically pulling on [FS #4] and saying something like C' mon (come on) [client #1] only a little kid."A September 26, 2022 Division of Health Service Regulation inspection report of Hope Gardens Treatment Center in Raeford, N.C.
The state health department has named improving child and adolescent behavioral health a top priority. But advocates say the state falls short of this goal. Coste said that's especially true of programs that take children out of their homes and into facilities that are sometimes hundreds of miles away from their families.
"Children come out usually reporting lots and lots of trauma," she said.
PRTFs are not hospitals but are supposed to provide inpatient levels of care to Medicaid-eligible children with severe mood or psychiatric disorders. A child's guardian will decide to place a child in a PRTF, often after a severe event like a suicide attempt or manic episode.
A WUNC review of more than 500 psychiatric residential treatment facility inspection reports since 2018 showed dozens of accusations of staff hitting, kicking or punching children in these facilities. One report described a staff member who had to be restrained by two other staffers after he was choking a 12-year-old boy. In another, a child reported not seeing therapists for weeks at a time. And on multiple occasions, police with bloodhound dogs had to search for a child who had snuck out from a facility and was hiding in the surrounding woods.
Not enough regulators
The state health department investigates these accusations. When one is substantiated, the department's regulatory arm, the Division of Health Service Regulation, identifies it as a deficiency, which could lead to corrective action, including firing staff, paying a fine, or mandating additional staff training. In the most serious cases, DHSR issues violations. The most severe of those is a Type A1 violation, which DHSR defines as "a violation of a licensure law or rule that results in death or serious physical harm, abuse, neglect, or exploitation." From 2021 to 2023, the state issued 26 Type A1 violation notices.
In a statement to WUNC, a spokesperson said the department "takes seriously its responsibilities to help ensure clients receive appropriate care and are protected from harm in a licensed mental health care facility."
"I was stressed annoyed, and I was sick of being here. No one ever listens to me and I get sick of it. This is very stressful people cut and talk about smoking and drugs they swear they yell and scream and self harm every day. I tried talking to staff but they wouldn't listen I've been using coping skills for days now I'm sick of it its not helping so I couldn't help myself I ran for it. In other words I couldn't do anything else no one would listen."Note written by a client of Anderson Health Services recorded in an inspection report dated June 1, 2018.
Anyone can file a confidential complaint, which facility operators and regulators review and potentially act on. In one example, a mental health technician with at least one former disciplinary letter for use of excessive force, was fired after he punched a 17-year-old boy. This occurred in 2018 at a center operated by Alexander Youth Network, which terminated the staffer. The group's chief clinical officer, Dr. Van Catterall, said when incidents like this occur, a "root cause" analysis takes place to improve processes.
"And I think that our safety record today benefits from all of those kind of process improvements that we've done over the years that kind of cumulatively lead to where we're at now where we're able to provide safe treatment to kids," he said. "And we kind of know how to address issues that come up with staff."
In addition, regulators make unannounced on-site visits to "determine compliance with applicable licensure laws and rules," according to DHHS.
But state officials recognize they could do more. DHSR has an 18% vacancy rate, which limits the number of unannounced visits department officials can actually conduct. Officials acknowledged the need to fill those vacancies, saying more inspections could lead to fewer violations.
"A strong and competitive workforce is critical to maintain appropriate care for North Carolinians," according to DHHS.
More than half of PRTF residents come from foster care
Advocates note that inspections that do result in violations represent only a small slice of everyday life in these facilities for children, including those in foster care. According to the state health department, of the 1,158 children in a PRTF in 2023, 651, or more than half, were in foster care.
Research shows that children who entered foster care are 10 times more likely to enter a PRTF, even when controlling for other factors.
Moreover, children in foster care are far more likely to be placed in an out-of-state PRTF. North Carolina's facilities are often at capacity, forcing some placements at PRTFs out of state. Of the 89 children at an out-of-state PRTF in 2023, 66 — a full three-quarters — were in foster care. Another 221 foster care children were in what DHHS calls a "border state" PRTF, those within 40 miles of the North Carolina state line.
Medicaid pays more than $100 million per year for PRTF care in North Carolina. That's despite pilot projects that have shown better outcomes and lower costs when efforts are made to provide more care outside of a residential setting.
The state Medicaid program, and the opaque network of managed care organizations that allocate Medicaid dollars, should do more to bring services to kids, not kids to institutions, according to UNC School of Social Work professor Paul Lanier.
"If there's not enough for kids, then go find it. Figure out a way to bring it to our communities to train the workforce, incentivize more providers to come get people trained up in these interventions if they're not there," he said. "We can't just throw up our hands and say, 'Oh well we don't have enough community-based services for these youth, we'll just go put them in a PRTF somewhere'."
State health leaders say they do provide community-based care, and do make efforts to avoid a PRTF placement. Indeed, these facilities housed 159 fewer children in 2023 than 2019, a 12% reduction.
While Disability Rights NC lawyers like that trend directionally, they say it's coming down far too slowly. Holly Stiles, an attorney with the organization, said the goal should be to help children without institutionalizing them.
"We are permanently changing how these children relate to the world. They don't understand what it's supposed to be like," she said. "And if you don't have a model for it, then you're just going to carry that through your life, and you're going to carry that, and you're going to carry that into your own future relationships. Your own future families."
Disability Rights North Carolina is the state's Protection and Advocacy System charged with overseeing facilities that care for people with disabilities. It had been in state government as the Governor's Advocacy Council for Persons with Disabilities, but was spun out in 2007 when then-Gov. Mike Easley redesignated it as an independent nonprofit organization.
State health department leaders agree they want to keep as many children out of a PRTF as possible.
"We do have community-based services. It just can be hard to kind of staff them and make sure there's enough of them across the state," said Kelly Crosbie, director of the health department's Division of Mental Health, Developmental Disabilities, and Substance Use Services.
Last year, state lawmakers appropriated $835 million to improve behavioral health services, marking the single largest investment in behavioral health ever by the state. Some of that money will increase Medicaid rates, which Crosbie said will help expand some pilot programs for youth psychiatric care that show better outcomes.
"We do see progress, but now is the opportunity to scale the progress that we are seeing," she said.
While advocates say they fully support the increased funding, it won't meaningfully fix the mental health crisis without structural change, according to Coste, who now works as a state attorney general.
"If it's more money prioritized the same way, it's not going to get us the objective, which is to keep kids and families together at home in the community," Coste said.
This reporting project on PRTFs was undertaken with support from USC Annenberg Center for Health Journalism 2023 Data Fellowship.
