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Child Welfare: Abuse of Youth Placed in Residential Facilities

GAO-24-107625 Published: Jun 12, 2024. Publicly Released: Jun 12, 2024.
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Fast Facts

State and local agencies are largely responsible for preventing abuse and neglect in youth residential facilities. Yet incidents continue. We reported on longstanding issues with protecting youth at such facilities, including ensuring the safe and appropriate use of psychotropic medications and restraints.

We testified that more could be done to address maltreatment, including better oversight and stronger enforcement mechanisms to hold facilities accountable.

HHS has yet to act on our prior recommendation to facilitate information sharing among states on promising practices to prevent and address abuse and neglect in these facilities.

Photo of a teenager with their hand on their forehead.

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What GAO Found

Prior GAO reports have described allegations of youth being maltreated, and sometimes killed, by staff employed at residential facilities. Many of the youth placed in residential facilities are in foster care. Youth in foster care may be placed in residential facilities for a number of reasons. For example, youth are sometimes placed in residential facilities due to an insufficient number of family foster homes, especially homes that are equipped to provide care for youth with mental or behavioral health needs.

The use of residential facilities as placements for youth in foster care has declined over the course of 20 years, according to data from the Department of Health and Human Services (HHS). Residential facilities were listed as the most recent placement for about 101,000 youth in foster care in 2002. By 2022, the most recent year of available data, that number had dropped to about 34,000 youth.

GAO has previously reported on challenges to preventing harm to youth placed in residential facilities, which include:

  • Monitoring youth in out-of-state placements. Youth are sometimes placed in out-of-state facilities if there are no available placements in their home state. Stakeholder groups and state agency officials said monitoring youth in out-of-state facilities is difficult because of limited access to the youth or information regarding their care. To address this challenge, one state established an interagency committee that monitored youth placed in out-of-state residential facilities.
  • Inappropriate use of psychotropic medications. Some youth placed in residential facilities are prescribed psychotropic medications, such as those used to treat depression and anxiety, among other conditions. However, health risks are associated with certain prescribing patterns—such as using multiple psychotropic medications. Some states have taken steps to curb inappropriate use of these medications among youth in foster care, such as requiring physicians to consult a child psychiatrist when prescribing certain medications.
  • Harming youth through use of restraints. In some instances, staff injure youth while attempting to restrain them, which may result in maltreatment allegations and findings. To address this challenge, one state set up an interagency advisory committee on restraints that meets regularly to analyze restraint data and review feedback from program providers on the use of restraints in their facilities.

Various state agencies are responsible for monitoring residential facilities and working with them to prevent and address abuse or neglect. At the federal level, HHS is the lead agency for addressing issues related to the safety and well-being of youth, which includes youth in residential facilities. HHS officials reported that they primarily support states' efforts by providing technical assistance and guidance. However, at the time of our 2022 report, some state officials told us they received little to no information from HHS.

Why GAO Did This Study

For over 20 years, GAO has reported on youth in the foster care system who are placed in residential facilities, including concerns with the physical, emotional, and sexual abuse of these youth. In multiple reports, GAO has recommended that HHS enhance the support it provides to states, which are primarily responsible for oversight of residential facilities.

This testimony summarizes findings from prior GAO reports on: (1) youth placed in residential facilities, (2) challenges to preventing harm to these youth, and (3) state and federal oversight of residential facilities.

This testimony is primarily based on prior GAO reports issued from 2008 to 2022. Each of GAO's prior reports contain a detailed description of the methodology GAO used. Generally, for each report, GAO reviewed relevant documentation and information gathered via interviews or surveys of relevant stakeholders, including officials from state and local child welfare agencies and residential facility administrators.


Most recently, in 2022, GAO recommended that HHS facilitate information sharing among states on promising practices for preventing and addressing maltreatment in residential facilities. HHS agreed with this recommendation but has not yet taken action to address it.

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Child abuseChild welfareChild welfare agenciesChildrenFoster careGroup homesMental healthResidential FacilitiesHealth careDeaths