While an investigation cleared Chad of blame in the death, New York and Tennessee stopped sending children to the residential treatment center.
But Philadelphia, despite a drumbeat of warnings that children were being violently subdued and injured, continued to send emotionally troubled children to Chad.
The city's Department of Human Services stuck with Chad even after a top DHS official concluded that "residents were being harshly and improperly restrained."
Not until the June death of 17-year-old Philadelphian Omega Leach did the city finally lose faith.
In a physical restraint gone wrong, Leach died after Chad staff pushed him face-down to the floor, apparently cutting off his air, investigators say.
When done safely, restraints can calm youths who are out of control and prevent children from hurting themselves or others.
But when they go wrong, these "holds" can be brutal. They can dislocate a shoulder, split a chin or snap an arm. In extreme cases, they can kill.
On the day Leach died, Philadelphia had 44 children and teens in Chad, all under DHS oversight. The Philadelphians - some from abusive homes, others with arrest records - made up the biggest share of 85 residents who slept, attended school and got therapy at Chad.
Since 2001, the city has sent scores of youngsters to the center, saying it has been forced to do so because no Pennsylvania facility would take them. It has paid Chad $6 million in the last three years.
Arthur C. Evans Jr., the acting DHS commissioner, took command late last year after Mayor Street ousted its top official following an Inquirer investigation into a string of child deaths in Philadelphia.
"A good facility should not rely on restraints," Evans said. "This is really unacceptable."
Further, he said, his agency's oversight of Chad was also unacceptable.
Nick Ragone, a Chad spokesman, said in a statement Friday that the facility put youngsters in physical holds only as a last resort to protect them or others.
Moreover, he said, Chad worked zealously to train its staff and responded quickly to issues raised by regulators.
Last week, as a result of Leach's death, Philadelphia began Family Court hearings in a first step to pull children out of Chad.
The court's top judge, Kevin Dougherty, said Friday that he had harshly rebuked Chad leaders in court.
"I told them I was not sending another kid down there," he said. "They were too aggressive."
On Friday, Dougherty ordered six children discharged from Chad, with more hearings to come.
The Inquirer has obtained hundreds of regulatory documents about Chad, drawn from government files in Pennsylvania and Tennessee. Based on these records and interviews with former Chad staff, regulatory officials in both states, and former Chad residents and their families, the newspaper found:
Chad's workers resorted to physical force at high rates - rates experts term excessive. By Chad's own count, filed with Tennessee officials, its workers used 104 holds in one month alone in 2006.
Chad staff would on occasion hold residents down for long periods - even though experts warn that deaths can occur within six minutes of a hold. In May, Chad reported one floor-hold that lasted 23 minutes, and others that lasted 20 and 15 minutes.
Tennessee repeatedly cited Chad for failing to tell its regulators about children who had been injured there. In one case, the state learned that three residents had tried to strangle another only when the victim's mother called police, records show.
Philadelphia acknowledges it never reviewed Tennessee licensing documents about Chad, which would have revealed the center's heavy reliance on physical holds.
No tour permitted
Set in rolling hills about 40 miles west of Nashville, Chad was refashioned out of a former county nursing home. The 20-acre site is surrounded by horse farms and not far from Fort Campbell, home of the 101st Airborne Division across the Kentucky state line.
When a reporter drove up its 800-yard entranceway recently, John McDuffie, a top administrator at Chad, emerged from its offices before his visitor could reach the front door.
He said no one at the facility would answer questions or provide a tour.
Chad was founded in 1996 by a psychologist, Robert D. Glasner, who named it after a son who had died young in a car crash.
It is owned by a King of Prussia for-profit corporation, Universal Health Services Inc. UHS, which owns 110 mental-health facilities in 33 states, bought Chad in the fall of 2005, paying $210 million for Chad and 29 other centers.
Chad has a gym, a classroom building and three dorms, where residents live two to a room. Boys range in age from 7 to 17, girls from 13 to 17.
When the youths arrive, they sign a form acknowledging that, if they misbehave, they may be put in a "protective hold." Leach signed his May 2, his first day there.
During holds, staff members restrain children by locking the residents' hands behind their backs. Sometimes, the children are held upright, or against a wall. In more serious cases, they are put to the floor, face-down.
Such holds are controversial.
In Pennsylvania, Gov. Rendell's administration has been on a crusade to all but eliminate physical holds in psychiatric hospitals, mental-health centers, reform schools and the like.
Instead, public welfare secretary Estelle Richman is pushing facilities to get control of unruly residents with conversation or by isolating them in a quiet space.
In interviews, experts and advocates said the sheer number of holds Chad used on children appeared troubling.
"I worry about the culture of the facility. Why is it so restraint-happy?" asked Michael Carter, a lawyer with the federally funded Disability Law and Advocacy Center of Tennessee. His staff has been investigating Leach's death.
When presented with the "restraint logs" from Chad, DHS Commissioner Evans agreed.
He said the data reflected a workplace culture with few alternatives for calming residents or gaining control.
"That, to me, is just not acceptable," Evans said last week. "One thing I can't and will never tolerate is the mistreatment of children."
Evans said DHS had failed to recognize Chad's problems soon enough. In response to recent reports about Chad's performance, he said, he reassigned the man who oversaw contracts for DHS, Steven C. Oakman.
Oakman did not respond to requests for comment in telephone calls and a letter left at his house.
In his statement, Chad spokesman Ragone disputed the data showing a high number of holds at Chad. He said the figures reflected a wide variety of "hands-on" contact by staff with residents, not just the most serious interventions.
Kim J. Masters, a child psychiatrist who wrote the guidelines on restraints for the American Academy of Child and Adolescent Psychiatry, said he was struck by Chad's data showing as many as 100 holds in a month.
"That's a lot," he said.
When he took charge some years ago at one center - larger than Chad - Masters considered its tally of 100 restraints a year to be "out of control."
Its staff now do about two per month.
A high number of restraints, Masters said, reflects "a coercive environment that says, 'You have to do this or else.' " Such techniques rarely work and may backfire, he said.
"Kids act out when they don't feel safe," Masters said. "And they don't feel safe when they're being restrained all the time."
A litany of problems
Regulatory files on Chad are publicly available in the state capital in Nashville and show a history of problems.
In 2004, for example, Tennessee officials wrote: "Serious incident reports revealed that the agency uses what appears to be an excessive number of physical restraints."
That year, Chad admitted that a worker had to be pulled off a resident after the staffer threw 16-year-old John T. Boy against a wall. The worker said he had "overacted" and apologized, records show.
Chad acknowledged that the aide had had "problems like this two or three times in the past" and said he would be fired "once they found someone to take his place."
In an interview in Tennessee, Boy's mother said she had been astounded that Chad kept the worker on.
"They did not care about kids at this facility," Sharon Pruett said. "It needs to be shut down."
The employee was finally dismissed, records show. Boy was shot to death last year, in a killing unrelated to his Chad experience.
In 2005, when Tennessee staged a surprise inspection of Chad, a girl told the inspectors that a Chad supervisor "will try to hurt students during restraints and 'wants us to scream.' "
Another youngster said she had seen "Big Mike slam kids down real hard on the floor. I don't want that happening to me, so I try hard to do everything they ask me to do."
In March 2005, the anonymous caller, identifying himself as a Chad employee, called the DHS hotline to warn about force at the facility.
In response, DHS dispatched an investigator to Chad - three months later.
According to the investigator's report, just 14 Philadelphia youths were at Chad at that time. All had been restrained - some as many as five times, the investigator found.
In one case, DHS staffer Haiying Xi reported, a youngster had been cut on the chin in a restraint, requiring stitches. Chad had not reported this to regulators, DHS learned.
Finally, DHS official Stephen Rosenberg wrote to Chad.
"The investigation could not determine any pattern for the use of illegal physical restraints," Rosenberg wrote. "However, the investigation did validate the allegations that some residents were being harshly and improperly restrained."
In a reply, Chad administrator McDuffie assured DHS that Chad was a "nurturing and positive environment." He said the facility had hired more staff and made children's safety a priority.
The former owners of Chad also said it was a safe and therapeutic place for children when they handed over the keys to Universal Health in October 2005.
"Our goal was to effect treatment in as nonphysical a way as possible," former chief executive officer Michael G. Lindley said.
Al Smith, another former top executive with Chad's former owner, said: "Did untoward events happen? Absolutely. But was it a culture? I don't believe so."
After Universal Health purchased Chad, regulators continued to flag problems.
In 2006, the state complained again that Chad wasn't reporting serious incidents to regulators. Another boy went to an emergency room for cuts sustained in a restraint. And a mental-health associate quit after she got into an argument with a youth and shoved her, records show.
According to a Tennessee investigation, other youths were injured this year.
On Jan. 2, Tennessee officials disclosed, staff broke the left arm of a 16-year-old boy during a restraint.
Later in the year, Chad told regulators, another teenage resident was "taken to the floor" in a restraint that required four stitches for cuts on the lips.
In May, Edith Ruland pulled her son, Dennis, 10, out of Chad after she found numerous bruises on him, she said.
Ruland, who lives near Chad, took photographs of the bruises, which the boy said staff had inflicted in a restraint hold. Though Tennessee had stopped sending children in state custody, it still permitted families to use it.
"They treat people wrong," Dennis said in an interview. "And they shouldn't be having a facility that would bruise people and stuff."
In response, a spokesman for Chad said Tennessee had investigated and had been "unable to substantiate these complaints."
Rob Johnson, a spokesman for regulators in Tennessee, agreed that investigators couldn't unravel the episode.
"They know that the child got injured somehow," Johnson said. "They just don't know how."
Out of sight, out of mind
Experts and members of the commission appointed by Street to overhaul DHS say the city's heavy use of Chad exemplifies another key failing of the agency: its reliance on out-of-state treatment centers.
At last count, 233 of Philadelphia's 1,554 children in residential facilities were outside Pennsylvania.
Critics note that a main goal for social-service agencies is to eventually reunite troubled children with their families. Yet faraway locations make parental or guardian visits far more difficult.
And as a DHS administrator noted in a 2005 report on Chad, such far-off facilities have an obvious weakness. It's hard for officials in Pennsylvania to regulate what happens in Tennessee.
Philadelphia officials said they recognized the problem and were moving to solve it.
They said they often had little choice but to lean on out-of-state facilities to care for the city's most troubled youths because many in-state treatment centers wouldn't take them.
Smith, the former Chad executive, said kids who lashed out violently at authority figures were hard to place.
"If a child has hit a teacher, you can be certain they'll have no problem going after staff," he said.
So, each year, Philadelphia shops its most hardened cases to area centers, but ends up sending hundreds to Tennessee, Utah and Virginia for mental-health treatment.
Child-welfare officials in other states, such as Illinois, and the second-largest child-welfare system in Pennsylvania, that of Allegheny County, say they have found ways to keep children closer to home.
Marc Cherna, who heads the Allegheny child-welfare agency, studied DHS as a member of Street's reform panel. He said none of the children under his care were placed out of state.
An agency task force makes sure that even the toughest cases are placed close to home. And money is no object, Cherna said.
"We will pay extraordinary rates for people who are extraordinarily difficult," he said. "Our goal is to return these children back to the community."
In 1995, Illinois was shipping 784 children out of state for care. Eventually, the state realized that counselors in far-flung treatment centers were abusing children.
"We flew to facilities we used in a dozen states, and in every one it got worse and worse," said Ron Davidson, a psychologist who helped the state evaluate the programs.
Today just a dozen children from Illinois are placed outside the state.
"Children just perform better closer to home," said Kendall Marlowe, an Illinois child-service official.
Philadelphia's acting DHS commissioner, Evans, agrees. He wants to reduce the number of children placed out of state.
"It's a very high priority for me," Evans said. "We send too many kids away from Philadelphia."
One of those kids was Omega Leach.
A month before he died, a therapist placed a note in his file. "Omega is frustrated with being placed so far from home," the therapist wrote.
"But he has expressed the desire to complete the program successfully so that he can return home and start working on getting his life together."
A Key City Report, Uncensored
In 2005, an investigator for the city wrote a detailed report focusing on the Chad Youth Enhancement Center in Tennessee.
The city made the report public at The Inquirer's request. Before releasing it, however, city lawyers removed the most explosive section - pages with allegations that Philadelphia children were being abused at Chad.
In redacting the document, the city cited an exemption in Pennsylvania's right-to-know law that allows governments to withhold investigations, even finished ones, from the public.
The Inquirer later obtained a complete version of the report. In this version, the only information removed is the names of children.
To read both the censored and unaltered versions, plus previous articles about the troubled city Department of Human Services, go to
For previous articles on the Department of Human Services, plus video and documents, go to http://go.philly.com/dhsdocs
Contact staff writer John Sullivan at 215-854-2473 or firstname.lastname@example.org.