A yearlong investigation led by APM Reports finds the company took in some of the most difficult-to-treat children while keeping costs low in pursuit of profit and expansion. The result was dozens of cases of physical violence, sexual assault and improper restraints. Despite repeated scandals, many states and counties continue to send kids to Sequel for one central reason: They have little choice.
September 28, 2020
Chris Hagman walked by the building almost every day for years with his dogs. It was a large, stately, pre-war structure with brick walls and white columns. To Hagman, it seemed like a nice place, a benefit to the historic Wichita, Kansas, neighborhood where he lived and worked as a middle school science teacher.
Hagman didn’t know much about what happened inside, only that the place had once been a hospital for unwed mothers and, more recently, a youth treatment center called Riverside Academy.
After the academy quietly closed last spring, the building became a nuisance in the neighborhood. People were breaking into it, sleeping there and using drugs. Hagman decided to look more closely and maybe complain to the new property owner.
As he walked up to the building, Hagman saw spray paint on the walls. When he got closer, he realized this wasn’t typical graffiti on an abandoned building. This was something different. “Pray 4 victims,” one message read. “We want justice.”
Next to an entrance, he saw another scrawl: “We need to talk about Riverside.” The door was unlocked, so he walked inside.
There, the spray-painted messages were more explicit: “Youth were abused here,” read the graffiti on one wall, “systematically.” Hagman grew alarmed as he photographed the messages.
“They weren't put where they were put by coincidence,” Hagman concluded. “Whoever had written these things on the walls, they purposely wanted these words to be seen and heard.”
In fact, something had happened at Riverside Academy. Kids had been mistreated there. In the four years before it closed, the facility had been cited 38 times by Kansas officials for problems including excessive force by staff, poor supervision, under-qualified medical personnel, neglect and bullying by residents, according to state licensing records. One investigation in 2018 concluded that the staff’s indifference toward a child in pain was “frightening.”
In spite of all that, the state of Kansas didn’t shut the place down. It closed voluntarily.
But what happened at Riverside wasn’t an aberration.
Riverside Academy was run by a for-profit company named Sequel Youth & Family Services, which operates 29 residential treatment centers in 15 states for kids with behavioral problems. It also operates clinics, outpatient programs, group homes and day schools.
A yearlong investigation led by APM Reports reveals a company founded on noble ideals that, in the past two decades, has pursued profit and expansion by housing traumatized kids while trying to keep expenses low.
The company’s model was, as one former employee put it, “a recipe for destruction”: inexperienced, low-paid staff charged with caring for some of the most vulnerable and difficult-to-treat children in the country. And it resulted in dozens of cases of abuse and neglect, including physical violence, sexual assault, filthy conditions, and improper restraints that led to numerous injuries and one death.
For much of Sequel’s 21 years, the company eluded public accountability. While news reports would occasionally detail scandals at its facilities, the full picture of the problems in Sequel’s programs was obscured by a patchwork of oversight bodies spread across multiple states and local jurisdictions. When conditions at a facility became too bad, the company simply closed it.
For the past year, a team of public radio reporters spread across 10 states conducted the first comprehensive examination of Sequel. The team, led by APM Reports, reviewed thousands of pages of records to reveal a litany of problems at Sequel facilities.
Since the beginning of 2019, Sequel has shut down eight of its 36 residential treatment centers. Six closures happened under pressure from, or amid investigations by, state or local governments. Additionally, the state of Ohio is in the process of revoking Sequel’s license to operate there, and the Alabama Department of Mental Health has frozen admissions to two of its treatment centers.
Disability rights groups in Alabama, New Mexico, Washington and Ohio have reported excessive use of restraints in the company’s facilities. The group in Alabama this year also highlighted “unsafe, squalid living conditions and a disturbing cultural and programmatic environment that further traumatizes extremely vulnerable children.” The group from Ohio raised alarms about “pervasive and disturbing problems embedded in the treatment culture” at Sequel’s facility there.
APM Reports documented 20 cases since 2010 in which government investigations concluded that Sequel staff engaged in sexual or romantic relationships with residents.
“While instances of sexual assault by a staff member are extremely rare among the thousands of kids we help around the country, even one case is unconscionable,” the company said in a written statement. It also noted “better hiring practices, background checks, and the installation of cameras and other security measures” have been implemented to prevent such incidents.
Reporters also compiled a database of more than 8,600 emergency calls from Sequel facilities in 18 states — including now-shuttered treatment centers in Indiana, Oklahoma and Michigan. The database includes more than 1,000 calls reporting residents running away from Sequel treatment centers since 2010.
Since 2017, at least seven riots have erupted among residents at Sequel treatment centers in Florida, Utah, Ohio and Michigan.
At least seven Sequel facilities have experienced Covid-19 outbreaks this year, including 123 people at its girls school in Arizona. At one point this year, every student and 86 percent of the staff at Sequel’s Capital Academy in Camden, New Jersey, tested positive for Covid-19, according to the minutes of a meeting where a Sequel executive spoke in June.
In spite of these outbreaks, none of its residents experienced severe symptoms, the company said, and many who tested positive had no symptoms at all. Sequel said it has also adjusted residents’ schedules to allow for social distancing.
During the past two years, Sequel has come under newfound scrutiny because a crusading state senator from Oregon has sparked both media reports and government action.
As public criticism grew, the company promised to improve its operations — more cameras, better training, fewer restraints and increased oversight. And yet, the problems seemed to get worse, culminating in an incident this spring in which a 16-year-old boy at a Sequel facility in Michigan died after staff members pinned him to the floor for 12 minutes.
Even as crises multiplied for Sequel, the company continued to pursue growth. Two weeks before the boy died in Michigan, Sequel announced it was expanding into Texas, taking over a chain of clinics for children with autism.
Sequel prospers because it’s one of the few companies willing to do a job almost no one else wants. In exchange for anywhere between $130 and $800 a day per child — usually paid by state and local governments — the company provides a home for children most places won’t. Its residents include foster kids who come from states that don’t have enough beds for them, and kids who have been turned away by other treatment centers because they have a history of violence.
When county and state government have trouble finding placements for foster kids, juvenile delinquents or children with behavioral problems, they turn to Sequel.
Critics say that Sequel’s approach leads to problems. “If you're a never-says-no agency, who are you going to get? You’re going to get … the kids who need the most help or have the most aggressive issues,” said Robert Block, whose son was placed on two occasions at Sequel’s facility in Columbus, Ohio.
Because the company takes such kids, state and county officials have been reluctant to sever ties with the company — although Franklin County, where the facility that housed Block’s son is located, did last year. Despite the scandals in recent years, only three states — out of more than 40 U.S. states and territories who contracted with the company in recent years — have chosen to stop sending children to Sequel facilities.
The result is a business model that banks on governments’ incapacity to create safe places for their most vulnerable children.
Sequel declined to make any of its leaders available for interviews. In response to a list of questions laying out the findings of the APM Reports investigation, the company issued a lengthy written statement.
“At Sequel Youth & Family Services, we have dedicated our careers to helping this nation’s most vulnerable youth. Their cases are incredibly complex — marked by significant trauma, broken families, mental illness, substance abuse, and systemic failures across our foster care and juvenile justice systems,” the statement read in part. “We are proud to say that in thousands of cases across the country, we have provided the care and support needed to help our students live productive and fulfilling lives.
“We know how many lives are at stake here and that without organizations like ours, vulnerable youth with the potential to live vibrant lives will continue to fall through the cracks and not receive the support they need to make that life a reality. … That’s why we can — and must — do better.”
In its statement, the company said it is moving “toward a restraint-free model of care on an ambitious timeline.” But it also acknowledged that “our successes do not excuse our failures.”
After Chris Hagman saw the graffiti on the walls at Riverside Academy in Wichita, he became obsessed with the place. He returned almost every day for a month, taking photos and videos, until he was confident he’d documented everything. He then reported what he saw to the police, the news media, even the FBI. No one seemed interested. “It fell on deaf ears,” he said. “It was very defeating.”
Last fall, the abandoned Riverside building was demolished to make way for an upscale apartment complex. The spray-painted allegations of abuse were erased forever. Only the photos on Hagman’s phone remained.
No place to go
When her son was in crisis, Angela Hunter had nowhere to turn.
Austin had started acting out at school around the time he turned 8. He’d steal things from other kids, disrupt the class, and refuse to do his work. He spent almost every day in the principal’s office at the local Catholic school, where he would lie on the floor under the desk.
Angela and her husband, Corey, live in western Minnesota, about 30 miles from the North Dakota border. They have six children, five of them adopted, including Austin.
The Hunters had only a few details about the first three years of Austin’s life. They knew his biological parents had used drugs, and there had been abuse, both physical and possibly sexual. They would later learn he had fetal alcohol spectrum disorder.
On his good days, Austin was an intuitive kid with a great sense of humor. He loved to read books about the military and the Wild West. But over the next few years, he grew increasingly violent at home and in school, throwing things, turning over desks and kicking holes in walls.
One day, when he was 11, he came at his older sister with a weed trimmer. Luckily, she was wearing a leather jacket that protected her. He also stabbed his father in the thigh with a lawn ornament.
That’s when Angela finally called 911. “It’s all we could do,” she said.
The Otter Tail County Sheriff’s Office took Austin to a juvenile lockup more than 100 miles away. Eventually he was transferred to a Catholic children’s home on the other side of the state, in Minneapolis.
“After that, things just went downhill,” Angela said. “It was like bad to worse.”
Austin returned home about six months later, but things didn’t go well. His parents would find makeshift weapons in his room. They put locks on the cabinets, but he managed to get a butter knife and tried to attack his dad with it. Austin warned his parents to “sleep with one eye open.” He even tried to set a fire next to the water heater.
“We’re never going to give up our kid because he has behaviors or problems or whatever,” Angela said. “He’s our son, and we love him to the end of time. We made a commitment when we adopted him at 3 years old.”
But it was also clear that it wasn’t safe for Austin to live in the same house with his younger siblings.
The county found Austin a place in another residential facility. He was there for a year, until one day, three staff members were trying to restrain him, and he kicked out their kneecaps.
That was the end of the road for Austin in Minnesota. When children assault staff or other residents in a treatment facility, most places want nothing to do with them. The county tried 15 treatment centers around the state, even reaching out to places that seemed pretty far-fetched to Angela, like a group home that catered to elderly disabled clients. They all refused to accept Austin.
There was only one place that said yes: Sequel.
“I was just excited and hopeful,” Angela recalled.
Sequel runs programs across the country under the broad banner of “behavioral health.” Its clients include juvenile delinquents, foster kids and children like Austin with serious mental health problems — in some cases, all in the same building.
Sequel is willing to take the kids other treatments centers won’t, including those with a recent history of committing violent assaults. It’s a niche that allowed the company to thrive in an industry that has been moving toward bringing services to children in their home communities rather than sending them hundreds of miles away to the kinds of large residential institutions Sequel operates.
Even though Sequel takes hard-to-place children and the government payments that come with them, that doesn’t necessarily mean the company has the expertise to help them. Authorities in Wyoming and Ohio have accused the company of accepting clients whose cases were too complex for its staff to handle.
Sequel has no treatment centers in Minnesota. The facility that accepted Austin was in Kalamazoo, Michigan, some 700 miles from his home. Minnesota counties increasingly relied on Sequel to care for their kids after a Minnesota-based treatment center called KidsPeace Mesabi Academy shut down in 2016 following a series of stories from APM Reports about its handling of abuse allegations. Angela had misgivings about the distance, so she went to check it out. As her Uber pulled up one day in late 2019, she felt relieved.
“It was beautiful,” she said. The former orphanage looked like a small, well-kept college campus, surrounded by wooded grounds. “From the outside, it looked really nice.”
She met a caseworker she liked, said goodbye to her 14-year-old son, and left thinking, “This is going to be OK.”
Before there was Sequel
Today Sequel is one of the market leaders in the behavioral health industry. It reported annual revenue of more than $200 million in 2017 and employed approximately 4,500 people in 2019.
Sequel formed two decades ago to operate a single facility. It arose from another for-profit juvenile corrections company called Youth Services International (YSI).
YSI was the brainchild of James Hindman, a serial entrepreneur who made his fortune first in the nursing home business and then by founding the Jiffy Lube chain of discount car repair shops.
Hindman had spent part of his childhood in an orphanage, and he had a vision of bringing private-sector business savvy to the juvenile corrections industry, which he saw as inefficient and ineffective.
The concept was similar to the model pioneered by the private prison industry, which has profited by cutting staff wages and other operating expenses. Reform schools in the U.S. at the time were typically operated by the government or as a charity, not like a business. The idea that a company could make money by rehabilitating juvenile delinquents struck many as odd. One headline referred to the concept as “juvy lube,” playing off the name of Hindman’s oil change empire.
But Hindman had few doubts. “Our profit comes from our ability to run better than the state,” he told the Des Moines Register. “We do not pay the fringe benefits. We do not give the vacation time. We do not give the sick leave a state employee gets.”
Hindman started with one facility — Clarinda Academy — in southwest Iowa in 1992, and he built an empire. Just two years later, Hindman took YSI public and during the next five years the company grew to house 4,400 residents in 35 facilities serving 20 states.
In 1999, YSI was purchased by Correctional Services Corp., which ran private prisons for adults but wanted to diversify into the juvenile market.
But while YSI was growing into a financial success, back in Clarinda, Iowa, local leaders were growing uneasy with the company’s direction. “They didn’t feel like they were going to handle the kids the way they wanted them to be handled,” said Gordon Kokenge, a Clarinda City Council member at the time.
Kokenge remembers being called into a meeting in 1999. It included Cindy Cox, a local civic leader who had wooed YSI to Iowa eight years earlier and had served as its assistant director in the early days. Cox worried that the acquisition by Correctional Services Corp. would turn Clarinda Academy into a harsher, more punitive institution, Kokenge recalled. But she and the board that oversaw the operation of Clarinda Academy had a plan to retain control.
Within weeks of YSI’s takeover, Cox filed papers to incorporate a limited liability company called Sequel Management Services. Her co-founders of the new company, Jay Ripley and Adam Shapiro, had also worked for YSI in the early days. The board broke ties with Correctional Services Corp. and hired the newly created Sequel to operate Clarinda Academy.
The name said it all. “That was the second go around,” said Jeff Nichols, who was Clarinda Academy’s final executive director under YSI. “It was a sequel.”
Like YSI, Sequel was a for-profit company, and it soon began to grow, expanding to Wyoming, Arizona, Michigan and Florida. Sequel snapped up local chains and spread to Alabama, Idaho, North Carolina, Kansas, New Jersey, South Dakota, Ohio and Utah.
In 2016, Sequel came full circle. It acquired some of the last vestiges of YSI, which had just lost its right to do business in the state of Florida amid media reports of abuse in its facilities there.
As Sequel grew, the full scope of what was happening inside its facilities became harder for its regulators — or the public — to see.
Because it operates in so many states, Sequel is overseen by a dizzying array of government agencies: state departments of human services, corrections, health and education, county probation, social services and courts, local police and sheriff’s offices, and the federal Centers for Medicare and Medicaid Services, to name just a few.
But each agency regulates only a sliver of the company’s operations. The full picture is visible to none of them.
In a sense, the company had become too big for any single government agency to regulate it. And it continued growing.
By 2016, Ripley, the only original shareholder still involved with Sequel, was still taking a founder’s fee of more than $1 million a year and in 2016 tried to take the company public, which could have earned him even more money.
In filings with the Securities and Exchange Commission at the time, Sequel presented itself as “well positioned” in a “highly fragmented industry ripe for consolidation.” It boasted that revenues had doubled over the previous six years and estimated the company was worth more than $420 million. It also reported taking “the highest acuity cases” — the kids other places turned away — and touted its “clean regulatory and litigation history.”
While Ripley was on the phone with Wall Street financiers and meeting them for dinners in New York, Baltimore and Huntsville, Alabama, state regulators in Wyoming concluded that Sequel’s operation there accepted children it was ill-equipped to care for and used restraints as a form of punishment. And in Florida and Michigan, investigators discovered staffers sent sexually explicit messages to a resident in one case and had sexual contact with a youth in another.
In New Jersey, staff were found sleeping on the job. In Kansas, the Department for Children and Families cited a Sequel facility for frequent bullying among residents. And in Iowa, the company’s flagship Clarinda Academy had its license penalized following “founded child abuse,” according to state records.
In May 2017, Sequel’s effort to go public dissolved for reasons apparently unrelated to the investigations. Luckily for Ripley, one of the investors involved in negotiations saw promise in Sequel, SEC documents show. A few months later, a Bay Area private equity firm called Altamont Capital Partners acquired a controlling stake in Sequel, adding to its portfolio of healthcare companies.
Life at Lakeside
Almost immediately after she said goodbye to her son Austin on the manicured grounds of Sequel’s Lakeside Academy in Michigan, Angela Hunter’s high hopes began to fade.
“Looks are deceiving,” she said.
Her first concern was that her phone wasn’t ringing. Even when Austin was in juvenile lockup, he’d always been allowed to talk to his parents. But at Lakeside, Angela was told, phone calls were a privilege. That’s in spite of a law in Austin’s home state of Minnesota guaranteeing residents in such facilities the “right to reasonable communication” with their parents and other important adults in their lives.
Like many Sequel facilities, Lakeside tried to encourage good behavior through a system of rewards. Residents who followed the rules could earn additional privileges, including phone calls, family visits and later bedtimes. Students who regressed could lose those privileges.
Angela says she went three weeks without hearing Austin’s voice. Her husband, Corey, finally called the facility.
“We want to talk to our son,” she recalled him saying. “This is ridiculous.”
When she did get to talk to Austin, Angela grew even more concerned. He told her a staff member had punched him in the ribs. Child protection officials investigated and couldn’t confirm his story, but two weeks after the allegation surfaced, Sequel gave notice that it wanted Austin out of the facility. According to an email from Austin’s county social worker in Minnesota, the company said his needs were too complex.
“I just found it very strange,” Angela said. After all, it was no secret Austin had serious problems. It’s why he’d been sent to Lakeside — hundreds of miles from his home — in the first place. “I just felt like it was because he reported what happened.”
In hindsight, she wished Lakeside had succeeded in getting rid of Austin, but it was easier said than done. Just like before, the Minnesota county where the Hunters lived couldn’t find anywhere else to send him. So he was stuck at the Sequel facility, even though the company had asserted that he needed “a higher level of care” than it could provide.
The conditions at Lakeside Academy would soon make national news.
‘A recipe for destruction’
The problems at so many Sequel facilities aren’t a coincidence, according to interviews with more than a dozen former employees from around the country. They described similar themes: low pay, high turnover, a staff stretched too thin, caring for children who have experienced trauma, and who have complex emotional problems and psychological conditions.
“It’s just a recipe for destruction,” said C.J. Huff, who worked as a shift supervisor for three years at Sequel’s facility in Owens Cross Roads, Alabama, while completing his master’s degree in counseling psychology.
In 2017, the year Sequel was bought by a private equity firm, Huff said the facility started accepting children with more significant developmental disabilities than it had before.
To Huff, it looked like the company was focused on keeping beds in the facility filled. “It just seemed more of a money ploy,” he said.
Kyla James, a teacher who worked for Sequel’s Lakeside Academy in Michigan, saw a similar trend.
“It was: Fill the beds, fill the beds, fill the beds,” she said.
Meanwhile, former employees say, the facilities were often short-staffed, with a constant churn of turnover. At Lakeside, for instance, a state inspection report from 2019 showed more than one-third of employees had been on the job less than a year.
“My understanding was they were willing to hire literally anyone who was willing to take the job and could pass a background check,” James said.
And the jobs didn’t pay much considering the danger and difficulty involved. Depending on the facility, former employees said, starting wages for staff working in the dorms tended to be in the range of $11 to $13 an hour.
“When you hire 20-year-olds for $13 an hour to take care of 17-year-olds, that might not be a recipe for success,” said Darcy Wilkin, another former teacher at Lakeside. “We needed more people who were better trained and better paid.”
The former director of Sequel’s facility in Sheridan, Wyoming, acknowledged in a public meeting last year that its employees weren’t paid enough.
“Not many people are going to work for $12-and-a-quarter doing what we’re doing,” Gary Flohr told the Sheridan County Commission. “You can go out to the truck stop and be the night clerk for $12.50 or stock shelves at Walmart for $12.50.”
The Wyoming facility recently boosted pay to $15.50 for employees “with experience.” But it has still had difficulty recruiting employees, something its new executive director attributed to fears over Covid-19, according to minutes of a meeting in April.
Despite these common problems, Sequel hadn’t received much attention from the media or state lawmakers. In 2019, that began to change.
In late January of 2019, Oregon state Senator Sara Gelser’s phone rang. It was a local reporter who wanted to know why Oregon was increasingly sending kids in the foster care system to treatment centers in other states — some as far away as Tennessee.
It was the first Gelser had heard of the policy, which was odd because Oregon’s top child welfare officials had recently testified in front of the Senate Committee on Human Services, which she chairs, and they hadn’t mentioned sending kids out of state.
At first Gelser thought there was probably a good explanation. But then she got a leaked document listing some of the programs where children were being sent. She started searching online. A report done by a disability rights group in neighboring Washington state was among the first to pop up.
It alleged excessive restraint practices and inadequate treatment at Sequel’s flagship Clarinda Academy in Iowa. In response to the 2018 report, Washington state immediately stopped placing children at Clarinda Academy. And yet, right next door in Oregon, referrals continued.
“Do we really have kids there?” Gelser texted a child welfare official. If the allegations were true, she wrote, they would be “far outside our safety and dignity practices.”
Throughout 2019, because of Gelser and a number of people who raised alarms, Sequel began to face greater accountability for conditions inside its facilities. In one year, the company closed six treatment centers across the country — more than it had ever shuttered in such a brief span of time. It was a year that revealed the scope of the problems at Sequel.
After learning about Washington’s decision to sever ties with Sequel’s Clarinda Academy, Gelser started collecting news reports about the company. The stories of licensing violations, sexual assaults, and physical restraints from across the country seemed overwhelming. She quickly came to believe the issues with the company were systemic.
Around this time, in early 2019, the Tennessee Department of Children’s Services received a disturbing email. It said children were being restrained face-down on the ground at Sequel’s Kingston Academy. Doors at the facility were held shut with two-by-fours. The buildings were crumbling and unsanitary. And, the email said, there were pictures.
“This just feels very icky and quite concerning,” read the email. The name of the email’s author was redacted in documents released to APM Reports.
The state of Tennessee launched an investigation, and three weeks later it removed 18 children from Kingston. A month later, Sequel shut it down.
Oregon had one kid in the Kingston facility. But Sequel assured state officials not to worry: The building was outdated and just needed some repairs. It never reopened.
One month later, a riot broke out at the Sequel’s Red Rock Canyon School in St. George, Utah. Gelser had been keeping a close eye on the facility because Oregon had more than 20 foster children there.
Gelser decided to launch her own investigation. She filed a flurry of public records requests to police departments and licensing agencies in Utah, Idaho, Illinois, and Michigan to name a few.
“OMG,” Gelser texted the same Oregon child welfare official in May. “The Red Rock records (recent!) are horrifying! Choke holds that prevented a child from breathing, a child stabbed in the stomach with a kitchen knife, blood on the walls of the ‘time out’ room.”
A 16-year-old foster girl was told to surrender all her belongings when she arrived at Red Rock, according to police reports obtained by Gelser. The teenager refused to give staff a cherished photograph of her deceased brother. Three staff put her in a “hands on” restraint, pinning her to the floor by her feet, arms and stomach. The girl said she struggled to breathe.
The police officer asked Red Rock staff what the protocol was for restraining residents. The facility director told the officer they were expected to restrain youth “until they have control and the student is cooperative,” according to the police report.
For Gelser, it took time to reconcile the licensing and police reports she was reading with the reassuring, friendly marketing staff and executives from Sequel who visited her office.
But it was starting to crystallize. The company had an uncanny ability to say all the right things and control what was revealed to the public, she told a reporter from Oregon Public Broadcasting.
And Oregon’s child welfare officials were buying it. They visited Sequel’s Red Rock Canyon School a few days after the riot and filed a complimentary report.
The same week, the state of Utah released a report on Red Rock that offered a more damning view of the facility. Utah investigators reported alleged abuses, including understaffing that led to violence and sexual misconduct in the program. They also noted that employees let residents physically restrain each other. In one instance they documented, a resident was put in a chokehold, dropping to his knees and rendered unconscious after being restrained by another youth in the program.
Two months later, Sequel closed the facility.
“[Oregon child welfare officials] were at the mercy of a company that is extraordinarily charming,” Gelser said. “And we had no structure in Oregon around who’s watching out for these kids. How do we know that they’re okay? How do we verify what this for-profit corporation is telling us?”
Long before Sequel, Gelser had earned a reputation as an advocate for Oregon’s most vulnerable children.
She had years of experience: The day before her 21st birthday, and shortly after she graduated from college, she gave birth to her first son, who had a rare genetic disorder. Gelser quickly realized that for her son to get the care he needed, she would have to learn to navigate a maze of bureaucracies and a complex health care system. She also couldn’t be afraid to be loud or assertive or persistent.
In the Legislature, Gelser became the first lawmaker to accuse a fellow senator of sexual harassment during the Me Too movement. Fifteen women followed her lead. TIME Magazine named her one of “The Silence Breakers” in its 2017 Person of the Year issue.
She brought that same assertiveness and persistence to her work on Sequel. She would wake up before her kids and pore through public records requests. Gelser fired off long emails to regulators and lawmakers in other states urging them to pay attention to what was happening. She would give speeches about Sequel on the Senate floor. She repeatedly blasted the company on Twitter.
When she couldn’t sleep or couldn’t stop thinking about the youth stuck in Sequel facilities, she would head out to a section of her back yard. She would punch at a web of tangled roots with her shovel, dig out pieces of old broken bricks and smooth the dirt. Now, that section is a patch of fragrant peonies, geraniums, colorful salvia, lupine, hydrangeas and lavender.
She calls it her “Sequel rage garden.”
Her anger with the company grew throughout 2019. The same month Sequel officials closed the Red Rock Canyon School, and another Utah facility, investigators were arriving at yet another Sequel treatment facility some 2,000 miles away. There, in Raiford, Florida, they discovered that four staff members had stood by and allowed residents to brawl so violently that one boy suffered permanent damage to his eye. The staff then failed to report the incident to the state as required by law. Three of the employees were charged criminally, and the Florida Department of Juvenile Justice revoked Sequel’s contract to run the facility.
Sequel began to attract more media attention. NBC Nightly News aired a segment that detailed abuse allegations at the company’s original facility, Clarinda Academy in Iowa.
In Columbus, Ohio, Christina Marshall went to the local TV stations after her 14-year-old son was beaten by other residents at a psychiatric facility called Sequel Pomegranate. “It was horrific,” she wrote. “I’ve never seen anything so bad in my life.”
One station started digging into records and aired a series of exposés highlighting the large number of calls to police from the facility, physical and sexual assaults by residents and improper restraints by staff.
The media attention helped bring to light incidents at Sequel Pomegranate that might have otherwise gone unnoticed. A nurse was caught on video punching a child. Following two riots this spring, the facility’s executive director admitted to police, his facility “isn’t safe right now.”
“We’ve got four or five girls here that are hell on wheels,” Executive Director Jeffrey Rice said, in a conversation captured by an officer’s body camera. “They’re threatening staff. They’re fashioning weapons. They’re destroying property. We aren’t equipped to handle that. We never have been.”
“Sounds like somebody needs to do a better job screening people coming in,” the officer replied dryly.
A disability rights group would later publish a report condemning the “pervasive and disturbing problems embedded in the treatment culture” at the facility. The state of Ohio is in the process of revoking Sequel Pomegranate’s license to operate.
By July 2019, after months of damaging media reports, Sequel officials had launched an effort to improve the company’s image. There was one person they needed to win over: Gelser.
Gelser was on a family vacation in Jackson Hole, Wyoming, when the 45-year-old lawmaker got a call from Chris Roussos, the new CEO of Sequel. He said he was in the midst of overhauling the company. He had installed hundreds of cameras and had been on “listening tours,” visiting the facilities and speaking with residents. He asked if he could meet Gelser. They arranged to tour some of the company’s facilities in Iowa together, including Forest Ridge Youth Services.
When Gelser and Roussos walked the hallways there, she started to wonder if she had misjudged the company. The staff members were smiling and positive. They had strong handshakes and made eye contact. The residents were polite.
But she still suspected that something wasn’t right. At another Sequel facility in Iowa, it seemed to her that some of the conversations were scripted.
She decided to stop at one more Sequel facility before flying home.
This time, though, she wasn’t going to tell Roussos. This visit would be unannounced.
As soon as she walked into Northern Illinois Academy in suburban Chicago, she saw a different side of Sequel. The place was a mess, Gelser said, with filthy walls and a terrible odor.
Within minutes of arriving, Gelser saw two adults pin a developmentally disabled girl against the wall. The teenager apparently entered an office and headed toward a fruit bowl without knocking on the door first.
Gelser also reported spotting a child zipped from toe to chin in a body sock. Another was in a seclusion room with the lights off.
The problems at Northern Illinois Academy went well beyond what Gelser saw, according to records.
In 2019, a former staffer was sentenced to 10 years in prison for sexually assaulting a resident at the Illinois facility. Another staffer gave drugs to a resident, sent her love letters, “rubbed her butt and bit her neck,” according to a state investigation. An 18-year-old resident was charged with allegedly raping a 13-year-old girl during a field trip, spurring a lawsuit. And a staffer allegedly choked a resident under age 13, in an incident caught on video. The staffer was later charged with battery and child endangerment. State records from previous years reveal incidents where staffers tackled, punched and body slammed residents.
A few months later, in January 2020, Gelser traveled to Lakeside Academy in Kalamazoo, Michigan, along with other Oregon lawmakers and officials, including the state’s director of human services. Oregon still had youth placed in Sequel facilities, despite Gelser’s crusade. The state wasn’t ready to sever ties with Sequel.
Roussos, Sequel’s chief executive, was at this meeting as well. It had been about six months since they toured facilities together in Iowa, and their relationship was no longer friendly. Gelser’s persistence had led regulators to crack down on Sequel’s Illinois facility, declaring that the deficiencies at the facility were so serious they constituted an immediate threat to the children’s health and safety.
At one point, the meeting at Lakeside Academy became heated. Gelser said she warned Roussos that the company’s use of physical restraints would result in serious injury or worse. “Someone is going to die,” she said.
The 12-minute restraint
A few months later, on April 29, a 16-year-old named Cornelius Fredrick Jr. was in the cafeteria at Lakeside Academy, sitting alone at a table, when he threw some bread at another resident. It’s nothing that hasn’t happened in every high school lunchroom in the country. Fredrick methodically removed the crusts from his sandwich and tossed it underhand to the next table.
A staff member, who had been standing next to Fredrick, trying to head off a food fight, responded by shoving the teenager to the ground. Other men came to help, first two, then three, then four. In all, eight adults took part in holding him down, as many as seven simultaneously. It lasted an agonizing 12 minutes.
At that point, Fredrick had been at Lakeside for about 17 months. He had lost his mom when he was 10. She had died in her sleep, and Cornelius was the one who found her. At the time, his father was in prison, and with no family to care for him, the boy became a ward of the state of Michigan.
He was a child so invisible, official records can’t seem to agree on the spelling of his name. The Kalamazoo police department says “Frederick.” One court petition says Fredericks. Another says Fredricks. On his Facebook page, it’s Fredrick.
He was called “Corn” for short. For his first two weeks at Lakeside, he didn’t say much, said Wilkin, who was one of his teachers there. But Fredrick was smart, good at math, and such a whiz with computers the teachers all had to change their passwords. Eventually they made him do his schoolwork on paper. “The best hacker we ever had,” Wilkin said.
James, another one of his teachers, told him he had the most elegant name she had ever heard. “I got a smile — a genuine smile,” she recalled. “He had a really beautiful smile. And I see it all the time.”
But he would also get into fights with other residents and with staff, records show. Just like Austin Hunter — the boy from Minnesota — Lakeside was trying to get rid of him. On April 28, a day before the cafeteria incident, Sequel had sent a letter to his social worker, saying the company wanted him gone within a month.
After pinning Fredrick to the ground for 12 minutes, the adults finally stood up. The boy was limp and unresponsive. Another 12 minutes passed. Finally, Heather McLogan, the head nurse at Lakeside called 911.
“Is he breathing?” The dispatcher asked.
“Yes, but lightly,” McLogan replied.
He was taken to a hospital, where he died two days later. The medical examiner ruled it homicide by asphyxiation.
It wasn’t the first time Fredrick was physically restrained for an extended time. In January, he was taken to the ground and held down for 31 minutes, according to a police report. Four to seven staffers restrained him, an event also recorded on video. When the restraint was over, they helped him to a seated position. He appeared disoriented and semi-conscious. He can be seen on the video crying and struggling to walk, according to a police report.
To defend themselves, Sequel officials often point to their written policy stating that restraints should only be used when a child is about to harm himself or another person. But as Fredrick’s case manager, Meghan Folkerson, told the Kalamazoo police, that policy often wasn’t followed.
The requirement to try non-violent, de-escalation tactics first often went unheeded, Folkerson told police. “She also said that often restraints would involve more people than is allowed,” an officer wrote. “She confirmed that usually, three is the maximum number of staff allowed in a restraint. Sometimes, four would be acceptable.”
“The tragic loss of Cornelius Frederick at Lakeside Academy has only served to strengthen our resolve to reduce, minimize, and eventually eliminate the use of restraints on our campuses,” Sequel wrote in a statement to APM Reports following the incident. “There is no question Cornelius should be with us today. We are committed to doing whatever necessary to ensure this does not happen again on our watch, in our programs. We will not tolerate the misuse of restraints in any situation for any child in our care.”
At the time, Sequel said it was cooperating with the investigation. But the police report tells a different story. It notes Sequel used its lawyer to block officers from interviewing Lakeside employees.
Installing hundreds of new cameras was one of the solutions the company had offered under Roussos’ leadership amid the barrage of negative press. Those cameras captured Fredrick’s last moments of consciousness. The horrifying video has led to national outrage, but it didn’t save his life.
Another reform the company promised was called Ukeru, a system that provides staff with padded shields, so they can protect themselves without restraining residents. At one point in the video, a staff member takes his weight off Fredrick long enough to retrieve a Ukeru shield. He leans it against a table, where it sits uselessly for a few minutes, until someone finally moves it out of the way. Ukeru didn’t save Fredrick either.
His death would draw comparisons to the infamous police killing of George Floyd a few weeks later in Minneapolis. It was condemned by everyone, from the governor of Michigan on down. Two of the staff who held Fredrick to the floor and the nurse who finally called 911 have been charged with involuntary manslaughter and child abuse.
Among the dozens of kids who witnessed the restraint that killed Fredrick was Austin Hunter, the 15-year-old boy from Minnesota. They’d been friends.
In the days that followed Fredrick’s death, riots erupted at Lakeside Academy. Students brawled along racial lines. ”Blacks against Mexicans,” according to the police reports. Staff were overwhelmed. “The entire campus was in utter chaos,” one officer wrote.
At least 10 kids ran away from the facility, including Austin.
“They were all starting to get scared,” his mother, Angela, said. “They thought they were going to end up [dead] like that.”
Austin broke into a YMCA and a motel. He ate food he stole from a vending machine. Police found him three days later, hiding in the woods. And, while in juvenile detention in Kalamazoo, he tested positive for Covid-19. Based on when he reported the symptoms began, he likely contracted the virus at Lakeside, part of a significant outbreak that infected at least 41 residents and 13 staff.
The 15-year-old had already experienced unimaginable trauma in his early life. He left Lakeside Academy even more traumatized, said his mother, and certainly no better for the treatment he received there.
“Something broke in him,” Angela said, sobbing in an interview with APM Reports. “I can tell there’s a difference.”
Fredrick’s death had consequences for the company, too. Lakeside Academy and its sister school in Michigan, Starr Albion, both closed about two months later under pressure from the governor. They join the list of six facilities the company closed in 2019. The boy’s family has filed a civil rights lawsuit against the company. Roussos is no longer Sequel’s CEO, according to his LinkedIn page. He was in the job a little more than a year. Today he remains an advisor to the board.
Gelser hasn’t stopped her crusade, though. She said she won’t stop until at least Northern Illinois Academy is closed.
“I don’t believe Sequel is about helping kids or helping families,” she said. “Sequel is about making a lot of money for investors, and Sequel is an organization that uses the kids as cash cows and uses low-paid, poorly trained frontline staff … as disposable tools.”
Ohio is trying to close Sequel Pomegranate. The Washington State Department of Children, Youth and Families and the Alabama Department of Mental Health have suspended admissions to Sequel facilities while they conduct reviews of the company. Two other Alabama state agencies — those overseeing foster children and juvenile delinquents — also conducted investigations this summer. The one by the Alabama Department of Human Resources is ongoing. Both agencies are currently sending children to Sequel.
Sequel may be smaller, but it still survives. Despite the many controversies, only three states — Minnesota, Oregon and Maryland — of the more than 40 U.S. states and territories that have been doing business with Sequel have severed ties with the company. Michigan has forced the closure of Sequel’s treatment centers, but county courts are still sending kids to Sequel facilities in other states.
In recent years, Wyoming has sent hardly any of its own kids to Sequel, but the state continues to license one of its operations. State regulations limit its ability to oversee the treatment provided by private companies.
“We’re a state that really does pride ourselves on regulatory restraint,” said Korin Schmidt, director of the Wyoming Department of Family Services.
California says it has no plans to block its counties from sending kids to Sequel’s remaining facilities. The state removed 41 kids from Lakeside Academy and revoked its certification following Fredrick’s death, but it still has 52 children at other Sequel facilities, including Clarinda Academy and Woodward Academy in Iowa.
“At this time, [the California Department of Social Services] is not revoking Clarinda’s or Woodward Academy’s certification,” Scott Murray, an agency spokesperson, said in a written statement to APM Reports. He declined to make department staff available for interviews as did regulatory agencies in Iowa, Florida and Tennessee.
Simone Marstiller, secretary of the Florida Department of Juvenile Justice, wrote: “The Florida Department of Juvenile Justice has a rigorous and comprehensive monitoring and oversight process for all our programs. We hold our contracted providers accountable and ensure they hold their staff accountable for their actions.”
Sequel still operates eight facilities in Florida, one in Kansas, two in Utah and four in Alabama, even after the company closed treatment centers elsewhere in those states in the past two years.
“We take very seriously any incident in which a child in our care is placed in harm’s way. These events are antithetical to our mission and who we are as individuals,” Sequel said in its written statement. “We hold ourselves to a high standard of care and are committed to improvement. We are proactively working closely with partner organizations and regulatory agencies around the country to ensure we prevent future incidents that are counter to our mission.”
The company is still trying to expand. It recently acquired facilities in Texas and opened a new program in Arizona.
While the video of Fredrick’s death led to a number of news stories about problems at Lakeside Academy, the company followed its pattern of closing a troubled facility and focusing on its businesses elsewhere. It’s not yet clear if the company will face larger consequences.
And there’s still an underlying need to house kids that other treatment centers won’t take.
Austin Hunter is back in Minnesota. Otter Tail County officials are once again searching for a place that will house him and help him. In the meantime, he remains in the juvenile lockup.