On her way home after picking up her son from Centers for Youth and Families, Tricia Ellinger pulled over to throw his shoes away.
The then-8-year-old had been at the nonprofit psychiatric facility in Little Rock from August 2019 to February 2020. When he was released, Ellinger was shocked at how unkempt her child appeared.
His long toenails were beginning to curl under. His clothes barely fit. His shoes reeked, and she couldn’t bear to keep them in the car.
“That was really alarming,” Ellinger said. “When I picked him up in February, he was filthy dirty.”
But grooming wasn’t her most disturbing discovery as she learned more about her son’s time at Centers.
Ellinger is among six parents and guardians, two former residents, and 11 current and former employees to identify shortcomings at Centers’ Little Rock psychiatric residential programs.
The behavioral-health provider recently drew a rare rebuke from a state licensing board after inspectors and advocates reported problems at its Elizabeth Mitchell Centers residential site, including suicide attempts, sexual contact between children and injuries. Four kids suffered broken bones during physical restraint holds by the staff in less than a year, inspectors said.
Now, reporting by the Arkansas Democrat-Gazette — spanning five months and drawing on dozens of interviews and thousands of pages of records — has uncovered more disarray at Centers than was widely known across a longer period of time than was previously understood.
Centers’ officials primary explanation for the turmoil, which also prompted the state to place the facility on a six-month corrective plan, has been the pressures of the covid-19 pandemic on clients and the staff.
The newspaper, however, spoke to families about several care failings that preceded the global health crisis.
Current and former employees of Centers, as well as the families, described a setting lacking in personal hygiene, mental health care, proper supervision and general order.
Documented problems did increase as the pandemic gripped Arkansas.
Police calls to the facility spiked starting in 2020, with officers summoned to take reports on violence, alleged sexual assault, runaways and suicide attempts, records show.
Children hurt themselves, hurt one another and were occasionally hurt by the staff.
One former client said Centers leaders failed to protect her after her roommate violently attacked her. The mother of another client said staff members allowed a 52-year-old man to repeatedly contact the teenager by phone during her stay, despite Centers having a copy of an order barring such contact.
A medical record obtained by the newspaper shows that a 13-year-old girl, who was hospitalized with “severe” diabetic ketoacidosis, was ill for up to two days before she was found “not responding” after failing to wake up.
After three kids were injured during restraint holds between August and October of 2020, an administrator at Centers asked that a staff member alleged to be involved in an incident that broke a teen’s arm “be allowed to” keep working at the 12th Street campus in an office role during an appeal, emails and other documents show.
Taken together, the accounts shed light on a facility entrusted with kids’ well-being by the state, parents and guardians who sometimes receive limited information about what’s happening behind closed doors.
For instance, after Ellinger’s son returned home from a different residential treatment program in Georgia, he asked if his new pediatrician was going to give him “booty juice.” Pressed on what that meant, he said it’s a shot “they give you in your butt that makes you fall asleep.”
He’d received such shots at Centers, before he went to the Georgia facility, Ellinger’s son explained to her. He said he got them often — more than once a week.
“No one ever called. I didn’t even know as a parent of a kid in residential that I should be asking” about injections, said Ellinger, who lives in Idaho. It was her son’s first stay at a psychiatric residential facility. With the exception of a nasal spray prescription after a bloody nose, she said Centers hadn’t told her the child was receiving new medications.
Two detailed voicemails, other calls and an email to her son’s former Centers therapist to ask for an explanation went unanswered last fall, she said.
In written responses to reporters’ questions, Centers officials said they’re unable to discuss specific clients because of confidentiality rules, but that the facility provides personal hygiene instruction. Parents must sign consent forms for injectable drugs before admission and are “always notified” following administration, they said.
As part of recent organizational changes, Centers added two new medical directors, a director of nursing and a full-time psychiatrist to its ranks. The facility also installed a new risk management director, two new nurse managers and a new program director, spokesman Bill Paschall said in an emailed statement. Officials also said in an Aug. 2 interview that they’ve improved training, changed restraint practices and dismissed employees.
Paschall acknowledged that “there’ve been mistakes that have been made,” but the facility had done everything “we can and we’re continuously looking at ways to improve every day.”
State Department of Human Services staffers have seen improved communication from Centers, as well as a reduction in “emergency safety interventions” since May, an agency spokesman said.
As of Aug. 1, 25 children were staying at Centers, according to census numbers obtained through the state’s open-records law. The facility is licensed for 49 psychiatric residential beds and 13 residential beds.
In interviews and written comments, Centers officials repeatedly emphasized that the facility treats kids with serious emotional difficulties and past trauma. The pandemic “created challenges for families, clients, and behavioral health providers” and “disrupted the structure and routine our clients rely on,” they said.
Responding to questions from the Democrat-Gazette, Centers disputed the accuracy of a police report, Department of Human Services records, parents’ comments and an April report from Disability Rights Arkansas advocates that referred to police records, state records, medical records, facility video, policy documents and client interviews.
RECURRING PROBLEMS
What happens at Centers matters because of its critical position in the treatment landscape. The facility treats some of the most vulnerable children from Arkansas and other states, including some that other facilities won’t take, a spokesman said. Some clients have suffered “indescribable” abuse, according to grant applications obtained through open-records requests.
Most clients are from households that live at or below the poverty line, an application said. Demographic estimates for a Centers program for survivors of child abuse and human trafficking said 40% of clients are Black and most have mental-health disabilities.
The trafficking program was part of treatment Crystal Stark’s daughter received during her final of three separate six-month stays at Centers. But the program, as well as the quality of routine therapy and education, proved to be lackluster, ineffective and underwhelming, said Stark of Sherwood.
In the fall of 2020, the teenager used the facility’s phone line — as well as a staffer’s cellphone — to contact a 52-year-old man who was barred from contacting her, Stark said.
A primary reason Stark admitted her daughter to Centers this third and final time was because Stark found written and photographic evidence indicating that the pair had been sexually engaged, she said.
Stark provided Centers a judicial no-contact order between the girl and the man when the girl was admitted, she said. That she was able to contact him while receiving treatment in the facility’s trafficking program was stunning, Stark said.
“It was never, I don’t think, a good facility to help children who need the help,” Stark said. “It’s not made to be that.”
In its response to written questions, Centers officials said they were “unable to respond … due to client confidentiality.” The statement went on to say, generally, that clients “are not permitted to speak by phone with anyone not on an approved call list.”
The facility told Stark that a staff member was dismissed over the calls, she said.
Stark, whose daughter first went to Centers in 2018, said her qualms about the facility preceded the pandemic.
A recurring problem, Stark said, was understaffing. Multiple times, her daughter went weeks without regular therapy sessions. Stark had to “harass the hell out of them” to trigger sessions, she said.
Each time her daughter returned home, Stark felt that the teen was not equipped to “self-maintain” her mental health and needed more care.
“Treatment is not one-size-fits-all, and if our program is not a good fit for a client we recommend and support pursuing alternative treatment options,” Centers leaders said in response to questions.
‘A BREAKING POINT’
It took “multiple” messages and at least three or four days, a Conway parent said, for Centers’ administrators to return her calls after her 13-year-old daughter was physically assaulted by an older client.
Centers officials said in their statement that they “refute the validity” of the parent’s claim, but did not provide further specifics.
The parent enrolled her daughter for treatment at Centers in August 2020 after reaching “a breaking point” with the child’s mental-health struggles. Centers was “what was available at the time — and it was the quickest to get her in somewhere,” the parent said. The family requested anonymity to preserve privacy.
More difficulties awaited in the treatment setting.
In a phone interview with a reporter and her mother, the child said her roommate at Centers — a 15-year-old, according to a police report describing the incident — attacked her. The older girl “choked me” and “busted my lip open,” she said.
Her mother heard about the event from her daughter during a family phone call and followed up until she eventually received a call from an administrator to discuss it. Centers said the staff would keep the children apart, she said.
But her daughter kept encountering the other girl, including during a fire-alarm evacuation. At that time, the other child physically threatened her, the Conway mother said.
“As a parent, it really bothered me. Here I have my child, and I have put my child in a position where she doesn’t feel safe. She doesn’t feel like the adults around her are keeping her safe.”
She withdrew her daughter from treatment ahead of schedule.
UNRESPONSIVE
Centers’ leadership has repeatedly disputed an account initially raised by Department of Human Services licensing staffers that a 13-year-old child was found “unresponsive” at the facility and had to be rushed to the emergency room.
The facility’s attorney, chief spokesperson and chief executive officer contend that the child was awake and responsive when a staff member decided to drive the client to Arkansas Children’s Hospital because of the child’s nausea and other illness.
A medical record obtained by the Democrat-Gazette, however, said the child was “not responding” when taken to the emergency room.
The “presenting problem” documented on the medical paperwork was “diabetic ketoacidosis with coma” associated with Type 1 diabetes.
The paperwork, a form filled out by Children’s Hospital, stated that the 13-year-old “did not wake up and was found to be altered and not responding” before she was taken to the emergency room. The child was “extremely thirsty” and suffered from two days of nausea, throwing up, diarrhea and stomach pain leading up to the emergency, it read.
After spending four to five days in the hospital, including time in the ICU, the girl was released to her family, according to her mom, who asked not to be named in this story for privacy reasons.
The Department of Human Services’ licensing staff brought the issue to light during a June 24 meeting of the state’s Child Welfare Agency Review Board.
Ebony Russ, program manager for the state unit that inspects facilities such as Centers, said then that the state was following up on a recent incident in which a child was “found unresponsive” and “had to be rushed to the ER.”
“The child was not found unresponsive,” Centers’ attorney, Ashley Hudson, told the board in response. “The child was experiencing nausea and some other symptoms. Centers did what they should, which is take them to the emergency room at Children’s, where that child was diagnosed with diabetes.”
Hudson is also a Democratic state representative from Little Rock.
Other officials stood by Hudson’s account in a recent interview. In response to questions, Centers’ Chief Executive Officer Melissa Dawson said the child was “responsive.” Paschall said “there’s no basis in fact in” the description by Russ that the child was not responsive, adding that Centers’ officials “don’t know where that [idea] came from.”
In response to written questions about the medical paperwork, Centers officials said they were “not legally privy” to the document. They did not dispute sections quoted by the newspaper.
“Once this client was transported and admitted to the hospital, The Centers cannot attest to the client’s condition or whether her condition changed upon being seen,” they wrote. “We can attest that she was conscious and responsive in transport and upon arrival.”
The girl was “being treated and under medical monitoring” at the time because of the symptoms over the earlier two days, the officials said when asked if they should have acted sooner, adding “the community was experiencing a stomach virus” and the facility had one active case of covid-19, for which the girl tested negative.
The medical staff “determined her symptoms were not improving and she warranted further evaluation,” the statement says. “We are proud of our staff for taking quick action to protect the health of this client.”
‘NO CONTACT WITH CHILDREN’
Last year, a Centers manager asked the state licensing staff “for approval” allowing an employee reportedly involved in a restraint incident that broke a child’s arm to continue administrative work at the site, according to emails and other documents.
Documenting a referral from the Arkansas Child Abuse Hotline, a November Little Rock Police Department report said a 31-year-old Centers staff member placed a 16-year-old client in a physical restraint after the client hit him in the face. He pushed the child against the wall, and both fell to the floor, the report said.
A child welfare board document that appears to describe the same incident says the client was diagnosed with a “comminuted” fracture to the arm at Children’s Hospital. (Centers said in response to questions that a video review of the hold showed it “appeared to have been administered appropriately. Unfortunately, it resulted in an injury.”)
After the incident, a member of Centers’ leadership wanted the OK for the staff member to remain with the facility during an appeal process, emails show. The staff member didn’t return requests for comment.
A Dec. 18 email from a Centers program manager to state officials with the subject line “Follow up- [The employee’s name]” asks that an employee, whose name is redacted in the email body, “be allowed to” continue to work on the 12th Street campus as a program coordinator.
“He will not have any interactions or contact with the students and will be under my direct supervision,” the manager wrote.
A human services licensing specialist wrote back to inquire what the employee’s responsibilities would be “where he would have no contact with children.” Centers’ manager said the employee would update the facility’s strategic plan, build partnerships with other agencies and attend to staffing issues or counseling.
Officials in a statement said Centers met requirements to move the employee to a position with no client contact. The employee was placed in a clerical role and is no longer employed with Centers, they said.
“Given that all individuals who are accused of child neglect or maltreatment under Arkansas law are entitled to due process, Centers complied with its obligation to protect its clients and to allow its employee the freedom to pursue his appeal,” they wrote.
Advocates from Disability Rights Arkansas — the state’s federally mandated monitor for people with disabilities — hinted at their dismay over the situation in a recent investigative report highlighting problems at Centers, though their report does not identify the employee by name. The newspaper obtained the group’s report via records requests.
Centers disputed the accuracy of the advocates’ report, suggesting in a written statement that it demonstrated “extreme bias.”
SELF-HARM
Situations that imperiled children at Centers persisted this year, state records show, including situations where children could hurt themselves, and sometimes, they did.
The facility’s licensing inspectors cited the facility six times since January over infractions related to children’s self-harm or access to items, such as drawstrings and shoelaces, that children could use to hurt themselves, according to Human Services Department compliance reports and other documents.
Centers disputed the accuracy of the reports and tied issues to “contraband” received from family members or obtained on home visits.
“Because The Centers is a treatment facility and not a prison, our clients are entitled to a certain level of privacy,” a statement said.
Twice this year, regulators cited the facility over supervision issues related to suicide attempts.
While on suicide precautions, a client was found lying on a bathroom floor with a shirt tied around her neck. A staff member was “found not to have followed the supervision guidelines,” board documents say.
A licensing specialist reviewed video footage of an attempted suicide “and noticed there was a period of time that elapsed while client was in the room alone and no one had checked to see what was happening or what she was doing,” documents referring to an April 5 citation show. Centers said the client was under video surveillance and was being monitored.
Later that month, a 16-year-old used broken glass from the kitchen to cut herself on “both wrists,” according to an April 30 police report. An email from one of Disability Rights’ advocates to the state said the glass was a broken coffeepot and that the child cut herself “severely enough” that she was treated in the emergency room.
Glass, plastics and other dangers have been “addressed,” Centers’ statement said, while raising questions about the accuracy of a report.
“The client breached a food service window during mealtime, grabbed a glass coffee pot, broke it, and threatened staff and clients with the broken glass. Unfortunately, the client injured herself in the process,” written responses said.
Centers’ response to questions says its records indicate that the staff member who called the police “was not physically present when the incident occurred.” Officials maintain that no “serious injury” has occurred from a suicide attempt.
‘INCIDENTS OCCUR’
Little Rock police were called to Centers 91 times between Jan. 1, 2020, and June 30, 2021, an average of five times per month, according to a review of police records.
The volume in that 18-month period marked a sharp increase from the 49 calls for service at Centers’ 12th Street address in 2018 and 2019 combined, according to police logs.
In 2020 and 2021, officers responded to nine calls pertaining to clients who tried or expressed desires to harm themselves and 19 cases of violence involving an adult — either as the victim or the suspect — according to police reports. Another 19 cases involved violence among children, according to the reports.
Centers accepted more clients from juvenile detention centers during this time frame because of pandemic closures of those sites, which “often resulted in clients not being placed in the most appropriate facility,” officials said in response to questions.
Suspension of family leave, off-site therapeutic activities and family visitation during the pandemic negatively affected treatment, they also said.
A former client, who is now 18, recalled violent incidents when describing her time at Centers. Being in the facility from November 2019 to April of 2020 “added on to” hurt she’d experienced, the young woman said. She asked not to be named in this article.
While being treated at Centers, a client once choked her for several minutes before the staff broke up the altercation, the former client said. During class, she watched as three clients “jumped on” another. She recalled that it was often younger girls who were the targets of attacks.
“It was a lot of trauma for me, and a lot of stress. I didn’t understand why they would have ever put a child through so much, when they’ve already been through enough at home,” she said.
Centers said in a statement that “while we regret that incidents occur,” clients in residential treatment have severe emotional and behavioral difficulties. “Not every client chooses to be here nor wants to be here,” the statement said.
Shortly before the girl left, another client hit her in the face and gave her a black eye, she said. The bruise didn’t fade until after she’d gone home — a reminder of a place where she said she didn’t feel safe.
Anyone experiencing suicidal thoughts can call the National Suicide Prevention Hotline at (800) 273-8255 or the Arkansas Crisis Hotline at (888) 274-7472.