A 17-year-old is dead. Assaulted in his room by the very adults responsible for his safety, he uttered his last words: "Get off me, I can't breathe."

He died at Wordsworth Academy, a Philadelphia institution euphemistically described as a "treatment center" for children with behavioral problems. Currently housing 82 children and youth, the majority of whom were placed there by juvenile courts, Wordsworth Academy is responsible for providing rehabilitative treatment for this challenging population.

Instead, according to state reports, children at Wordsworth are housed in unsanitary crowded conditions, abused physically and sexually, and now, a child is dead. In this case, therapy has proven worse than punishment. Unfortunately, this is the case with all too many treatment centers, to which children and adolescents are referred by courts and social services agencies. This child's death is not the first to happen in such a center, and sadly, it is unlikely to be the last.

This wasn't always the case. Juvenile courts were created at the turn of the 20th century in order to rehabilitate, rather than simply punish, children whose illegal behavior was thought to stem from difficult home lives, poverty, or psychological troubles. By the 1940s and 1950s, a group of child-welfare experts founded small, progressive institutions called residential treatment centers to treat so-called delinquent and troubled children. They reclassified these children as "emotionally disturbed," tracing their problems back to difficult home lives and offering them intensive inpatient therapy, and ultimately, a chance at a better life.

Fifty years before Wordsworth Academy, Walton Village in Philadelphia took such an approach to juvenile delinquency. There, boys received group and individual therapy, and were encouraged to set up a peer self-governance system. When they acted out, they were offered more treatment, rather than punishment. Unfortunately, such centers were small and often inaccessible, especially to racial and ethnic minorities. Instead, many poor African American children were sent to "training schools," punitive institutions where they often experienced verbal and physical abuse.

By the 1970s, child mental-health and welfare experts were faced with an exploding population of emotionally disturbed children, many of whom were African American. Youthful offenders were increasingly viewed as dangerous, rather than emotionally disturbed. This coincided with a shift in racial demographics of arrests and imprisonment. More black boys were now involved with the juvenile justice system, and they received harsher treatment than their white counterparts. Fueled by racism and an unfounded concern over an increase in violent crime, the 1990s heralded the inflammatory rhetoric of "super-predators" and harsher sentencing.

Still, rehabilitation remains the stated goal of the juvenile justice system. The therapeutic model gives the court a great deal of discretion, which is an opportunity for personal bias to come into play. Punishment does not need to fit the crime. Children can be sent for indeterminate periods of time to treatment institutions of questionable benefit until they are "fixed," a term with no clear definition. They can be moved from one institution to the other for "failure to adjust," which in Pennsylvania enables the system to place a child in a secure detention center until a new placement is found. There is little accountability as to what treatment entails, and when it is complete. Treatment centers, some of which are private for-profit companies, define measures of success, and have clear incentives to fill beds.

But if centers like Wordsworth aren't the answer, what is?

The success of the "Missouri model," a novel approach to juvenile justice, suggests that the residential treatment movement of the past can inform how we treat juvenile offenders today.

In Missouri, youth offenders are sent by juvenile courts to small residential institutions, where they sleep in comfortable dorm rooms. When they feel upset or act out, the response is not strict punishment but rather a conversation with peers. This model seems to be working. Recidivism rates are lower than in states using a more traditional approach, violence has significantly decreased, suicides of youth in custody have stopped completely, and costs are down.

Unfortunately, many "treatment centers" remain prisons by another name. Until juvenile justice is reformed, children will continue to suffer abuse and even death in the very facilities designed to treat them.

Mical Raz (micalraz@mail.med.upenn.edu), M.D., and Deborah Doroshow (deborah.doroshow@yale.edu), M.D., are physicians and historians of medicine.