Residential work or in-home interventions?

When youth are having difficulties (ranging from mental health issues – like depression, anxiety, anger, etc – to substance abuse to criminal activity), it is rare that these difficulties exist outside the context of the youth's family. Whenever possible it is probably better to attempt first to treat the difficulties in the context of the community and family. If out-of-home placements are used inappropriately, the youth for simply return to a family or community environment that has not changed. The problems are likely to re-emerge.

The efficacy of residential placement
According to the extensive Surgeon General's Report on Mental Health, “Residential treatment centers are the second most restrictive form of care (next to inpatient hospitalization) for children with severe mental disorders. Although used by a relatively small percentage (8 percent) of treated children, nearly one fourth of the national outlay on child mental health is spent on care in these settings. However, there is only weak evidence for their effectiveness.”

The Report states that in the past, admission to a residential treatment center was justified based on community or child protection and the benefits of such treatment per se. “However, none of these justifications have stood up to scrutiny.” The Report suggests that “highly targeted behavioral interventions provided on an outpatient basis can ameliorate [violent or aggressive behavior]” and that children needing protection from themselves usually benefit from a very short inpatient stay as opposed to longer-term residential treatment. The Report concedes that when there are no supportive services in the community, a longer term program might be useful or necessary.

The Report looks at studies on the efficacy of residential treatment and concludes that most of these are uncontrolled studies completely largely in the 1970s and 1980s. One of the three controlled studies “suggested that interventions in the child's community might be as effective as placement in the treatment setting.” In another of the controlled studies it was found that therapeutic foster care was as effective as residential placement, yet cost half as much. One large longitudinal study found that 75% of youth treated at a residential facility had either been readmitted to a mental health facility or were incarcerated.

The Report concludes that “youth who are placed in residential treatment centers clearly constitute a difficult population to treat effectively. The outcomes of not providing residential care are unknown. Transferring gains from a residential setting back into the community may be difficult without clear coordination between the RTC staff and community services, particularly schools, medical care, or community clinics. Typically, this type of coordination or aftercare service is not available at the time of discharge. The research on RTCs is not very enlightening about the potential to substitute RTC care for other levels of care, as this requires comparisons with other interventions. Given the limitations of current research, it is premature to endorse the effectiveness of residential treatment for adolescents. Moreover, research is needed to identify those groups of children and adolescents for whom the benefits of residential care outweigh the potential risks.”

Floyd Alwon and Denise Hallfors, writing for the New England Association of Child Welfare Commissions (1996) state that “Residential treatment for troubled children is expensive, typically assuming a substantial portion of a state's child welfare, mental health and education budgets. Despite high costs, little is known about the effectiveness of this intervention. Inconsistent data collection makes it impossible to perform proper effectiveness studies.”

A report by the Government Accounting Office (GAO) completed on 1/28/94 entitled “Residential Care” concluded that “Not enough is known about residential care programs to provide a clear picture of which kinds of treatment approaches work best or about the effectiveness of the treatment over the long term. Further, no consensus exists on which youths are best served by residential care rather than community-based care or how residential care should be combined with community-based care to best serve at-risk youths over time.”

The GAO studied went on to explain that “Longer term data are needed to test the endurance of treatment effects. Our review of the literature identified a number of studies that found that some youth leaving residential facilities have a difficult time maintaining treatment gains” and that “Information is also limited on the appropriate place of residential care in the service continuum “that is, which at-risk youth are best served by residential care rather than community-based care and howresidential care should be combined with community-based care to best serve at-risk youth over time.”

The study suggests that residential care “is a restrictive form of care”, “can disrupt youths' attachments because it removes them from family and community, which is the setting to which treatment gains will have to transfer if positive outcomes are to be sustained after discharge, and “is costly”.

The report concludes that “The scarcity of rigorous outcome studies limits the ability of policymakers to determine whether support for residential programs constitutes the best use of limited public resources.”

A 1998 report to the governor of Washington by Megan Rutherford, Ph.D. of the Alcohol and Drug Abuse Institute concludes that adolescent inpatient substance abuse treatment has just as poor potential outcomes. The report cites a study of 75 adolescents treated in an inpatient chemical dependency program in which 64% relapsed in the first 4-6 months following treatment. Another study of 54 adolescents found that only 30% could be described as “abstainers” for the entire 6 month period following inpatient treatment. A 1995 study of 139 adolescents reported that 86% of discharged youth had at least one episode of substance abuse in the year following treatment. “Continued involvement in substance use and illegal activity are thought to be the result of an individual's failure to make a successful transition from the treatment setting to independent living. It is relatively easy for people to temporarily change undesired behaviors; however, it is much harder to maintain those behavioral changes.” Additional assistance in the community is crucial for continued success.

Non-residential treatment
The surgeon general's report found that “the improvements with outpatient therapy are greater than those achieved without treatment; [that] the treatment is highly effective... and the effects of treatment are similar, whether applied to problems such as anxiety, depression, or withdrawal (internalizing problems) or to hyperactivity and aggression (externalizing problems).”

The same report finds that partial hosptializaton/day hospital programs tend to have favorable outcomes, especially with regard to school outcomes and that family participation is essential to obtaining and maintaining results.

The surgeon general cites a study that compared multisystemic therapy (or MST – a kind of community-based treatment) to inpatient treatment which found that MST “was more effective than psychiatric hospitalization in reducing antisocial behavior, improving family structure and cohesion, improving social relationships and keeping children in school and out of institutions." Multisystemic therapy efficacy has “been established in three randomized clinical trials for delinquents within the criminal justice system.”

Studies of case management services cited in the surgeon general's report suggest that youth who have these kinds of community services “showed substantial.. improvement in mental health and social adjustment.”

Home-based services, the report concludes, are also highly effective. “Studies suggested that 75-90% of the children and adolescents who participated in such programs subsequently did not require placement outside the home. The youths' verbal and physical aggression decreased, and the cost of services was reduced.”