Listen to thisMary G. Malia, Richard Quigley, Gregg Dowty and Michael Danjczek
Abstract: Although various policy reviews at the state and federal levels have raised important questions about how to support children and families, residential programs continue to be critical to a continuum of care, achieving safety, well-being, and permanency goals with a strong focus on family reunification.
The Residential Care Consortium is a national organization of highly dedicated, multi-service youth agencies with deep roots and long histories in their communities, having served upwards of 100,000 youth over the last two hundred years. The Consortium works to advance the interests of underprivileged, at-risk, traumatized and disadvantaged children, young adults, and their families. The children that enter our care are often here after the system has failed them in very vital ways. It is the work of residential based programs to help both youth and their families heal in order to reunite them when possible, and when not possible to support youth in preparing to become productive adults.
The problems youth face
Across the United States today, hundreds of thousands of youth have
found themselves without many of the basic rights that most Americans
take for granted. Nationally, 800,000 children and youth were removed
from their homes in 2005. Of those, over 500,000 remained out of their
home for at least one year (AFCARS, 2007). This is a telling story about
the facts of life for many children who have become the victims of abuse “often extreme abuse, both sexual and physical. The right to live with
a family that loves and cares for them cannot exist in a home where
children are blatantly abused or left to fend for themselves. This is
just the tip of an iceberg, whose submerged mass has the potential to
sink hundreds of thousands of youth into a lifelong struggle with mental
and emotional illness.
The mass of an iceberg hiding below the surface of the water is the most dangerous part because it cannot be seen. In the United States what is hiding below the surface is a growing epidemic of children and youth with increasingly complex emotional, behavioral, and mental health issues. Some of these issues are created by various kinds of trauma, but for many other youth these mental health issues are manifesting in normal, healthy families and preventing these children from participating in the joys of family, community, and success in school. The Center for Mental Health states that approximately 20% of youth, ages 9-17, have a diagnosable emotional or behavioral disorder (Friedman, Katz-Leavy, Manderscheid and Sondheimer, 1996, 1998). Of these youth, five to nine percent are considered to have conditions so extreme that they are severely compromised in their ability to relate successfully to others and to succeed in a community-based environment. According to U.S. Census (2006) data, there are approximately 41.9 million people between the ages of 10 and 19. This translates to approximately 8 million youth with a diagnosable mental health disorder and upwards of 300,000 that suffer from extreme emotional and mental health issues.
This population of youth displays behaviors that include physical aggression, oppositional defiance behavior, relationship difficulties, conduct disorder and many other behaviors (Quinn, Newman and Cumblad, 1995) that prevent them from being able to live normally within their communities. The total percentage of 12- to 17-year-olds who received treatment or counseling for emotional or behavior problems increased consistently between 2000 and 2003: 14.6% in 2000, 18.4% in 2001, 19.3% in 2002, and 20.6% in 2003. This trend is not slowing down. In some situations family and community based interventions can work to help these youth develop stability, but this is not always the case. Community services can sometimes be the wrong placement for youth who have been removed from an abusive family situation, abandoned by family, experienced multiple out-of-home placements, or who have family members too impaired themselves to participate or who are incarcerated (Duchonowski, Johnson, Hall, Kutash and Friedman, 1993; Epstein, Cullinan, Quinn and Cumblad, 1994; Silver, et al., 1992). Then a more institutional intervention providing trained staff around the clock can serve as the best treatment option offering placement stability and the shortest stay (McCurdy and McIntyre, 2004).
Ultimately whatever the presenting issue for the youth, caregivers are dealing with multiple system failures. Providers of care and treatment have an overall responsibility to help youth overcome these tremendous hurdles in order to live healthy, productive lives.
Residential care’s history: Meeting the
needs of children
Residential care and treatment programs came into existence out of the
need to find safe homes for unsafe children and have evolved from the
orphanage model of care to our current day multi-service providers. In
the 1800’s all children entering care were orphans or had a single
parent too poor to feed and clothe them. Homeless and impoverished
children were sent far away to farming communities in the Midwest. Known
as the Orphan Train, the New York Children's Aid Society (CAS) sent
thousands of children westward to Christian homes. By 1890, 84,000
children were sent to the Midwest, and by 1929 the number would total
150,000 (Pieroth, 2003). The orphanage model evolved to the era of “depression day care” and the need to care for the growing number of now
unwanted children and youth. Since , the evolution of aid to poor
mothers (–the mother’s pension–) as one answer to keeping children with
their family, care of youth has continued to advance to meet the
constantly changing needs of our society.
Residential programs exist in a highly complex environment and must meet the equally complex needs of youth and families of today. Operating as part of a continuum of care, services provided include community services, foster family care placement, residential treatment, intensive residential treatment, emergency shelter, short term diagnostic care, secure treatment, detention, residential day school, supervised apartment living, group homes, wraparound services to entire families, and highly individualized treatment to children. Residential programs serve a multitude of problems in youth, ranging from children who suffer from the disruption of their families to the most serious emotional and behavioral problems including juvenile delinquency, suicidal or self-harming conditions, psychotic symptoms, sexual behavior problems and behavioral issues complicated by chronic medical problems and serious developmental issues.
In their current form, residential programs exist as a response to the needs of the American family and the ongoing changes in the social fabric of society. Many youth in America are desperately in need of the intensive services provided only within a residential program setting. Most youth in the child welfare system do not need this level of care and are best served in less restrictive settings in their communities, and when possible, within their respective families. Those working in this field are dedicated to doing what is in the best interest of the youth in their care. Children coming into residential programs generally require some type of serious intervention to help them stabilize behavior and begin to practice new skills for family and community living. When appropriately utilized, a stay in a residential program can and often does lead to successful permanency. Studies show that high level residential programs can effectively achieve both stabilization with behavioral problems and the greatest placement stability, whereas the rate of stability worsens with lower levels of care for the same problems (Sunseri, 2005).
A necessary response
With the increased cost of care and the ever increasing number of
troubled children, residential programs have come under scrutiny and
criticism as being a part of the problem. The fact is that residential
programs exist in response to a society that is producing dysfunctional
and broken families at an alarming rate. Divorce rates have skyrocketed
in the past 30 years; the number of single-mother families has increased
from 3 million in 1970 to 10 million in 2003 (US Census Bureau, Table
FM-2). This breakdown of the two-parent American family has put great
numbers of children at risk. The proportion of children under 18 living
in two-parent households significantly declined between 1970 and 2002,
decreasing from 85% to 69%. The lack of a two-parent family structure is
related to self-reported problems, such as running away, sexual
activity, major theft, assault, and arrest (Snyder and Sickmund, 2006).
Given this clear trend toward the increasing number of single parent
households, problematic teenage behavior will continue to multiply and
put even larger numbers of young people at-risk. Residential programs
have emerged as one solution.
Permanency for children in foster care: An
elusive target
In an ideal world, all children would have a permanent home where they
are cared for by loving and nurturing parents. Unfortunately, permanent,
nurturing families have never been a reality for many children.
Societies have been creating “make-shift” families for centuries. Today
those families might be an adopted family, foster family or group home
family. The turmoil and chaos surrounding many troubled children and
families can sometimes make the goal of permanency an elusive target.
As child care advocates better understand a child's need for permanency, the reality of children bouncing from placement to placement is a continued frustration. It is very sad to examine the chaotic life of a child that has been passed amongst 10 to 25 or perhaps 50 different placements. The Consortium has been tracking youth participating in an Independent Living Program for three years in five states. Placement data was available on 535 youth who had a combined total of 1424 placements in the course of their stay in the foster care system. One hundred and fifty-one were in their first placement, 281 had 2-5 placements, 85 had experienced 6-10 placements and 18 had endured 11-20 placements (Malia, 2007). Federal policy states that a child should be placed no more than twice, but for 71% of the children that came into our care during the course of this program, that had not been their experience. Because both federal and state governments are emphasizing outcome and accountability measures that seek to reduce multiple placements, child welfare agencies are focusing a great deal of time and resources on this issue. Our data show that this emphasis is not producing the desired results.
Multiple failed placements are a problem not only for the child but also for agencies placing children. Failed placements are very costly in both dollars spent on ineffective treatment and the time it takes to manage the crisis of a failed placement. Placements are failing in part because children are being placed in less restrictive settings when a higher level of placement, i.e. a residential program, would be a much better placement (Sunseri). Unfortunately along the way, the well-being of the child is often being ignored because of an emphasis on reducing the costs of care as the ultimate goal.
Stabilization leads to permanency
Residential programs function like a social hospital, as opposed to a
medical or psychiatric hospital. Agencies that provide this level of
care perform serious triage, including assessment, treatment, education,
and stabilization. After these necessary interventions are successfully
administered, permanent placement can become a realistic option as
children are ready to lead a more functional lifestyle. Residential
programs have a history of care that helps lead children to permanency
(Sunseri). One of the first tenets of counseling is “listen to your
client; they’ll always tell you what they need.” Not every young person
wants to be stepped down into yet another temporary “permanency
placement” when there is no option to return to family. Many young
adults with a history of foster care, when asked about their desires
regarding permanency options, reply that what they really want is
someone to listen to them about their own desires, not an option
assigned by a case worker (Freundlich, et al. 2006).
Protective and restorative factors
In their landmark longitudinal study of at-risk children in Kauai,
Werner and Smith (1992) identify protective factors that have the
potential to positively impact the environment, efficacy and opportunity
of at-risk children. Werner (1995) further states that as the number of
disadvantages and stressful life events increase, protective factors
must correspondingly increase and intensify in order for these youth to
continue to overcome adversities.
In the continuum of care for children, residential care is both a protective and restorative factor that provides a means to meet the wide variety of needs of the children placed in care. Most have come to care having faced multiple adversities. Sexual and physical abuse are certainly heinous acts perpetrated against children, but a lack of attention to emotional needs, poor educational experiences and environments characterized by crime, poverty and drugs also contribute to the myriad of issues and anxieties these children face.
In 2004, the rate of child abuse and neglect was 9.3 per 1,000 12- to 15-year-olds, and 6.1 per 1,000 16- to 17-year-olds. (HHS, 2006) Adolescents living with a mother who has a serious mental illness, abuses alcohol, or uses illicit drugs are themselves more likely to use alcohol and illicit drugs (SAMHSA, 2005) Teens who have fathers with substance abuse problems are also more likely to use alcohol (Hartman et al., 2006) and drugs (Hopfer et al., 2003) or to have mental health disorders such as anxiety, depression, or conduct disorder (Clark, 2004). Between 1992 and 2002, the number of adolescents aged 12 to 17 years who were admitted to facilities receiving some public funding for treatment of substance abuse increased 65%, from 95,000 admissions in 1992 to 156,000 admissions in 2002 (Johnson et al., 2006).
A quality residential program has an opportunity to serve as a restorative factor for these children. It can serve as an intervention that stops a downward spiral toward a life of desperation, in part by the simple fact that a youth involved in drug abuse or alcohol abuse is removed from temptation. To those charged with providing for traumatized children it is important to recognize that these children need effective treatment interventions, a safe environment, emotional support, and education. Failing in any of these areas will spell failure overall.
Providing a safe environment is paramount in rebuilding the lives of at-risk children. Caring adults, continuous quality improvement, a comprehensive staff training program, skill in crafting individually unique interventions and a focus on outcomes are hallmarks of quality programs. For some children, we must provide an intensive intervention carefully monitoring behaviors, interactions with peers, and building positive relationships with adults. For others, the opportunity to experience a healthy family-oriented environment is the necessary treatment intervention. Interacting with peers, accepting responsibilities of a family unit, and building healthy relationships become important experiences as the child grows in confidence and comfort. Many will be able to transfer these new skills and understandings as they re-unite with their natural families who have also been experiencing growth and change through family counseling.
For some children there will be no re-unification. Children who will come of age in a foster care or residential placement number approximately 20,000 annually (Courtney, 2005). Residential programs owe it to these children to provide the opportunity to transition into a successful adulthood. Independent living programs, curriculum designed to teach life-skills, life coaches, and mentors are all tools at the disposal of residential agencies. This requires a life-span perspective in working with at-risk youth. Residential programs are positioned to provide the support and resources necessary to see at-risk youth through both the short term and the long term. In residential agencies across the country, there is a commitment to be there for the long haul “service over time as opposed to a point in time.
Individualized treatment is essential
Attending to a safe environment is just one of the tasks facing
residential programs. It is also necessary to address the emotional and
psychological needs of the children placed in care. Residential care and
treatment agencies recognize that a service milieu must exist that deals
with all the needs of each individual child; a well run facility treats
each child as an individual with an individualized treatment program. To
ignore the psychological harm caused by the risk factors is to fail in
the very mission of treatment. Individual counseling, crisis
intervention, group counseling and access to psychiatric evaluation and
support are essential parts of the service plan for at-risk youth.
Residential programs are uniquely positioned to connect the child with
the appropriate level of support and are involved in changes that
provide for family engagement and even family-driven care.
Research has indicated that when individuals believe that events and outcomes are controllable, active attempts are made to overcome adversity (Luthar, 1991). Residential programs recognize the need for children to work through those aversive conditions, internalize control and externalize environmental conditions. In doing so, resilience is supported and children learn to overcome obstacles. Therefore, providing counseling and the opportunity to understand those issues becomes an essential component of a quality program for children.
For many children, the negative behaviors caused by the adversities they face manifest themselves in the educational setting. Children who are angry, emotionally hurt, worried about the family unit, or focused on survival in a dangerous environment cannot attend to learning. This only contributes to a rapidly deteriorating situation. Staff in residential programs have long understood the need to attend to education and learning. Many organizations have established licensed and accredited schools within the agency in order to provide a comprehensive approach to meeting the needs of children. Others have worked closely with public schools to ensure learning opportunities are optimized. Close partnerships have evolved which have often led to alternative school programs for at-risk community youth, day treatment programs for students at risk, and special education services that meet individual needs.
Cost effective residential care the most
appropriate solution
How can one of the most expensive alternatives for treatment be the most
cost effective? The answer is “when it is the most appropriate
intervention for the right individual.”
When regulators and funders speak of the “least restrictive” treatment alternative, the phrase “most appropriate” is not included. Consider the same thought process in terms of medical treatment. If a patient arrives at a hospital emergency room and is in need of an emergency appendectomy, one would hope the staff does not conclude that two aspirin are less restrictive and certainly less costly! In fact, to pursue this absurd course would possibly cost the patient his life or, at best, result in a much more complicated and far more costly treatment later.
Regrettably, this logic is no less absurd in the treatment of children, youth, and families. There are social service gate keepers who literally believe that “least restrictive” means that at-risk children need to fail at a less restrictive alternative first, before being referred to more intensive services. This type of cost savings truly puts children, youth, and families at grave risk. Data from a California study of 8,993 children and adolescents show that this route is often more expensive in the long run (Sunseri). The greatest cost in these cases is the extended trauma to children and their families as a child must now fail in a placement in order to receive appropriate care. Clearly, the resources spent on “least restrictive” alternatives versus “most appropriate” alternatives are a waste of real and significant dollars.
The treatment milieu of residential care is a powerful tool to positively impact children and families. And this force must be married to a foundation of standards of care that include licensing and regulation, accreditation, and continuous quality improvement. These grounding standards set the bar for best practices to be in place within residential care and treatment organizations and help to ensure the best level of care is being provided (AACRC, 2006).
The partners of The Residential Care Consortium have a long history of strong public-private partnerships, and within our communities, bring more private dollars into America’s safety net for children than alternative methods of treatment. Our residential campuses have been built with private donations and many of our programs have a significant amount of private funding underwriting our true costs. Many of our partners offer higher education opportunities for the children that have been in their care. Endowment funds, alumni support, partnerships with local colleges and other educational stipends are available for student graduates.
The President’s New Freedom Commission (2003) has called for transformational change in the children's mental health system, and this process has been underway for the last four years in earnest. This needed change has brought about beneficial and important changes to the field that are benefiting America’s families. Along the way there are many lessons being learned. It was expected that the shift to community based systems of care would reduce the costs of care. This has not always proved true. Wraparound service models can be expensive, nearly equaling the cost of residential programs (Lieberman, 2004). Along with costs, we have capacity issues as more children are involved in the mental health system. If we could reach the level of truth where the public sector admits it simply cannot afford the most appropriate alternative for every child at risk, we could enter into a public appeal and ask our donors to assist in getting what is needed for vulnerable children. What is needed is an honest discussion on the impact that limited resources have on placement decisions.
Lastly, squeezed budgets all too often drive many decisions within the child welfare system, and we want to challenge that thinking as a short term perspective lacking a long term solution. Children who do not successfully overcome the negative issues of their childhood will continue to use the services of the government for years to come, if not for their entire lives. The final question is do we pay now or pay later? Paying later will always be more painful for both the adults who could not overcome their past and the tax payers that foot the bill.
One of the biggest challenges faced by residential programs is that we have been so busy with the work of helping youth, that we have let federal and state funders define our overall mission and reason for being. As a result, residential care has not been invited to the policy table and was left off the playing field as changes have taken place in the model of services being provided in our communities today. On the one hand, this has pulled us into the mainstream of dealing with those problems deemed worthy of special attention and funding from the public sector. It is important to state that residential care and treatment agencies are responsive and willing partners in addressing these special needs as defined by the state. That makes us collaborative players.
The Residential Care Consortium is not making a case for residential programs to be the alternative of choice, but rather for the full continuum of options to be maintained so that the best alternative is available for each very human case. And sometimes, a residential program is the best choice for youth and their families.
Summary
Finally, just what are we saying?
Youth face growing rates of mental illnesses.
Families are more fragmented, and often the care a youth needs is not available.
Permanent placement is an important goal for youth in care, but it is not always attainable. Youth having to fail out of a “least restrictive” placement in order to qualify for a “most appropriate” placement is ineffective policy and practice and is often driven by budget decisions at its core.
Residential programs are a response to the condition of America’s families and their need for help treatment, stability, safety, and education for their children. We work to strengthen both protective and restorative factors through a combination of treatment and services that focus on helping youth overcome all types of adversities.
When a residential program is the most appropriate placement for a child, it is also the most cost effective! The right placement in a residential program reduces overall time in care, and return to family has higher rates of stability then other “least restrictive” forms of care.
As youth and family serving agencies, we listen to many different voices: those of the children we work with and their families, the communities we live in, schools, the businesses that support us, policy makers and funders of all types. We want our voice to be heard in the midst of this discussion. We want to actively participate and shape the ongoing process of change happening in the field. We provide highly specialized services that are immensely important to the children that we serve. We actively work to improve and expand our practice in serving families in order to improve the success rate of youth returning home after participating in a residential program.
The Residential Care Consortium is speaking up as a
leader in providing care, treatment and education to over 5000 youth
annually to bring a greater awareness to the issues that youth and
families are facing and ensure that the importance of residential
programs is not undermined in the fight over budget dollars. We want to
ensure that residential programs are included in all community based
systems of care as a service option for families and youth and are
within the guidelines for state block grants focused on mental health
treatments. We want to ensure that the well-being of youth in care is a
top priority in every discussion about treatment options and permanent
placement. And we are working to be a part of the conversation on the
ongoing evolution of treatment and care for America’s youth and families “families our organizations have been serving for multiple generations.
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This feature: Malia, M.G.; Quigley, R.; Dowty, G. and Danjczek, M. (2008). The historic role of residential group care. Reclaiming Children and Youth, 17, 1. pp. 43-51.
