Youth In Residential Treatment Research Articles

Bolstering family therapy: Assimilating EMDR into ABFT in youth residential treatment.

The psychotherapy field has a long history of integration to improve treatment effectiveness. One type, assimilative integration, offers innovative opportunities to family therapy to incorporate the clinical and research contributions of different approaches. This paper contributes to the literature on integration by exploring how Eye Movement Desensitization and Reprocessing (EMDR) can be assimilated into Attachment-Based Family Therapy (ABFT) for youth in residential psychiatric treatment. ABFT seeks to improve attachment security to parental figures by asking adolescents and young adults to discuss attachment ruptures. This process, specially designed for patients with internalizing disorders, can provoke anxiety, particularly for a patient population that commonly has a history of trauma and adverse life experiences. EMDR is a first-line therapy for post-traumatic stress disorder and has the potential to be effective in treating various other mental health conditions. When patient emotional withdrawal or dysregulation due to breaches in trust between child and parent emerges in ABFT, EMDR may help desensitize associated memories and bolster the family therapy process. The authors provide an overview of both models, and a detailed case study as an example. The paper concludes with a discussion on implications, integration efforts, and limitations.

Direct Care Staff Vacancies and Adverse Youth Events in Illinois Child Welfare Residential Treatment During the COVID-19 Pandemic

ABSTRACT Direct care staff provide 24/7 care and supervision in residential treatment for youth; vacancy rates for these positions increased significantly during the COVID-19 pandemic. This study used multi-level, two-stage least squares regression to examine the relationship between staff vacancies and adverse events experienced by 1352 youth in Illinois child welfare residential care during October 2019-February 2022. Hierarchical cluster analysis was used to explore whether particular adverse event clusters were differentially related to vacancy rates. We hypothesized that direct care staff vacancies would be related to an increased number of adverse events overall and a specific increase in safety-related events. Although direct care staff vacancies were not significantly related to the overall number of adverse events, they were significantly associated with the magnitude of adverse events related to school suspensions, substance use, and law enforcement encounters. Several other novel, unanticipated findings emerged, with various youth- and facility-level factors (e.g. race, age, length of admission, facility level of clinical acuity) showing significant relationships with the magnitude of adverse events. This study fills a notable gap in the literature in its novel empirical approach to exploring administrative data capturing direct care staffing and adverse events in child welfare residential care.

Study protocol: implementing and evaluating a trauma-informed model of care in residential youth treatment for substance use disorders.

Comorbidity between Substance Use Disorders and trauma/post-traumatic stress disorder (PTSD) is common, particularly within residential treatment services. Comorbidity is associated with poorer treatment retention and treatment outcomes. Integrated treatment approaches are increasingly recommended but are still under examined in residential treatment services. This study will implement and evaluate a novel model of trauma-informed care (TIC) in a youth (18-35 years) residential substance use treatment service. A single-armed, phase 1 implementation trial will be conducted in one residential treatment service. The model, co-developed with staff, incorporates: (i) workforce development in TIC through staff training and clinical supervision; adaptions to the service (ii) policies, procedures, and physical settings and (iii) treatment program adaptions (in delivery style and content) to be more trauma-informed; (iv) client screening and feedback for trauma and PTSD at service entry; and (v) the provision of support, referral and/or trauma-focused therapy to those with PTSD. Service outcomes will include adherence to the TIC model and client treatment completion. Client substance use and mental health measures will be collected at service entry, and 1-, 3-, 6- and 12-months follow up. Staff outcomes, including workplace satisfaction, burnout, and fatigue, as well as perceptions and confidence in delivering TIC will be collected at baseline, and at 3-, 6-, 12- and 18-months following training in the model. The sustainability of the delivery of the TIC model of care will be evaluated for 12 months using service and staff outcomes. The study has received ethical approval by the University of Queensland (Approval number: 2020000949). The results will be disseminated through publication in a peer-reviewed scientific journal, presentations at scientific conferences, and distributed via a report and presentations to the partner organization.Clinical trial registration: ACTRN12621000492853.

De-Implementing a Point and Level System in Youth Residential Care without Increased Safety Risk: A Case Study

ABSTRACT Point and level (P&L) systems are commonly used for behavior management and modification in youth residential treatment centers. In 2019, the Association of Children’s Residential Centers (ACRC) released a position paper urging youth residential programs to abolish prescriptive, universally applied point and level systems because they are inconsistent with the principles of trauma-sensitive care and can be counterproductive to treatment. Despite this, few residential agencies have executed this change, possibly due to the complexities of dismantling long-held practices, concerns about youth safety, and lack of knowledge about other trauma-sensitive approaches. In this case study, we describe how one agency de-implemented its universal P&L system across three residential campuses, replacing it with the Neurosequential Model of Therapeutics (NMT) and Collaborative Problem Solving (CPS). An analysis of administrative data before and after the removal of P&L suggests no evidence of increased safety risk for youth or staff. We discuss the agency’s strategies for de-implementation and the determinants that helped and hindered the process and provide recommendations for other residential agencies seeking to make this change.

Strengthening the Residential Care Workforce: Exploring the Role of Organizational Climate and Culture and Staff Intention to Stay or Leave

ABSTRACT Staff turnover in youth residential treatment centers (RTC) has immense potential to disrupt the therapeutic environment and prompt an increase in mistrust, aggressive and anti-therapeutic behaviors, and feelings of abandonment and worthlessness among residents. The current study examined factors associated with intent to leave the workplace at an RTC in the southeastern United States, focusing on staff role and identity presentation and their effects on workplace culture and climate. Results suggest that indicated job satisfaction, burnout, and perceptions of culture and climate are the best predictors of turnover and retention. Dimensions of culture and climate were rated lower by specific underrepresented minority groups in the organization, highlighting the importance of the agency’s imperative to protect racial, sexual, and gender minority groups to promote retention and a diverse workforce reflecting the demographics of the youth it serves.

Evaluation of the Developmental Trauma and Attachment Program for Decreasing Disruptive Behavior Among Adolescents in a Residential Setting

This evaluation inspected the degree of symptom improvement associated with the Developmental Trauma and Attachment Program for decreasing disruptive behavior symptoms among youth in residential treatment following traumatic experiences within domestic and international adoption and foster care systems. Participants were 82 youth (M age = 14.03 years) who were predominately born in the United States (n = 55) with 27 identifying with international domiciles. Analyses of pre–post data contrasts indicated statistically significant decreases in disruptive behavior symptoms from admission to discharge associated with small and medium effect sizes. Nearly 1 in 4 participants reported clinically significant changes associated with treatment, with about 1 in 3 reporting improvements, but not within the clinically significant range. Limitations to the generalization of findings and recommendations for future investigations are provided.

Efficacy of the Developmental Trauma and Attachment Program in a residential setting

AbstractThis evaluation inspected the degree of symptom improvement associated with the Developmental Trauma and Attachment Program for decreasing symptoms of posttraumatic stress disorder (PTSD) among youth in residential treatment following complex trauma scenarios associated with domestic and international adoption/foster care. Participants were 61 youth (Mage = 13.23 years) who were predominately born in the United States (n = 41) with 20 identifying with international domiciles. Results indicated statistically significant decreases in symptoms from admission to discharge associated with medium‐effect sizes across PTSD symptoms. Nearly one in three participants reported clinically significant changes associated with treatment, whereas two in five reported improvements but not in the clinically significant range. Female participants reported greater decreases in negative cognitions; however, no other differences in treatment response based on participant characteristics were detected. Limitations of the generalization of findings and recommendations for future researchers are provided.

Dissemination of a Behavioral Health Home Model with Improved Physical Health and Wellness across Behavioral Health Settings

Research ObjectiveBehavioral Health Home Plus (BHHP) is an evidence‐based model to enhance physical health and wellness for individuals with serious mental illness (SMI) and chronic medical conditions. To better understand model effectiveness and best practices for dissemination, we implemented BHHP in 7 adult Opioid Treatment Programs (OTP) and 5 youth Residential Treatment Facilities (RTF).Study DesignWe utilized a hybrid study design to examine dissemination and support of BHHP through a 12‐month Learning Collaborative (LC) and outcomes via propensity‐score matched analyses. Mixed methods included semi‐structured staff interviews and confidence surveys to assess feasibility. Data were collected on involvement/confidence in managing physical health (survey) and utilization of primary/specialty care and unplanned healthcare (claims) over 18‐months.Population StudiedIn Pennsylvania's Medicaid HealthChoices program, behavioral health agencies serve as health homes with support and training in wellness by a behavioral health managed care organization, Community Care Behavioral Health of the UPMC Insurance Services Division. Enrollment into BHHP for OTP included adults (n = 689), average age 39.19 ± 9.99 years, 60% female and youth (n = 354) for RTF, average age 14.04 ± 2.52 years, 31% female. Propensity score matching was successful for OTP (n = 688) and RTF (n = 312) members.Principal FindingsProviders reported barriers (training time, staff turnover, workflow integration, family engagement) and facilitators (model resources, education on population‐specific health topics, learning from other sites implementation experiences) to implementation. At 18‐month follow up, over 70% of staff reported being highly confident in working with individuals on physical health and wellness; over 60% of service‐users reported being highly involved in working with their behavioral health provider on physical health and wellness, and 67% of OTP and 43% of RTF service‐users reported being highly confident in their ability to manage their physical health and wellness.Service utilization outcomes showed large decreases over 18 months in medically emergent care for OTP members while rates remained steady for the matched comparison group (p = 0.0055); a similar pattern was found for medications for physical health chronic conditions (p < 0.0001). For OTP, more individuals remained connected to ambulatory substance use disorder services in the comparison group at 18 months. For RTF both intervention and comparison groups showed decreased behavioral health hospitalizations; however, a greater proportion of the intervention group remained connected to ambulatory psychiatric service at 18 months (62% v. 48%). The comparison group showed larger decreases in medically emergent care over time (p = 0.0186).ConclusionsSites have fully integrated the BHHP model into workflows and promote physical health and wellness amongst their complex and medically vulnerable populations. BHHP is associated with positive changes in service utilization outcomes but was comparable to matched comparison groups.Implications for Policy or PracticeHealth homes offer an opportunity for improved health outcomes for vulnerable populations with chronic conditions. The LC approach, which allows for full virtual implementation, is an effective and scalable approach to wide‐spread implementation and successful uptake of care models.Primary Funding SourcePatient‐Centered Outcomes Research Institute.

Digital Pathways to Wellness Among Youth in Residential Treatment: An Exploratory Qualitative Study

Digital media use is central for youth as a means to facilitate identity development, social connection, and vocational competence. Emerging literature suggests that the influence of digital media use is more nuanced than the contemporary risk/benefit discourse, particularly for youth who experience social and emotional vulnerability. This youth-centered, developmentally informed study attends to the gap in literature addressing the digital media use experiences among youth in residential treatment (RT). McCracken’s Long Interview Method was utilized to conduct and analyze in-depth interviews with youth ( n = 15) aged 13 to 18 in RT. The analysis involved movement from particular to general coding, applying categorical observations, and thematic comparison of transcripts. Consistent with existing literature on other youth populations, participants reported that digital media use had both beneficial and problematic implications for their well-being. Internet access decreased experiences of isolation and stigma and increased capacity to contend with marginalized identities (e.g., disability, Lesbian, Gay, Bisexual, Transgendered, Queer, Two Spirited Plus [LGBTQ2S+], child welfare guardianship). They reported that following an initial digital disconnect and stabilization, digital media use facilitated pathways toward agency, leadership, and community engagement (e.g., LGBTQ2S+ community, recovery blogs, animal advocacy). The findings suggest that supporting youth in RT to identify their online opportunities and needs can encourage individual growth, wellness, and participation in social change.

Worker and perceived team climate factors influence the use of restraint and seclusion in youth residential treatment centers: Results from a mixed-method longitudinal study

BackgroundRestraint and seclusion (R&S) are controversial methods of intervention aimed at protecting children from immediate harm in residential treatment centers (RTC). Previous studies have mainly focused on situational factors and youth characteristics to predict its use. ObjectivesThis study sought to evaluate the role other potential predictors could play in the decision to use R&S, namely characteristics of residential workers and their perceived team climate. MethodsFor two months, a total of 132 residential workers from different RTC in the greater Montreal area completed weekly diaries of standardized questionnaires. Using an explanatory sequential design (i.e., mixed methods), this study aimed at exploring the role of residential workers’ characteristics (e.g., exposure to client aggression, stress and fatigue) and aspects of their perceived team climate (e.g., order and organization, communication and openness) as predictors of R&S use. Survey results were later also presented to four focus groups for discussion. ResultsResults indicated that exposure to verbal violence from youths was associated with the increased use of R&S. Meanwhile, perceived communication and openness were associated with lower rates of R&S use. Participants shared that repeated exposure to verbal violence diminished their level of tolerance while teamwork provided them with the emotional space needed to focus on the needs of youths and find alternatives to R&S. ConclusionThis study sheds light on the complex role of human emotions in the decision to use of R&S. Specifically, intense momentary emotions during crisis interventions had a greater influence on the use R&S than chronic states, such as fatigue.

Acute and chronic stress among workers in residential treatment centers for youth: Effects on restraint and seclusion

Abstract Workers in residential treatment centers for youth are often victims of violence, including verbally and physically aggressive behavior. Restraint and seclusion (R&S) are the last-resort methods used by residential workers to deal with the aggressive behavior of youths. However, their use has been found to contribute to building negative interactions between residential workers and youths, which can escalate to violence. To better understand the factors contributing to the use of R&S, the objective of this study was to investigate the effects of acute and chronic stress of workers as measured by psychological and physiological markers on the use of R&S in residential treatment for youth from an exploratory perspective. The data used for this study were collected from 70 workers in residential treatment centers for youths in Montreal, Canada, using questionnaires for chronic stress and salivary cortisol as measure of acute stress. Results revealed non-significant correlations and a lack of pattern in the longitudinal analyses between R&S and acute or chronic stress measures. Bayesian analyses were computed to assess the evidential value of the non-significant results. These results suggest that workers’ stress may not be a significant factor associated with the use of R&S in residential treatment centers for youth.

The influence of residential workers social climate on the use of restraint and seclusion: A longitudinal study in a residential treatment center for youth

Restraint and seclusion (R&S) are two types of interventions residential workers can use to manage aggressive behaviors in youth residential treatment centers (RTC). Factors related to the environment, children, and residential workers have all been associated with their use. Although research in psychiatric settings has shown a relationship between social climate and the use of R&S, no similar studies have been conducted in RTC. The first objective of this paper was to assess the extent to which social climate was associated with the use of R&S in RTC. The second objective was to observe how each dimension of social climate predicted the use of R&S. To accomplish this, a sample of 198 residential workers completed a monthly questionnaire on their unit’s social climate at three different time points. Crossed-lagged analyses were performed to test associations between different dimensions of social climate and the use of R&S over time. Results suggest that good communication and openness among team members are associated with lower rates of R&S use while the focus on common objectives and planning are associated with an increased use of these measures. Perceptions of a negative team climate were not associated with the use of R&S. Results imply that if residential workers had the time and the training needed to meet the needs of individual children they would favor alternative interventions instead of worrying about creating tensions with colleagues.

Trauma and Violence as Predictors of Internalizing and Externalizing Symptoms of Youth in Residential Child Welfare Placements

Youth in residential treatment centers have high rates of internalizing and externalizing symptoms, and most youth in residential placements do not demonstrate long-term positive improvements in mental health. These youth also often experience high levels of exposure to violence and trauma, yet little is known about the interrelationships between exposure to violence, trauma, and mental health outcomes including internalizing and externalizing symptoms. As such, the primary purpose of this study was to determine the linkages between youth exposure to violence, trauma, and internalizing and externalizing symptoms. The current study examined these interrelationships and tested gender and race as moderators. The sample included youth in residential treatment with a mean age of 13.75 years, a diverse racial makeup, and almost an equal percentage of males and females. Trauma and exposure to violence were associated with internalizing and externalizing symptoms, and gender significantly moderated the relationship between trauma and externalizing symptoms, demonstrating a strong positive relationship for males in particular. Results highlight key associations between trauma and exposure to violence and youths’ internalizing and externalizing symptoms. Findings also revealed that gender moderated the link between trauma and externalizing symptoms with a positive association for males and a negligible association for females.

Investigating the Efficacy of Relational Savoring among Male Adolescents in Residential Treatment

ABSTRACT Relational Savoring (RS) is a recently-developed, brief, transdiagnostic intervention that can be administered by paraprofessionals. Although RS has demonstrated efficacy, it has not been examined among at-risk youth. This pilot study adapted RS for the at-risk adolescent population and examined its efficacy. Twenty male youth in residential treatment participated in a four-week long experimental study in which they were randomly assigned to participate in weekly sessions of RS or a savoring control. The study measured participants’ state affect, relationship schema, and attachment styles before and after the intervention. Compared to control participants, participants assigned to RS showed significantly greater reductions in negative affect and attachment anxiety, as well as significantly greater improvements in relational schema. Findings are discussed both in terms of their contribution to theory and as support for a test of the intervention with greater statistical power within this population of youth residing in residential treatment.

“Double-edged sword” of Digital Media Use among Youth in Residential Treatment: Perspectives of Service Providers

ABSTRACT The social significance of digital media and technology is incontestable, particularly with youth. While digital media use can offer youth in residential treatment (RT) opportunities, it also carries risks. Although there has been a shift in RT from a model fostering isolated, self-contained settings, toward the promotion of family and community integration, there is a dearth of scholarship addressing youth digital media use in RT. To address the gaps in research on digital media use among youth in RT and the absence of system-wide policies and formal consensus on guidelines for addressing the issue, the findings of the current study offer insight into the experiences of 25 service providers from four programs. The findings highlight that regardless of location or treatment approach, RT is addressing youth digital media use. There exists a continuum of approaches ranging from risk prevention to risk resilience. As social media have made prohibiting contact between youth impossible, digital media use has been a catalyst for programs to attend to youth relationships outside of the programs. Digital media have thus both introduced new challenges to supporting youth and facilitated a more contemporary resilience-oriented and ecologically informed the approach to treatment.

Mixed Methods Analysis of Youth Attitudes and Self-efficacy regarding Psychotropic Medication in Residential Treatment

ABSTRACT Many youth in residential treatment are being prescribed one or more psychotropic medications with uncertain outcomes regarding the effectiveness of this treatment, especially due to issues with poor medication adherence. Having positive attitudes about psychotropic medications, proper psychoeducation, and ability to discuss these aspects with their mental health providers are all factors associated with better adherence and more positive outcomes overall. This cross-sectional study examines differences in attitudes about medications and self-efficacy to take medications through a mixed model approach using survey data, electronic health record files, and focus groups with a sample of youth in residential treatment (N = 127). Qualitative findings indicate that youth have an overall negative subjective experience with medications, whereas quantitative results found youth who are prescribed medications have significantly more positive attitudes than those who are not prescribed medications. In examining only youth who were currently prescribed psychotropic medication, having more positive attitudes about medications is associated with higher self-efficacy in taking medication, but attitudes, self-efficacy, and number of prescribed medications did not predict their adherence. Results have implications for residential providers and physicians to better support youth around issues relating to their psychotropic medications as well as developing psychoeducational materials.

Preliminary Findings of KINNECT: A Psychosocial Intervention for Youth in Residential Treatment

ABSTRACT Early intervention programs for youth in residential treatment can have a positive impact on numerous outcomes, including health, educational performance, and reduced prevalence of high-risk behaviors. Yet, there is currently a limited number of evidenced-based interventions that treat youth in these settings. This paper presents preliminary findings of a new psychosocial treatment for adolescents in residential treatment that can be implemented by front-line youth professionals. A 20-session multimodal group social skill building intervention, called KINNECT, was developed to address numerous health-risk behaviors through movement-based psychosocial skill building. A quasi-experimental post-test only design using non-equivalent groups was used on 63 participants from two residential treatment facilities in the Midwest. The findings of this study found a reduced likelihood of non-emergency medical visits and self-harming behavior in those who participated in the KINNECT intervention. The authors provide a discussion of these findings along with recommendations for future research.

Shining a Light: Youth in Residential Treatment with History of Sexual Exploitation

ABSTRACTResidential treatment providers increasingly are aware of histories of sexual exploitation among youth they serve, and have begun to question whether these youth require specialized programs and treatment. While it is evident that Commercial Sexual Exploitation of Children (CSEC) is a significant problem with profound emotional and behavioral consequences, there is little research focusing on treatment. This study assesses the perceived incidence of CSEC among youth in residential treatment, and explores treatment currently provided by residential programs. A survey instrument was administered to members of The Association of Children’s Residential Centers (ACRC), and follow-up interviews were undertaken with providers of CSEC-focused program. Nearly two-thirds of organizations reported CSEC history among youth. Despite this high proportion, only six agencies provided explicit, discrete programs/units specifically to treat these youth. Follow-up phone interviews conducted with the six providers with specialized treatment programs/units revealed many commonalities with respect to referral source, admission criteria, and treatment approach. Recommendations are proposed for improving screening, awareness, treatment, evaluation and research for CSEC-involved youth in residential treatment, and to increase communication and interaction both among providers of services to CSEC youth as well as with the advocacy community.

Intensive oversight of youth residential treatment: Staff perspectives on the New York State Justice Center for the Protection of People with Special Needs.

Youth care workers in U.S. residential treatment centers (RTCs) provide 24-h care to youth whose significant psychosocial needs cannot be managed in a less restrictive setting. They have sometimes abused or neglected youth in their care. This study investigates staff perspectives on a new form of intensive oversight developed in New York State to prevent maltreatment of youth in care facilities. It asks: How does intensive oversight and investigation mandated by a state-run agency for the protection of people in care affect residential youth care workers in RTCs? Derived from a 15-month ethnographic study of an RTC serving a child welfare population conducted in 2015 and 2016, these results suggest that intensive oversight may have unanticipated consequences for RTCs, the youth care workforce, and youth in care. Consistent with other studies of regulation and surveillance in risk societies, participants reported that fear of prolonged and intimidating investigations, false allegations, and unavoidable violations of policy negatively affected their practice and contributed to staff turnover. Organizational consequences included serious staffing challenges and increased costs of overtime and administrative management of compliance. Some participants suggested that the form of intensive oversight studied here may have reduced the quality of care received by youth by disrupting therapeutic relationships, causing youth to be cared for by unfamiliar workers, and compelling workers to act defensively to prevent allegations rather than in the best interest of youth. We suggest that, under conditions of intensive oversight, youth care workers, like their clients, should be considered an at risk population whose well being is essential for the provision of high quality care. We conclude with modest recommendations to organizations and jurisdictions using or considering intensive oversight practices to protect the rights and safety of youth in RTCs.

Moral People or Moral Projects? Worker Altruism in Youth Residential Treatment

Paraprofessional youth care workers in residential treatment centers (RTCs) are responsible for the everyday care, supervision, and treatment of youth with serious behavioral and mental health challenges. Turnover rates among this poorly paid workforce are high, and it is not known why individuals seek and maintain youth care work despite its significant challenges. Following anthropologists who study morality as situated practice, we investigate the role of altruism in recruiting and retaining workers in RTCs. We ask: How do managers and youth care workers understand altruism and its role in youth care work and what are the consequences of those understandings? Through organizational ethnography of an RTC, we show that workers and management understood altruism differently. Managers viewed altruism as an inherent trait of some and attributed turnover to its lack. Although workers sometimes enacted this script, they understood themselves as engaged in far more complex situated moral projects in which altruism was only one part. We demonstrate political effects of these differing understandings of altruism, namely, that management deflected institutional critique by viewing it as a sign of workers' immorality. We offer modest recommendations for RTCs seeking to recruit and retain competent youth care workers and address potential new directions for moral anthropology of organizations.