Youth In Residential Treatment Research Articles

An exploration of the role of adverse childhood experiences (ACEs) on youth engagement in residential treatment

Literature suggests that child maltreatment may have a negative impact on a youth's ability to engage in treatment, particularly because it might hinder their ability to form a therapeutic bond with the clinician. Despite the prevalence of this viewpoint, there have been few empirical studies that substantiate this negative relationship. This study uses a sample of youth in residential treatment to assess the relationship between child maltreatment, as assessed by the Adverse Childhood Experiences (ACE) Questionnaire, and engagement in treatment, including readiness to change, bond with staff and collaboration on goals and tasks. Results from a sample of 130 youth in residential treatment indicate that instead of a negative relationship between maltreatment and engagement, including its components, a positive relationship exists. Youth with higher levels of maltreatment as measured by ACEs displayed higher levels of engagement in treatment and its components. The findings suggest that more research needs to be done to better understand how maltreatment impacts engagement in treatment and its components.

Multidimensional Family Therapy as a community-based alternative to residential treatment for adolescents with substance use and co-occurring mental health disorders

This randomized clinical trial (RCT) compared Multidimensional Family Therapy (MDFT) with residential treatment (RT) for adolescents with co-occurring substance use and mental health disorders on substance use, delinquency, and mental health symptoms. Using an intent-to-treat design, 113 adolescents who had been referred for residential treatment were randomly assigned to either RT or MDFT in the home/community. The sample was primarily male (75%) and Hispanic (68%) with an average age of 15.4 years. Seventy-one percent of youth had at least one previous residential treatment placement. Participants were assessed at baseline and at 2, 4, 12 and 18 months post-baseline. During the early phase of treatment (baseline to 2 months), youth in both treatments showed significant reductions in substance use [substance use problems (d = 1.10), frequency of use (d = 1.36)], delinquent behaviors (d = 0.18) and externalizing symptoms (d = 0.77), and youth receiving MDFT reported significantly greater reductions in internalizing symptoms than youth receiving RT (d = 0.42). In phase 2, from 2 to 18 months after baseline, youth in MDFT maintained their early treatment decreases in substance use problems (d = 0.51), frequency of use (d = 0.24), and delinquent behaviors (d = 0.42) more effectively than youth in RT. During this period, there were no significant treatment differences in maintenance of gains for externalizing and internalizing symptoms. Results suggest that Multidimensional Family Therapy is a promising alternative to residential treatment for youth with substance use and co-occurring disorders. The results, if supported through replication, are important because they challenge the prevailing assumption that adolescents who meet criteria for residential treatment cannot be adequately managed in a non-residential setting.

Developing, implementing, and evaluating a trauma-informed care program within a youth residential treatment center and special needs school

ABSTRACTYouth in residential settings have significant trauma histories, and staff are challenged by traumatic stress reactions and youth behaviors. We describe the process of developing, implementing, and evaluating a trauma-informed care program focused heavily on workforce development within a youth residential treatment center and accompanying special needs school. The 3-year program included a needs assessment, leadership buy-in, train-the-trainer model, reflective practice groups, staff incentives, and evaluation. Over 100 staff participated in the (voluntary) trainings, 60 participated in reflective practice groups, and 51 met the requirements to receive an hourly pay raise incentive. Using bivariate correlations, the results from the staff surveys (n = 178) demonstrated that self-reported trauma knowledge and skills, but not felt safety or job satisfaction, were significantly correlated with “dose” of staff participation in trainings and reflective practice groups. In addition, there was a 22% reduction in critical incidents over the study period, although there were minimal changes in staff retention.

Putting research in place: an innovative approach to providing contextualized evidence synthesis for decision makers

BackgroundThe Contextualized Health Research Synthesis Program (CHRSP), developed in 2007 by the Newfoundland and Labrador Centre for Applied Health Research, produces contextualized knowledge syntheses for health-system decision makers. The program provides timely, relevant, and easy-to-understand scientific evidence; optimizes evidence uptake; and, most importantly, attunes research questions and evidence to the specific context in which knowledge users must apply the findings.MethodsAs an integrated knowledge translation (KT) method, CHRSP:Involves intensive partnerships with senior healthcare decision makers who propose priority research topics and participate on research teams;Considers local context both in framing the research question and in reporting the findings;Makes economical use of resources by utilizing a limited number of staff;Uses a combination of external and local experts; andWorks quickly by synthesizing high-level systematic review evidence rather than primary studies.Although it was developed in the Canadian province of Newfoundland and Labrador, the CHRSP methodology is adaptable to a variety of settings with distinctive features, such as those in rural, remote, and small-town locations.ResultsCHRSP has published 25 syntheses on priority topics chosen by the provincial healthcare system, including:Clinical and cost-effectiveness: telehealth, rural renal dialysis, point-of-care testing;Community-based health services: helping seniors age in place, supporting seniors with dementia, residential treatment centers for at-risk youth;Healthcare organization/service delivery: reducing acute-care length of stay, promoting flu vaccination among health workers, safe patient handling, age-friendly acute care; andHealth promotion: diabetes prevention, promoting healthy dietary habits.These studies have been used by decision makers to inform local policy and practice decisions.ConclusionsBy asking the health system to identify its own priorities and to participate directly in the research process, CHRSP fully integrates KT among researchers and knowledge users in healthcare in Newfoundland and Labrador. This high level of decision-maker buy-in has resulted in a corresponding level of uptake. CHRSP studies have directly informed a number of policy and practice directions, including the design of youth residential treatment centers, a provincial policy on single-use medical devices, and most recently, the opening of the province’s first Acute Care for the Elderly hospital unit.

Beyond “Common Sense”: The Role of Local Knowledge in Youth Residential Treatment

Social work scholars have challenged the reliance on so-called “common sense” to guide clinical practice. This article reports findings from an ethnographic study of knowledge use and decision making in a residential treatment center (RTC) for children. Specifically, it asks what knowledge informs the everyday practice of mental health workers and analyzes participants’ assertions that expert practice requires the possession of what they refer to as “common sense.” Approximately 1,560 hours of participant observation and 36 semistructured interviews were conducted with 78 consenting mental health workers at the participating RTC. Participants reported that they valued and relied on common sense in their everyday practice and emphasized it in assessments of others’ expertise. They described common sense as a natural quality of individuals, not learnable through professional education or on-the-job training. These assertions that practice expertise requires common sense obscure a rich body of local knowledge that workers drew on in practice. Common sense is more accurately understood as site-specific local knowledge calibrated to the unique demands of the organization. Further study of the character and transmission of local knowledge may inform social work research, education, and practice with implications for models of clinical decision making and knowledge transfer within and between organizations.

A Work in Progress: Electronic Health Record Utilization in Residential Treatment

ABSTRACTThe use of Electronic Health Records (EHRs) has increased dramatically in the past few years, in part as a result of the 2009 Health Information Technology for Economic and Clinical Health Act (HITECH), and has significant potential benefit for youth residential treatment providers. Although use is widespread in the medical profession, youth residential treatment providers have only recently begun to use EHRs, and there is little information available to guide them in selection. Members of the Association of Children’s Residential Centers (ACRC) were invited via the association newsletter, and targeted email and phone call reminders, to participate in a 13-item on-line survey focused on use, satisfaction and concerns with EHRs. Eighty-seven percent of ACRC member organizations responded to the survey. Two thirds (66%) of the organizations reported using a wide variety of EHRs, and cited a range of strengths and challenges of the various systems; no single EHR product dominated the residential agency market. The authors discuss the need for further comparative EHR information and stress the importance of EHRs for data exchange and outcomes evaluation.

“Sense” and sensitivity: Informal apprenticeship among youth care workers in a residential treatment center for children

AbstractThis article reports findings from a 13‐month ethnographic study of knowledge use and expertise among 78 workers in a U.S. residential treatment center for children. It investigates the question of how youth care workers developed expertise in an organization that did not require graduate professional education and provided little didactic training. It demonstrates how processes of informal apprenticeship allowed some workers to develop locally recognized expertise through working alongside more experienced peers. It analyzes the puzzling initial finding that workers simultaneously attributed expertise to innate “common sense” and reported that they developed this form of expertise through informal on‐the‐job apprenticeship. Taking a cultural perspective on learning, this article conceptualizes youth‐serving organizations as communities of practice in which informal apprenticeship contributes to the development of locally valued forms of expertise and addresses the question of why youth care workers appeared to differ in their ability to make use of opportunities for such learning. It explores implications of these findings for workforce development in youth residential treatment and for social work education in general, suggesting simple methods for maximizing opportunities for situated learning.

The Impact of Types and Extent of Trauma on Depressive Affect Among Male Juvenile Sexual Offenders.

High levels of depression have been found among incarcerated youth, which suggests that mental health problems are associated with delinquent behavior and are part of a constellation of risk factors that contribute to youth entering the juvenile justice system. In this project, we investigated trauma and mental health issues among male youth in residential treatment, and addressed the following questions: (a) Does childhood trauma predict current depression for male juvenile sexual offenders? (b) If so, do different types of traumas predict depressive affect better than others? and, (c) Does extent of trauma exposure predict depression? Data on incarcerated male juvenile sexual offenders were analyzed ( n = 379). Multiple regressions of various types of traumas and cumulative trauma and depression were conducted. Emotional abuse was the strongest predictor of depressive affect for this sample, and multiple exposures to trauma were the second strongest predictor.

Minimizing Seclusion and Restraint in Youth Residential and Day Treatment Through Site-Wide Implementation of Collaborative Problem Solving

ABSTRACTDespite a growing understanding of the need to reduce seclusion and restraint (S/R) in all types of youth psychiatric facilities, published accounts of success in the psychological literature have been limited to inpatient facilities. Furthermore, existing publications on successful S/R reduction rarely include details about implementation that would be helpful to other agencies looking to follow their lead. This article presents the case of one multiservice agency that reduced S/R rates in youth residential and day treatment programs after adopting the Collaborative Problem Solving (CPS) approach. It includes detailed information on implementation, data illustrating the reduction of S/R after CPS implementation, and discussion of possible benefits to youth outcomes and organizational costs.

Therapeutic Engagement of Adolescents with Emotional and Behavioral Disorders

Youth engagement is increasingly recognized as a preferred approach and often necessary step in the treatment of emotional and behavioral disorders. The purpose of this study was to explore the degree and quality of youth engagement in the therapeutic process, compare engagement scores between youth accessing residential and day treatment, and explore the association between engagement and interpersonal difficulties in a sample of youth with an emotional and/or behavior disorder in residential and day treatment programs based in Southern Ontario. Cross-sectional surveys of standardized measures were administered to youth and a separate survey to their Prime Workers. Relevant constructs included client engagement (as rated by youth and Prime Workers), and youth-rated behavioral screen, interpersonal problems and family functioning. Both Prime Workers and youth rated youth as moderately high in their level of engagement in therapy. Furthermore, Prime Worker and youth ratings did not significantly differ statistically, suggesting that youth may have actually engaged at a moderate level. Interpersonal problems were shown to be negatively associated with youth engagement, and family functioning approached significance for only youth in residential treatment. Assessing youth engagement during the treatment process as an intervention technique may highlight areas where greater clinical efforts are needed. Future considerations include testing methods of sharing and discussing results of an engagement measure within the context of a one-on-one clinical encounter with youth.

Comparison of non-sexual crimes committed by juvenile sexual offenders and delinquent youth in residential treatment in the USA

In this study we explored differences and similarities in criminal behaviour between incarcerated adolescents who committed sexual and non-sexual crimes with adolescents who committed only non-sexual crimes. Cross-sectional data on 606 adolescents were collected at two points in time (five years apart) from residential treatment facilities in the USA. After controlling for all the other variables (data collection site/time, race and poverty) in a model using logistic regression, general delinquency and property damage significantly predicted membership in the juvenile sexual offender group whereas felony theft and selling drugs significantly predicted membership in the non-sexual offender group (χ2 = 91.80, p < .001; Naglekerke = .278). A large number of juvenile sex offenders had also committed serious non-sexual crimes. These findings highlight a need for practitioners and researchers in juvenile justice to address non-sexual and sexual behavioural challenges among adolescent sexual offenders.

To Forgive and Discredit: Bipolar Identities and Medicated Selves Among Female Youth in Residential Treatment.

Based on 11 months of ethnographic fieldwork at a residential treatment center in the United States, this article explores the varied meanings that female youth attribute to behavior and the strategic (mis)use of knowledge about psychiatric diagnosis and medication at a time when the scope of behaviors pathologized in young people continues to expand. Drawing upon psychological and critically applied medical anthropology, as well as contributions from philosophy on how classifications of people come into being and circulate, attention is paid to the multiple contradictions at work in diagnosing young people with mental disorders. A detailed examination of an exchange that occurred during one particular group therapy session is presented to demonstrate how psychiatric selves emerge in this environment when conventional labeling practices no longer suffice as an explanation of behavior. This turn to psychiatry reveals both the salience of and confusion around mental health treatment and diagnosis among adolescents, opens up the distinctions young people make between "real selves" and "medicated selves," and invokes the possibility of psychiatric disorder as a means to both forgive and discredit.

Development and Implementation of Trauma-Informed Programming in Youth Residential Treatment Centers Using the ARC Framework

This project describes application of an evidenced-based, trauma-informed treatment framework, Attachment, Regulation and Competency (ARC), with complexly traumatized youth in residential treatment. The processes of implementing the ARC model into clinical and milieu programming at two residential treatment programs are described. Particular attention is paid to system-level processes and strategies for embedding ARC in a sustainable manner. Pilot data demonstrated a significant relation between use of ARC and reductions in PTSD symptoms, externalizing and internalizing behaviors, and the frequency of restraints used across programs. Preliminary findings contribute to an emerging empirical basis for the ARC model and are supportive of its clinical utility as a practice in the residential context. Next steps include: a) expanding the study findings by conducting controlled efficacy research, b) examining system level variables as mediators of change, and c) describing the full operation stage of implementation of the ARC framework.

Concurrent reductions in psychotropic medication, assault, and physical restraint in two residential treatment programs for youth

Abstract Over the past decade, the level of clinical needs of youth in residential treatment has increased significantly. Youth in out-of-home settings typically experience higher levels of psychotropic medication use than their peers living at home, even when controlling for the severity of clinical issues. The purpose of the current study was to examine the effects of an approach to clinically reassess psychotropic medication utilization for youth residing in residential treatment settings while also observing the impact on the youth's need for physical containment. Medication changes were based on a data-informed process, using input from a multi-disciplinary treatment team. Data for 531 youth who were consecutively admitted to one of two non-affiliated intensive residential treatment programs, one in the Midwest and one in New England, was analyzed. Over half of these youth (n = 292, 55%) had their medications reduced during their stay and only 14% (n = 76) were prescribed more medication at discharge than they had been taking at admission. The remainder either saw no change during their stay (n = 104, 20%) or were never on medication at any time (n = 59, 11%). From admission to discharge there was a 62% decrease in the number of assaultive incidents as well as a 72% decrease in the use of physical restraints. These results support the view that residential treatment can provide a treatment milieu that allows for thoughtful reassessment of the clinical basis for behavioral disorders in children that can achieve the dual goals of medication reduction and behavioral stabilization.

Psychotropic Medication Management Within Residential Treatment Centers: Physician Opinions About Difficulties and Barriers

Research has shown that between 40 and 98 % of youth entering residential treatment are taking at least one psychotropic medication and that psychotropic medication management is often an integral component of treatment in residential settings. To determine physician opinion about the difficulty of managing psychotropic medications for youth in residential treatment and to determine the resources that are used in the process, a survey study was conducted. Overall, physicians indicated that youth involved in residential settings were much more complex than those in traditional outpatient settings, due to multiple mental health diagnoses, polypharmacy, and unknown treatment histories. They also reported that many existing resources are not applicable to youth, particularly those in residential settings, and that they are difficult to read and interpret.

Caregiver–Teacher Agreement on Emotional and Behavioral Problems in Traumatized Youth in Residential Treatment

The purpose of this study was to investigate agreement and theoretically relevant moderators of agreement between non-parent caregivers and teachers in a sample of traumatized youth. Two hundred eleven children (ages 5–16 years) who had experienced abuse and/or neglect were administered the Trauma Symptom Checklist for Children (TSCC) shortly after their admission. Additionally, their primary non-parent caregivers were administered the Child Behavior Checklist (CBCL) and their teachers were administered the Teacher Report Form (TRF). Inter-rater agreement between caregivers and teachers was low (Total problems, ICC = 0.29). Agreement was higher for Externalizing Problems as compared to Internalizing Problems. Agreement was generally not moderated by age, gender, or severity of posttraumatic stress, although there were several exceptions. These data suggest that non-parent caregiver and teacher agreement of emotional and behavioral problems in traumatized youth is low but comparable to agreement between parents and teachers. Assessment and treatment implications are discussed.

Evaluating Components of Residential Treatment Success for the Most Complex Youth

Residential treatment for youth has an unfortunate reputation due to a paucity of experimentally designed effectiveness studies. To contribute to the literature base and better understand residential treatment's effectiveness, demographic and treatment variables of the most highly complex youth were examined for their association with discharge placement success. Specific treatment variables were identified as being highly associated with discharge to more restrictive environments. Findings provide a way of using clinical treatment response data to better understand residential youth and suggest that familiarity with specific features of treatment may be helpful to supporting successful discharge placements.

Exploring Diversity Attitudes of Youth Placed in Residential Treatment Facilities

The increasing ethnic, cultural, and class diversity in the United States calls for a proactive approach in helping youth develop into socially competent adults. Youth in residential treatment may exhibit deficits in perspective-taking ability, social competence, and relationship skills, which are important outcomes of healthy diversity attitudes. For some, the milieu may be their first experience with youth of diverse backgrounds. However, little is known about this topic. The purpose of this study was to explore diversity awareness, attitudes, and skills of youth in residential treatment. The current study highlights the need for diversity education programs within treatment.

Poison Apples, Big Bad Wolves, and Other “Happy Ending” Spoilers: Overcoming Barriers to Enduring Change Following Youth Residential Treatment

Poison Apples, Big Bad Wolves, and Other “Happy Ending” Spoilers: Overcoming Barriers to Enduring Change Following Youth Residential Treatment

Psychopathology as a Predictor of Medical Service Utilization for Youth in Residential Treatment

Rising health care costs have led to an emphasis on identifying factors that contribute to medical service utilization. Previous research has suggested an association between youth psychopathology and service utilization; however, prospective studies among high-risk populations are needed. The current study examined youth psychopathology as a predictor of subsequent medical service utilization among a large sample (N = 536) of youth entering residential treatment. Youth psychopathology and medical status were assessed at intake, and medical service utilization was tracked across the duration of the residential placement. Results indicated that higher levels of psychopathology predicted greater youth medical service utilization, even after controlling for the presence of a diagnosed medical condition. Internalizing problems was a significant independent predictor of utilization, but externalizing problems was not. These findings highlight the association between mental health and medical service utilization and suggest that effective behavioral health services may be helpful in reducing costly medical service needs.