Provided by David Satcher, M.D., Ph.D.
Surgeon General of the United States of America
Chapter 3: Children and Mental Health
Residential Treatment Centers
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 (Burns et al., 1998). However, there is only weak evidence for their effectiveness.
A residential treatment center (RTC) is a licensed 24-hour facility (although not licensed as a hospital), which offers mental health treatment. The types of treatment vary widely; the major categories are psychoanalytic, psychoeducational, behavioral management, group therapies, medication management, and peer-cultural. Settings range from structured ones, resembling psychiatric hospitals, to those that are more like group homes or halfway houses. While formerly for long-term treatment (e.g., a year or more), RTCs under managed care are now serving more seriously disturbed youth for as briefly as 1 month for intensive evaluation and stabilization.
Concerns about residential care primarily relate to criteria for admission; inconsistency of community-based treatment established in the 1980s; the costliness of such services (Friedman & Street, 1985); the risks of treatment, including failure to learn behavior needed in the community; the possibility of trauma associated with the separation from the family; difficulty reentering the family or even abandonment by the family; victimization by RTC staff; and learning of antisocial or bizarre behavior from intensive exposure to other disturbed children (Barker, 1998). These concerns are discussed below.
In the past, admission to an RTC has been justified on the basis of community protection, child protection, and benefits of residential treatment per se (Barker, 1982). However, none of these justifications have stood up to research scrutiny. In particular, youth who display seriously violent and aggressive behavior do not appear to improve in such settings, according to limited evidence (Joshi & Rosenberg, 1997). One possible reason is that association with delinquent or deviant peers is a major risk factor for later behavior problems (Loeber & Farrington, 1998). Moreover, community interventions that target change in peer associations have been found to be highly effective at breaking contact with violent peers and reducing aggressive behaviors (Henggeler et al., 1998). Although removal from the community for a time may be necessary for some, there is evidence that highly targeted behavioral interventions provided on an outpatient basis can ameliorate such behaviors (Brestan & Eyberg, 1998). For children in the second category (i.e., those needing protection from themselves because of suicide attempts, severe substance use, abuse, or persistent running away), it is possible that a brief hospitalization for an acute crisis or intensive community-based services may be more appropriate than an RTC. An intensive long-term program such as an RTC with a high staff to child ratio may be of benefit to some children, especially when sufficient supportive services are not available in their communities. In short, there is a compelling need to clarify criteria for admission to RTCs (Wells, 1991). Previous criteria have been replaced and strengthened (i.e., with an emphasis on resources needed after discharge) by the National Association of Psychiatric Treatment Centers for Children (1990).
The evidence for outcomes of residential treatment comes from research published largely in the 1970s and 1980s and, with three exceptions, consists of uncontrolled studies (see Curry, 1991).
Of the three controlled studies of RTCs, the first evaluated a program called Project Re-Education (Re-Ed). Project Re-Ed, a model of residential treatment developed in the 1960s, focuses on training teacher-counselors, who are backed up by consultant mental health specialists. Project Re-Ed schools are located within communities, facilitating therapeutic work with the family and allowing the child to go home on weekends. Camping also is an important component of the program, inspired by the Outward Bound Schools in England. The first published study of Project Re-Ed compared outcomes for adolescent males in Project Re-Ed with untreated disturbed adolescents and with nondisturbed adolescents. Treated adolescents improved in self-esteem, control of impulsiveness, and internal control compared with untreated adolescents, according to ratings by Project Re-Ed staff and by families (Weinstein, 1974). A 1988 followup study of Project Re-Ed found that when adjustment outcomes were maintained at 6 months after discharge from Project Re-Ed, those outcomes were predicted more by community factors at admission (e.g., condition of the family and school, supportiveness of the local community) than by client factors (e.g., diagnosis, school achievement, age, IQ). This suggested that interventions in the child’s community might be as effective as placement in the treatment setting (Lewis, 1988).
The only other controlled study compared an RTC with therapeutic foster care through the Parent Therapist Program. Both client groups shared comparable backgrounds and made similar progress in their respective treatment program. However, the residential treatment cost twice as much as therapeutic foster care (Rubenstein et al., 1978).
Despite strong caveats about the quality, sophistication, and import of uncontrolled studies, several consistent findings have emerged. For most children (60 to 80 percent), gains are reported in areas such as clinical status, academic skills, and peer relationships. Whether gains are sustained following treatment appears to depend on the supportiveness of the child’s post-discharge environment (Wells, 1991). Several studies of single institutions report maintenance of benefits from 1 to 5 years later (Blackman et al., 1991; Joshi & Rosenberg, 1997). In contrast, a large longitudinal six-state study of children in publicly funded RTCs found at the 7-year followup that 75 percent of youth treated at an RTC had been either readmitted to a mental health facility (about 45 percent) or incarcerated in a correctional setting (about 30 percent) (Greenbaum et al., 1998).
In summary, youth who are placed in RTCs 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 RTC staff and community services, particularly schools, medical care, or community clinics. Typically, this type of coordination or aftercare service is not available upon 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.