Provided by David Satcher, M.D., Ph.D.
Surgeon General of the United States of America
Chapter 3: Children and Mental Health
Services Interventions
Treatment Interventions
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.
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