Position Statement 44: Residential Treatment for Children and Adolescents with Serious Mental Health and Substance Use Conditions

Policy

MHA believes that it is essential to avoid out-of-home placement whenever wrap-around care could meet the child’s or youth’s and family’s needs. But high-quality residential treatment programs for children and youth with mental health and substance use conditions are essential components of a continuum of care. A child or youth may require residential treatment when available community-based alternatives have been explored and have not successfully addressed the person's needs, when the complexity of his/her needs confounds community-based care and requires a 24-hour environment to accurately understand those needs and adequately respond, and when the severity of the behavioral problems requires a 24-hour treatment environment in order to keep the person safe and prepare him/her to be responsive to community-based care. 

The greatest dilemma in intervening to help children at risk of bad outcomes is determining when to abandon the family-centered, community-based therapy that we know works best and place a young person in a residential treatment facility. When is a referral to residential treatment therapeutically appropriate and medically necessary? When is the avoidance of harm in and to the family worth the resultant disruption of family life and community integration?

For people with access to high-quality, local, community-based, non-profit residential facilities, and a comprehensive system of care,[1] residential treatment may result in a relatively quick transition back to the community. Transitioning back is much harder for parents who enroll their child in a private, for-profit, often distant facility that may prove unresponsive and even abusive. The private for-profit residential care industry has grown very fast, without yet incorporating the ethos of the public sector alternatives that it is replacing, is impervious to community pressures, and is resistant to transparency and family collaboration.

Hardest of all, when should parents consent to any out-of-state placement, knowing that the regulatory structures that now exist will not effectively monitor the care and treatment given to their child?

MHA advocates that the mental health movement act to mitigate these legitimate concerns and improve the quality, transparency, collaboration and responsiveness of residential treatment.

Short-term residential treatment with family-based aftercare linkage has been found to be more effective than long-term residential treatment.[2] Thus, residential treatment must not be conceived of as a long-term housing option, though longer-term treatment should be available when medically necessary. Residential treatment is best when it involves the family in the treatment process, promotes collaboration with community treatment for discharge, and is shorter in duration.

MHA cautions that the quality of care in residential treatment facilities for children is very uneven, and vigilance is essential to promote good outcomes. These concerns are documented in the Background section that follows. MHA has been actively involved in urging tighter and better regulation of the burgeoning private residential care industry. MHA believes that community-based, non-profit residential programs are usually better run and more subject to community scrutiny.

MHA urges more effective state and federal regulation, greater openness and a greater public service ethos, more collaborative and recovery-oriented partnerships with families and communities, respect for the voice of the youth being served, integration with other services, and full embrace of what the SAMHSA Child Mental Health Initiative describes as system of care values.[3]

Background 

Residential placement of children, and the loss of custody and family and community integration that it implies, should be avoided whenever it can be.[4] Wrap-around services to maintain the integrity of the family should be an authorized use of child welfare funding, to prevent out-of-home placement, without requiring a waiver as it now does. And the residential care industry must be more scrutinized and better regulated. But when residential treatment becomes medically necessary, it is an essential tool to respond to the needs of children, youth and their families.

Residential facilities for children and youth cover a wide spectrum of needs and can serve as a good alternative to jail or a locked mental health treatment facility. Olmstead principles are applicable, and the legal requirement under the Americans with Disabilities Act (ADA) is to use the least restrictive means. Thus, both child welfare and juvenile justice placements must consider the option of residential treatment as part of the dispositional spectrum in order to comply with the ADA.

As mental health professionals have seen the failure of larger inpatient treatment facilities, smaller and medium sized group homes promoting a recovery and family oriented community and greater consumer autonomy have been developed by non-profit groups around the country, with sometimes impressive results.[5]

However, the reality is that good residential treatment facilities can be hard to find. The United States Government Accountability Office’s 2007-8 studies remain the best evidence we have of quality of care, and a recent expose of one major for-profit provider shows that the problem continues.[6] These studies dramatically demonstrate ineffective management practices, lack of staff training, misuse of physical restraints and deceptive marketing practices in eight case studies of abuse and death in residential facilities and called for “enhanced oversight” of facilities that deal with youth with behavioral and emotional challenges.[7]

Mental Health America (MHA) believes that, despite improvements, deficiencies in residential facilities for children with mental health conditions are widespread, that the recent growth of non-community-based, for-profit programs is a matter of serious concern, and that urgent action is needed to address issues of quality of care in residential treatment facilities. States should consider amending existing legislation to promote evidence-based practices, monitor outcomes, ban most use of seclusion and restraints,[8] mandate effective licensure, training, and continuing education, and require background checks of all treatment personnel in child- and youth-serving residential treatment facilities and to develop comparative outcome reporting systems so that families and agencies can determine where good results will be most likely achieved.

State agencies should be vigilant in inspecting and monitoring residential treatment facilities by focusing on outcomes rather than processes and avoiding the kind of “regulatory capture” and “paper compliance” that makes such programs ineffective. And families and caregivers should be provided with honest, understandable, and detailed information about the service options available and the mechanisms by which these services can be funded. The Federal Trade Commission has outlined guidelines for parents seeking quality residential treatment programs.[9]

Clifford Beers, the founder of Mental Health America, made his mark in exposing the brutality of the state hospitals for the mentally ill, the residential treatment facilities of his day. As with asylums, mental hospitals and nursing homes, whose scandals fueled the modern mental health movement, assuring quality of care in residential treatment facilities for children and adolescents has proved a difficult task. With some exceptions,[10] periodic scandals have not produced effective regulation at the state level, which is the level of government that regulates residential treatment facilities, though the federal government has recently expressed concern.[11]

MHA believes that the state and federal government both should act to demand greater accountability from the residential care industry. That role is incumbent on the states because these private facilities have replaced state institutions and now market themselves directly to families with minimal state oversight. A greater role for federal regulation and guidance should be considered given that many residential treatment programs enroll youth from families out of state and given the lack of standardized oversight across states.

The April, 2008 GAO Report to the House Committee on Education and Labor[12] documented the regulatory gaps that have permitted abuse, neglect and misrepresentation at private “wilderness therapy programs, therapeutic boarding schools, academies, behavioral modification facilities, ranches and boot camps, among other names….” The GAO documented how many states exempt faith-based residential facilities and that the majority of states do not require independent accreditation.[13]The private children’s and adolescent’s residential treatment industry was directly indicted by a second report, which concluded from the study of eight deaths in treatment that there was: “significant evidence of ineffective management,” “leaders neglecting the needs of program participants and staff,” “hiring of untrained staff,” “lack of adequate nourishment for enrolled children,” and “reckless or negligent operating practices, including a lack of adequate equipment.”[14]

“In the eight closed cases that [the GAO] examined, ineffective management and operating procedures, in addition to untrained staff, contributed to the death and abuse of youth enrolled in selected programs. In the most egregious cases of death and abuse, the cases exposed problems with the entire operation of the program. The practice of physical restraint also figured prominently in three of the cases.”[15]

The other focus of the GAO investigation was deceptive marketing, Posing as concerned parents, the GAO uncovered conflicts of interest and  “potential fraud, false statements, and misleading representations related to a range of issues including tax deductions, education, and admissions policies.”[16] The most egregious case was a “referral” counselor who acted as a feeder for her husband’s boot camp.

The U.S. Department of Health and Human Services, Center for Mental Health Services, issued a report on state regulation of residential mental health facilities for children in 2006, but the report was only a taxonomy and did not test how well the regulation worked.[17] Significantly, the study did not identify any form of outcome monitoring or monitoring of use of seclusion and restraints beyond critical incident reporting.

The US Department of Justice Office of Juvenile Justice and Delinquency Prevention published a 2010 survey that urged only one policy priority, which MHE heartily endorses: Improve the quality of youth-staff relations, require fair treatment, and establish an effective grievance process.

The DOJ concluded that, “poor relations with staff characterize life in custody for more than two in five youth (43 percent). A majority of youth in custody say punishments are unfair, while more than one-third feel that staff use unnecessary force. Similarly, one-third of youth have difficulties with their facility’s grievance process—either they do not know how to file a complaint or they fear retribution if they do so. Standards for staff conduct should require that staff treat youth fairly and issue fair and reasonable punishments commensurate with the infraction. The facility should maintain a grievance process that is clear and universally understood and that includes protections for youth who submit complaints.”

Call to Action

• Mental Health America urges that its affiliates support federal and state legislation and funding to improve oversight of residential treatment facilities.

• Federal and state governments should consider legislation to promote evidence-based practices, monitor outcomes, ban most use of seclusion and restraints,[18] mandate licensure, training, and continuing education, and require background checks of all treatment personnel.

• Federal and state agencies should be vigilant in inspecting and monitoring residential treatment facilities by focusing on outcomes rather than processes and avoiding the kind of “regulatory capture” and “paper compliance” that makes such programs ineffective.

• Federal and state governments should require improved quality of treatment including youth-staff relations, adequate staff to child ratios to ensure safety and recovery, fair treatment, and an effective grievance process.

• A federal and state funded complaint line should be available to families and other witnesses to alert states to the need for increased vigilance and proactive enforcement as needed.

• Protection and advocacy agencies should prioritize Olmstead compliance and quality of care in residential facilities.

• Whenever practical, affiliates should monitor concerns about care and advocate for incentives for non-profit residential care for children.

• Families and caregivers should be provided with honest, understandable, and detailed information about the service options available and the mechanisms by which these services can be funded.

• When a child enters residential treatment anywhere, it is imperative that the parents and service agencies in that child's community redouble their efforts to be actively involved in treatment and discharge planning and post-discharge preparation, ensuring that the treatment facility has comprehensive information about the child's history and the impact of previous treatment efforts, participating in the development and implementation of the care plan in the facility, working with family members to increase their ability to manage the child's behavior after his or her return to the home, and ensuring that a responsive, updated care plan is developed to support the child's return to the community after the goals of residential treatment have been met.

After accepting responsibility for care and treatment, each residential facility should:

• fully involve the family in placement, treatment and discharge planning,

• update the family on any concerns detected through monitoring the child,

• furnish statistical information regarding the outcomes for the children and youth whom they have served,

• fully discuss side effects and contraindications with the family, and

• acknowledge whenever a particular program or service might be inappropriate to meet a child's needs for any reason.