Are Restrictiveness of Care Decisions Based on Youth Level of Need? A Multilevel Model Analysis of Placement Levels Using the Child and Adolescent Needs and Strengths Assessment

Youth entering into the foster care system face many challenges, not the least of which is finding an appropriate placement in which their behavioral and emotional needs can be addressed. This secondary data analysis of foster youth placed in residential care and treatment foster care will study the connection between youths’ scores on a functional assessment and level of placement in the child welfare system using a multilevel model analysis. Data were obtained from an online case management system operated by a state child serving system. The dataset included information for 9,893 youth within 295 residential and foster care provider agencies, with 23,853 functional assessments at multiple time points. Initial findings show a linear relationship between scores on a functional assessment and a placement’s level of restrictiveness; all of the level 2 program variables were significantly associated with the total CANS score for a youth at intake. These findings support prior literature and least restrictive placement policies.     

The Carolinas Project: A Comprehensive Intervention to Support Family-Centered Group Care Practice

SUMMARY

The child welfare system continues its challenge to find better ways for achieving safe permanent connections between children, youths and their families. The importance of maintaining these relationships, especially when children have been removed from their families for periods of time, has been consistently substantiated in the literature (Braziel, 1996; Pecora, Whittaker & Maluccio, 1992; Wells, Wyatt, & Hobfoll, 1991). However, many residential providers, particularly those with long histories as orphanages and children's homes, have been reluctant to embrace family-centered practices as these are often perceived to conflict with their historical, child-rescue missions (see Table 1).

Some providers who have attempted to move toward more family-centered residential care have found it necessary to confront a lack of support from the service systems in which they operate. Other organizations, however, have been able to make extraordinary progress in reinventing their treatment philosophy and services (Gruenwald, 1996). Not surprisingly, the leadership in these settings strongly supported the changes and helped to secure the extra resources needed to facilitate strategic change (Kanter, Stein, & Jick, 1992; Kotter, 1990; Nadler & Tushman, 1989). This article describes a unique strategic change intervention designed to help a large number of residential providers in North and South Carolina become more family-centered. The article also reports on the project's outcomes and outlines lessons learned from this experience.

The Duke Endowment of Charlotte, North Carolina has provided direct and indirect support to residential child caring agencies in North and South Carolina since 1924. The Group Child Care Consultant Services of the University of North Carolina at Chapel Hill and the state trade associations, longtime beneficiaries of this endowment, helped many of these programs in their initial transition from orphanage/children's home to a more treatment-oriented approach.

The Child Care Division of The Duke Endowment under the leadership of Robert Mayer, was committed to strengthening family-centered practice. The Endowment had previously funded an initiative whose efforts focused on enhancing family-centered competence among clinically-oriented staff. In 1993, in response to a request for a proposal, the Albert E. Trieschman Center submitted a plan to provide training and technical assistance to help residential providers in North and South Carolina become more family-centered. This multi-year project, The Carolinas Project, initially featured a comprehensive staff development program with an accompanying technical assistance component. The project later focused on facilitating closer collaboration between private providers and public agencies. The Trieschman Center, a Massachusetts based, national resource center, helps practitioners find better ways of working with high risk children, youth, and families.¹     

Outcomes in Children's Residential Treatment Centers: A National Survey 2010

In 2010 the Research Committee for the American Association of Children's Residential Centers (AACRC) embarked upon a project to repeat the survey that was originally sent out in 1999, hoping to learn how agencies have adapted as well as what was new in the residential treatment environment. The committee was interested in population changes, length of stay, diagnosis, gender, and race, and whether there had been changes in sources of funding and services funded. The committee was particularly interested in the role of data collection and analysis, and how agencies use data to improve process and evaluate outcomes. The growth and sustainability of residential treatment as a viable service option may depend upon the field's willingness to track results, partner with families and the youth they serve, and to make themselves accountable to all stakeholders in the children's services system.     

Mental health knowledge in residential aged care: a descriptive review of the literature

Health care staff knowledge of mental health is vital in the provision of quality care for older people in residential aged care settings. This paper aims to describe mental health knowledge competence of health care staff in residential aged care through a review of existing literature and to explore the link between knowledge, attitudes and education about older people and mental health. A literature review was conducted using electronic databases and library catalogues to identify articles published in English during the period 1982-2002. There is insufficient evidence within the literature to draw conclusions about staff knowledge levels in relation to mental health, however, the literature identified a link between continuing education, knowledge levels and staff attitudes to older people with mental health disorders. Future studies are needed to investigate existing levels of mental health knowledge among health care staff in residential aged care and to identify and evaluate strategies to enhance their ability to provide care for this population.     

Characteristics Associated With the Continuity of Atypical Antipsychotic Treatment Among Youth Discharged From Residential Treatment

This article examined the continuity of atypical antipsychotic medications among children and adolescents following discharge from a residential mental health treatment facility in the state of Florida from 2005 through 2011. Discharge data are reported by the residential providers, while post-discharge data are from Medicaid enrollment and claims files. Fifty-five percent of youth were receiving antipsychotic medications when discharged from residential treatment. Of those receiving such medications, 55% continued with their medication after discharge. Antipsychotics were more likely at discharge among youth who were older, had longer treatment episodes, showed greater improvements during treatment, and had prior involuntary examinations and out-of-home treatment episodes. Continuation of antipsychotic medication was more common among youth who had greater family involvement in treatment, longer treatment episodes, improved more during treatment, and had prior involuntary examinations. Continuation was less likely for youth with prior out-of-home treatment episodes. These results contribute to the existing literature by examining the continuity of atypical antipsychotic medication among children and adolescents following residential treatment.     

. . . on Foster Care International Society of Psychiatric-Mental Health Nurses

PROBLEM:  Mental health problems are particularly widespread for foster children. There are approximately 700,000 youth in foster care and nonfamily settings in the United States. The mean entry age is 3 years. The average stay is 2 years. Experts estimate that between 30% and 85% of youngsters in out-of-home care have significant emotional disturbances. Foster care children represent 5% of Medicaid enrollees but use approximately 40% of Medicaid funds. A substantial number of these children have psychological problems so serious that they require residential placement. Adolescents living with foster parents or in group homes have about four times the rate of serious psychiatric disorders than those living with their own families (2009a). Despite this level of need, less than one-third of children in the child protective system are receiving mental health services (2009a).
SOURCES:  Child psychiatric nurse advocates from the Association of Child and Adolescent Psychiatric Nurses Division of the International Society of Psychiatric-Mental Health Nurses compiled this position statement for adoption by the Board of Directors as the Association's formal statement on the plight of children and adolescents in foster care.
CONCLUSIONS:  Areas that need to be addressed include (a) lack of consistent and comprehensive service planning; (b) communications across agencies and with the youth, their foster parents, and key stakeholders; (c) use of evidence-based interventions to prevent and reduce the incidence of disability; (d) education of child welfare case workers about mental and emotional therapeutic management; and (e) education of foster parents and youth about mental health issues and appropriate treatments.     

Background,Offence Characteristics,and Criminal Outcomes of Aboriginal Youth Who Sexually Offend: A Closer Look at Aboriginal Youth Intervention Needs

Canada's Aboriginal peoples face a number of social and health issues. Research shows that Aboriginal youths are over-represented in the criminal justice system and youth forensic psychiatric programmes. Within the literature on sex offending youth, there appears to be no published data available to inform clinicians working with adjudicated Aboriginal youth. Therefore, the present study examines the background, offence characteristics, and criminal outcomes of Aboriginal (n = 102) and non-Aboriginal (n = 257) youths who engaged in sexual offending behaviour and were ordered to attend a sexual offender treatment programme in British Columbia between 1985 and 2004. Overall, Aboriginal youths were more likely than non-Aboriginal youths to have background histories of fetal alcohol spectrum disorders (FASD), substance abuse, childhood victimization, academic difficulties, and instability in the living environment. Both Aboriginal and non-Aboriginal youths had a tendency to target children under 12-years-old, females, and non-strangers. Aboriginal youths were more likely than non-Aboriginal youths to use substances at the time of their sexual index offence. Outcome data revealed that Aboriginal youths were more likely than their non-Aboriginal counterparts to recidivate sexually, violently, and non-violently during the 10-year follow-up period. Furthermore, the time between discharge and commission of all types of re-offences was significantly shorter for Aboriginal youths than for non-Aboriginal youths. Implications of these findings are discussed with regards to the needs of Aboriginal youth and intervention.     

The fragmented story of pain: a saga of economic discourse, confusion and lack of holistic assessment in the residential care of older people

The long-standing problem of overlooked and/or undertreated pain experienced by so many older people living in Australian residential care facilities condemns these people to a life robbed of quality. Such a degree of suffering experienced by older people calls into question the pain assessment skills of staff who work in residential care. However, the problem of undetected and unresolved pain experienced by older people is not simply a skill or knowledge issue. It is much broader than that. In this paper we portray pain as likened to a story; a narrative that only the older person, as the author, can impart and one in which only they can communicate their experience of pain. Nevertheless, as opposed to seeking the older person's pain narrative, nurses attempt to measure the immeasurable. In part, their actions relate to the confusing terminology which envelops pain assessment. However, political policy and economic discourse also influences nurses' pain assessment practises to the detriment of older people and the profession of gerontological nursing. Discussion in this paper includes the experience of pain for the older person, an overview of the specific role of pain-screening tools compared with the requirements of a person-centred pain assessment, and person-centred pathways to help nurses and others interpret and heed the older person's pain story. Analysis also incorporates the argument that current and previous Federal Government funding tools for residential care subtly impact on holistic pain assessment causing confusion for caregivers and fragmentation of the older person's pain story.     

Measuring Experience of Care: Availability and Use of Satisfaction Surveys in Residential Intervention Settings for Children and Youth

Many public and private mental health agencies have mandated the inclusion of client satisfaction measures in performance outcome initiatives. Unfortunately, there have been limited concurrent developments in methods to assess consumers’ perceptions of care, especially for youth. This article reports the findings from a survey of 66 American Association of Children’s Residential Centers (AACRC) member organizations, the Brief Survey of Specific Youth-Guided Practices in Residential Care Settings, that was conducted in Spring 2014 as part of a project that investigated the integration of youth-guided philosophy into residential intervention services and the extent to which AACRC member organizations incorporate “youth-guided” principles into everyday practice. The survey collected information on a range of youth-guided practices within agencies, but in this article we focus on some of the management practices most directly associated with administration of experience of care (satisfaction surveys). Specifically, this article explores how AACRC member organizations currently assess consumers’ perceptions of experience of care and seek to answer the following questions: 1) Are AACRC member organizations currently assessing youth experience of care?; 2) What tools are most widely used in the residential intervention services community to access youth experience of care?; and 3) At what point in time during the residential intervention is experience of care surveys administered?     

三位一体联合健康教育对青少年高脂血症疗效的调查及分析

目的探讨医院、学校、家庭三位一体联合健康教育治疗青少年高脂血症的效果。方法医院、学校、家庭联合对68位高脂血症青少年（低密度脂蛋白〉2．86mmol／L，总胆固醇〉4．42mmol/L）进行健康教育；健康教育干预后3月检测青少年血脂、体重。结果62位低密度脂蛋白〈2．86mmol／L，62位总胆固醇〈4．42mmol／L；9位超重青少年的体重降至正常，59位肥胖青少年体重降了10％～19％。结论医院、学校、家庭三位一体联合健康教育能降低青少年高脂血症者的血脂水平。     

The Other Side of the Bridge: A Follow-Up Study of Israeli Young Adults Who Participated in A Transitional Housing Program after Aging Out from Care

The Bridge to Independence program aims to provide youths who age out of residential group homes or foster care, and cannot be reunited with their families, with a roof over their heads, emotional and instrumental support, and services that they may need during their transition to adulthood. A follow-up study focused on how youths who graduated from this program fared in terms of their military or civilian service, housing, tertiary education, employment, income, health, leisure activities, social relations, and general satisfaction with their lives. The study was also designed to obtain a retrospective evaluation of their experience as residents in the housing provided by the program. Semi-structured in-depth interviews with 25 participants revealed a complex picture of young people facing a variety of hardships, and experiencing some of the same challenges that face youths when they age out from care. Changes introduced in the program in response to the findings are discussed.     

Feasibility of Inpatient and Outpatient Multidimensional Family Therapy for Improving Behavioral Outcomes in Adolescents Referred to Residential Youth Care

In this study, half of a cohort of adolescents referred to a secure residential youth care institution in The Netherlands was actually placed in the center where they received well-tested Multidimensional Family Therapy (MDFT). The others were offered outpatient MDFT in a last-minute effort to avert juvenile judge accorded out-of-home placement. All adolescents had problems with their family, and virtually all of them with school. Externalizing behavior problems were prevalent. As expected, both groups of adolescents benefited from MDFT on externalizing behavior, family, and school outcome measures. MDFT was well-liked by adolescents and parents.     

Youth suicide

After a review of the statistics on suicide increase among youths, the author offers an analysis of that increase. A review of the literature reveals a number of theories of contributing causes. Drawing on both the literature and his work with suicidal youth at a suicide prevention center, the author offers a general psychodynamic profile of suicidal youth. Finally, he explains the non-traditional categories of youth suicide used at the center in the hope that they will be useful in identifying and treating suicidal youngsters.     

Exposing challenges in transitioning post residential mental health treatment: The case of the “Poster child”

A case report is employed that illustrates the need for residential mental health treatment (RT) and the need for continuation of support post RT. Children and youth with moderate-to-severe mental health needs that require intensive treatment in a safe setting for a duration of several months might access RT. RT is sometimes the treatment of choice, and, in fact, is the best treatment option for some youth regardless of whether the youth is in the care of the family or child welfare authorities. However, mental health needs do not stop after discharge from RT. A continuation of supports and continuation of contact with a mental health professional may provide stability that can foster the youths’ progress in education and interpersonal relationships that are significantly affected by the mental health disorders but are simultaneously essential for transitioning to adulthood.     

Circumstances of substance use by street youth in Egypt support the case for intervening to prevent adverse childhood experiences

Background: Egyptian street youth use substances including tobacco, illicit drugs, and pharmaceutical drugs. To understand the circumstances, including adverse childhood experiences, that place adolescents at risk for engaging in substance use, we conducted in-depth interviews among a sample of Egyptian street children. Methods: From youth residing at or attending Caritas, a non-profit organization, which provides shelter and education to street youth, seven girls and twelve boys, aged 12–18 years, participated in open-ended, in-depth interviews. Results: Eight out of the 19 participants reported family history (early exposure) to substance use; and seven of them were initiated by either a family member (sibling), friend or coworker. Most of the participants reported a history of conflict with or abuse (verbal or physical) by their parents or siblings, or stressful situations at home; they used substance(s) to alleviate their stress. Few attended school, and some were forced to work and help their family. Conclusions: Among Egyptian youth, adverse childhood experiences, such as poverty, child abuse, and family substance use, challenge somewhat susceptible youths and lead them to the path of substance use and addiction. Prevention intervention should be multifaceted, culturally adaptable, and primarily targeting the social environment during childhood.     

Economic evaluation of residential length of stay and long-term outcomes

ABSTRACT

The high cost of residential services for troubled youth is an ongoing concern, and has formed the basis for arguments made for reducing or eliminating residential services for these youth with some recommending that lengths of residential stay be less than 6 months. This is countered by the view that the challenges faced by troubled youth are associated with high public funds expenditures in the future due to limited education, underemployment, and increased risk of criminality. Analysis used 24 month follow-up education, employment, and criminality data from 1476 former residential care youth who were now in their 20s. Individuals who were in the program for more than 6 months had better educational, employment, and criminality outcomes than youth that were in the program for less than 6 months. These improved outcomes were associated with significantly better estimated financial societal benefit over the long-term, specifically a 361% return on investment from a societal perspective.     

A Survey of Mental Health Service Provision in New York State Residential Treatment Centers

Thirty-seven of 43 (86%) agencies operating child welfare residential treatment centers in New York State responded to a survey about the provision of mental health services. Questions were asked about provision of services, satisfaction with services, and suggestions for improvement in five domains: therapeutic milieu, individual therapy, group therapy, family therapy, and psychiatric services. Results revealed that due to funding constraints most agencies reported hiring direct care staff with limited formal education to work with children who present with increasing intensity and severity of emotional and behavioral problems, which in part led to high turnover rates and moderate levels of satisfaction with services. Taken together, the data highlight the demands on the system as more severely troubled youth are being served with fewer dollars provided for their care. The findings suggest many avenues for advocacy, clinical intervention, staff development, and further research.