Compassionate Accountability in Residential Care: A Trauma Informed Model

This article examines techniques for holding youth in residential care accountable for their behavior. Based on the use of trauma treatment theory, the authors believe that holding one accountable can actually be conceptualized and put into practice as a nurturing operation. For traumatized individuals, more traditional approaches to accountability do not validate their perspective or feelings and, most likely, threatens them. Consequently, they feel discounted, their freedom restricted, and will feel unsafe and ultimately re-traumatized. Compassionate accountability improves relationships between staff and youth, and the achievement of mastery over trauma related symptoms is enhanced and facilitated versus diminished and blocked. Youth in residential care are empowered to take responsibility while simultaneously feeling validated and safe. Step-by-step guidelines and examples of how to implement this approach effectively are provided.     

Developing a Clinical Framework for Children/Youth Residential Treatment

The idea of implementing consistent overall clinical approaches in residential treatment facilities may improve care by influencing family engagement, interactional styles of residential staff and clinicians with children and youth, specific therapeutic interventions including the management of problematic behaviors, milieu approaches, and group interventions, as well as inform programmatic structure, rules, and expectations of residential living. A clinical framework should demonstrate contemporary and evidence supported practices in order to achieve meaningful success. This article summarizes a literature search and discussion points regarding family/community engagement, individualized assessment/treatment, interprofessional teams, and organizational factors in developing a clinical framework for children/youth residential treatment.     

Private Service,Public Rights: The Private Children's Residential Group Care Sector in Ontario,Canada

This article explores the core themes and issues of private residential service delivery for children and youth in Ontario, with a specific focus on staffed group care within this sector. Such exploration highlights the juxtaposition of the public rights of children with the private world of service provision. Based on twenty interviews with owners of private residential care facilities and an examination of government and professional writing and reports about residential care in Ontario, there is no obvious reason to dismiss or be critical of private residential care. However, both private and public residential care in Ontario are under-regulated, resulting in significant variations in terms of organizational structures, the quality of staffing and training, accountability and transparency, and ultimately, the efficacy of specific residential services.     

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.     

The Restorative Healing Model: Implementation at the Woodbourne Center

This study describes the Restorative Healing Model used at the Woodbourne Center (Baltimore) to improve socially adaptive functioning and behaviors among youth residing in a residential treatment center. This treatment model requires collaborative work with youth, their families, staff members, and community members. Unlike program models built on pathological or punitive approaches, the Restorative Healing Model offers empowerment and strength-based perspectives to vulnerable youth by integrating three evidence-based or promising practices: aggression replacement training, restorative justice, and trauma-centered care. In addition to reviewing empirical support for the model, we present examples of the model's use within the residential treatment center environment.     

Older Youth Nearing Their Exit from Congregate Care: Current Innovative Programs

The present paper reviews literature on older youth in foster care with a focus on those older youths in residential. We aim to examine what has been written in the scholarly literature about this specific group. Literature was reviewed from the last decade on the problems these youths face and potential solutions for them in the program literature. A literature review was done utilizing keywords. Further, this paper presents highlights from two informational interviews with residential agencies. Here we aim to describe what the Executive Directors and staff members believe older youths need, how they work with them and the important components of a residential facility for older youth. Findings uncovered that both agencies highlighted the importance of pro-social attachments, or caring relationships, along with education and safety. Also, the critical importance of preparing youths enough so that when they leave residential they will have reduced the gap between their skills and others their age, so as to be able to compete in society for jobs and further education. Limitations include lack of generalizability, among others.     

Fasten Your Seatbelts: Holiday Issues with Children and Youth in Residential Treatment

Employees working in residential treatment know from experience that holidays will be stressful and treacherous for the children and youth placed in their programs (and, consequently, for the staff themselves). Using a multiple systems approach, this article examines risk factors for holiday-related stress and crisis in residential settings treating children and youth. Holiday-related stress and crisis is conceptualized as arising from three distinct domains: child vulnerabilities, worker vulnerabilities, and contextual vulnerabilities; the accumulation of multiple vulnerabilities increases risk. The article concludes with practice recommendations to assist residential staff in minimizing the potential for holiday-related stress and acting-out.     

Residential Education in the Unites States

The authors explore some of the crucial issues on which the future success of residential group care programs for children and youth in the United States depends, including funding, legal considerations, race and culture, the role of religion, and evaluation.     

Pharmacologic Advances in Residential Treatment

The author has worked as a child psychiatry consultant to several residential treatment centers from 1965 to the present. Prior to the last 5 or 10 years, the psychiatric consultant role was mainly one of providing diagnoses, assisting with the formulation of psychodynarnics, consulting with residential staff, providing psychotherapy, etc. However, there is a remarkable revolution in psychiatry in the areas of neuroscience and psychopharmacology. These advances, especially in psychopharmacology, offer a great deal of potential for children and youth in residential care, especially those whose problems of mood and behavioral control interfere with the standard, non-pharmacologic approaches. This paper will mention the older drugs (Ritalin , Thorazine , Haldol), but will focus on the use of the newer drugs (the SSRI antidepressants, clonidine, lithium carbonate, valproic acid, betablockers and carbamazepine) in diagnosing and ameliorating behavioral pathology.     

Youth and Family Participation in the Governance of Residential Treatment Facilities

This study used data from a national survey of residential treatment facilities and conducted interviews with stakeholders in systems of care that serve children and youth with serious emotional disturbances to examine the extent to which youth and families participate in the governance activities of residential treatment facilities. Twenty percent of residential treatment facilities included youth and families in some type of governance activity, such as serving on the board of directors or participating in quality assurance. Thirty-eight percent of residential treatment providers agreed that licensing or accreditation standards should require the participation of youth and families in facility governance, and these facilities were more likely to have adopted treatment practices consistent with a commitment to partnering with youth and families in the delivery of services. These practices include unrestricted visitation and allowing youth and families to select their treatment team. Residential treatment providers and other stakeholders in systems of care identified several challenges to engaging youth and families in facility governance and proposed solutions for overcoming them. Further work is needed to encourage and monitor the participation of youth and families in the governance of 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.     

Family-Driven Youth-Guided Practices in Residential Treatment: Findings from a National Survey of Residential Treatment Facilities

Family-driven, youth-guided practices have shaped the development of community-based mental health services for children and youth; however, the extent to which residential treatment providers have adopted these practices is unclear. This study reports the findings from a survey of 293 residential treatment providers conducted to examine the adoption of family-driven, youth-guided care. Residential treatment providers reported several practices consistent with family-driven, youth-guided care, including strength-based individualized treatment planning, collaboration with community-based providers to develop treatment plans, and the provision of various forms of support to families. Thirty percent of providers reported that the youth or family member was the primary decision maker in the development of treatment plans, 20.9% included youth or family members in program oversight, and 88.0% reported that staff had not heard of family-driven, youth-guided principles or required further training to implement them.     

An Outcomes Perspective of the Role of Residential Treatment in the System of Care

A variety of factors are putting great pressure on residential treatment centers to justify their role in the child serving system through evidence of impact on the lives of children, youth, and families. The present study describes the role of residential treatment from an outcomes perspective in a midsized state over the course of a 5 year period in which efforts were made to reduce out-of-community placements. The process of developing a system of care approach to the child serving system while matching children and youth needs to the use of residential treatment resulted in placing more challenging children and youth in these placements over time. The results of this process included an improvement in within-episode outcomes from residential treatment. A hinge analysis in which children and youth were described using a common assessment before and after placement in a range of treatments/programs helped explicate the role of residential treatment serving the most challenging children and youth successfully. The necessary length of stay for residential treatment from a clinical perspective depends greatly on the continued treatment options post-discharge.     

Augmentative and alternative communication intervention in children with traumatic brain injury and spinal cord injury

Children and youth who sustain a traumatic brain injury (TBI) and/or spinal cord injury (SCI) may have temporary or permanent disabilities that affect their speech, language and communication abilities. Having a way to communicate can help reduce children's confusion and anxiety, as well as enable them to participate more actively in the rehabilitation process and thus, recover from their injuries. In addition, effective communication with family, care staff, peers, teachers and friends is essential to long-term recovery and positive outcomes for children with TBI and SCI as they are integrated back into their communities. This article describes how rehabilitation teams can use augmentative and alternative communication (AAC) and assistive technologies (AT) to support the communication of children recovering from TBI and SCI over time.     

Paediatric palliative care delivered by an adult palliative care service

BACKGROUND: In recent years, the discipline of paediatric palliative care has emerged in response to the awareness of the distinct needs of dying children. To date, in Ireland there is no paediatrician trained in palliative medicine, and specialist paediatric palliative care is generally delivered by adult trained teams. AIMS: We wished to examine the experience of an adult palliative care service providing palliative care to children. Methods: The study entailed three stages: (1) a retrospective chart review of all children referred to the service; (2) a questionnaire survey; and (3) a focus group to explore the views of staff in caring for children. RESULTS: The main themes highlighted were staff competence, staff stress, uncertainty of prognosis, resource implications and co-operation with other teams. CONCLUSION: This study highlights some of the challenges for an adult palliative care team providing paediatric palliative care. Many skills developed for adult patients can be used in paediatric palliative care. Adult palliative care teams and paediatric teams have complementary skills. The challenge is to integrate services to meet the needs of terminally ill children.     

Residential Care and Cure: Achieving Enduring Behavior Change with Youth by Using a Self-determination,Common Factors and Motivational Interviewing Approach

Residential treatment for youth includes both care, such as basic care-taking tasks and pedagogical child-rearing tasks, and cure elements, such as the therapeutic milieu and individual treatment plans. With these elements, residential treatment aims to achieve a healthy development and a decrease of the present problems with youth. However, achieving enduring change with youth after they have left residential treatment is a great challenge. This challenge can be explained by care workers’ difficulties to establish good, genuine therapeutic relationships with individual youth. Furthermore, it can be explained by the commonly used treatment approach to achieve behavior change with youth during residential care. In this paper, I suggest that higher long-term effectiveness of residential treatment can be achieved by applying a combination of three treatment approaches. First, by focusing on youth’s individual needs and intrinsic motivations using the Self-Determination Theory (SDT) perspective. Second, by using the Common Factors model as residential care element to promote professionals’ interpersonal skills and good, genuine therapeutic relationships with youth. Third, by applying the Motivational Interviewing (MI) approach as a residential cure element. By integrating these approaches as intervention components, it is very likely that residential treatment will contribute to more enduring behavior changes with youth.     

A Strategic-Systemic Family Therapy Model

Over the past five years, "Family Therapy" has become an increasingly familiar term to many residential facilities for children and youth. But along with its growing popularity have come questions about its efficacy when used apart from the overall therapeutic milieu. Unfortunately, too many facilities maintain programs which regularly offer family therapy, but fail to integrate a family therapy model into their residential treatment program. The strategic-systemic family therapy model provides child and youth care professionals with a residential treatment model which successfully incorporates family therapy with residential child care practice.     

Implementing Non-violent Resistance,a Method to Cope with Aggression in Child and Adolescent Residential Care: Exploration of Staff Members Experiences

Staff members in residential care for youth are frequently confronted with aggressive behaviour, which has adverse effects on their stress levels and work satisfaction. This paper describes a qualitative evaluation to find out how staff members benefit from Non-violent Resistance (NVR), a method to create an aggression mitigating residential climate. Staff members were positive about NVR and reported feeling more relaxed. Most valued aspects of this method were the focus on being a team, delayed response and giving up the illusion of control. However, training and the intention to use NVR isn't enough, high quality implementation and maintenance are crucial.     

CAPACITY FOR SELF-CARE OF PERSONS WITH MENTAL ILLNESSES LIVING IN COMMUNITY RESIDENCES AND THE ABILITY OF THEIR SURROGATE FAMILIES TO PERFORM HEALTH CARE FUNCTIONS

Persons with chronic mental illnesses have a higher prevalence of medical illnesses and higher mortality rates than the general population. Those living in the community are usually linked with mental health services but are expected to manage their own medical care. The ability to manage their health care and the ability of "surrogate families" to assist them were measured among residents and staff of supervised community residences. In its surrogate role, the agency promoted routine health examinations and followup care. Its staff was a central resource for the residents, who sought out staff members for assistance with their health problems. However, residents and staff alike lack knowledge about health problems, medications, and approaches to modifying unhealthy lifestyle practices. Although residents identified lack of knowledge about sexually transmitted diseases as a major concern, staff indicated discomfort with this topic. These findings suggest the importance of supporting chronically mentally ill persons and residential staff in managing residents' health care functions.     

Redefining Residential: Strategic Interventions to Advance Youth Permanency

ABSTRACT

This is the 13th in a series of papers by the Association of Children’s Residential Centers (ACRC) addressing critical issues facing the field of residential treatment. ACRC is the longest standing association focused exclusively on the needs of children and youth who need residential intervention and their families. The purpose of the papers is to stimulate dialogue and self-examination among organizations, stakeholders, and the field.

This paper focuses on the overarching goal for all children in out-of-home care to achieve safety, permanence, and well-being, and the role of those providing quality residential interventions in accomplishing this mission. While it particularly focuses on children and youth in the child welfare system, it is applicable to all young people and families. With residential interventions a necessary therapeutic option in community systems of care (Blau, Caldwell, & Lieberman, 2014), it is important that residential providers embrace their critical role in helping children and families move toward permanency and achieve successful outcomes.