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This study explored the peer relationships and behaviors of 17 adoptive children in a residential treatment center. Compared to a group of 17 nonadoptive children, the youngsters tended to be rejected more by peers and to be perceived as having greater attentional difficulties by child-care workers.
On January 22, 2001, we published an interim final rule with comment period (66 FR 7148) that established a definition of a "psychiatric residential treatment facility" that is not a hospital and that may furnish covered Medicaid inpatient psychiatric services for individuals under age 21. The interim final rule established standards for the use of restraints or seclusion that psychiatric residential treatment facilities must have in place to protect the health and safety of residents. In response to some of the concerns submitted in comments on that interim rule, this document clarifies what facilities are subject to the requirements of the interim final rule, modifies reporting requirements to facilitate HCFA monitoring, and amends staffing requirements applicable to restraints and seclusion. Due to the operational significance of these issues, amendment to the interim final rule is required by the May 22, 2001 effective date of the interim final rule. Without such amendments, we are concerned that substantial numbers of facilities would not be able to comply with certain requirements of our interim final rule, and that beneficiaries will suffer needless displacement from those facilities. We are also concerned that HCFA will not be able to timely obtain data necessary to monitor for situations involving jeopardy to program beneficiaries. We will accept comments on these amendments, and will address all comments on the interim final rule and these amendments at a later date.
Mutual- and self-help groups for persons with severe mental illness have typically been most accessible to individuals who live independently. In an effort to make their organization more accessible to those who live in residential treatment facilities, Schizophrenics Anonymous (SA) ran introductory mutual-help meetings in four group homes. The results of a quantitative/qualitative case study of this effort are reported. The SA meetings were characterized as more and less successful based on the criteria of residents' attendance, participation, evaluation of the meetings, and interest in continued participation. The following characteristics distinguished between more and less successful meetings: staff support, referent power (i.e., identification with group leaders), and resident characteristics (e.g., gender, education, marital status, level of symptomatology). In spite of behavioral and self-reported evidence of interest and involvement in the meetings and the potential for continued involvement in the organization, no group home residents continued their participation in SA following the introductory meetings. This finding is interpreted from an institutional theory perspective that focuses on incompatibility between the ideologies underlying mutual help and the residential treatment system.
One of the intentions of Aichhom, Redl, Wineman, Bettelheim, and Anna Freud in their writings about group care was to advocate for the need to simplify the lives of youths who had known only chaos, to create an atmosphere in which everything has a purpose and predictable positive responses were given unconditionally. Recent efforts, such as those by Greenberg et at, have focused on building community-wide early interventions to forestall later emergence of emotional or behavioral disorders. The efforts also mark a shift away from punishment and exclusion for troubled children at school to more inclusive systems of positive behavioral interventions and support by providing a place to achieve academic and social behavioral success. Contemporary social policy regarding residential care for troubled children reflects the belief that a child's development is inevitably enhanced by residence ina family environment. This belief in the value of home and family, so central to contemporary child welfare policy, has been challenged by the recognition that some family situations are not conducive for growth. Redl and Wineman observed that the children who ended up in residential treatment had used up all community treatment resources and soon became the children that nobody wants. Eventually, the homes that produced them, the communities in which they lived, the schools they attended, and the neighborhoods in which they played were unwilling to tolerate their disruptive and disturbing behavior. The chaotic lives of the parents of these children hindered effective monitoring and management,which limited the family's ability to spend time with children, teach conflict-resolution skills, or communicate consistent behavioral expectations. Walker suggested that divorce, abuse, poverty, drugs, and other forces that interfere with normal parenting increasingly disrupt advantaged and disadvantaged families. Vogel and Bell and Spiegel observed that some troubled young people become the family scapegoat. Within these families, therapeutic efforts directed either at the troubled child or the whole family often fail to resolve conflict. Among these families, placement of a child in a therapeutic milieu provides refuge for children and permits parents to marshal their own resources in an effort to restore their own lives. Although many young persons with severe personality disorders meet the criteria formerly acceptable for residential care, such treatment facilities have proved particularly vulnerable to the effects of funding declines and increasing regulatory demands. Increasing visibility of pediatric pharmacology has lessened the impact of a child's disruptive behavior and may have facilitated decreased length of treatment. If, as Bettelheim maintained, psychological symptoms are a response to a world felt as overwhelming, early return to community in the absence of a young person's enhanced awareness of his or her own situation and impact on others may exacerbate return to care. As Rinsley observed, the pathologic family organization that led to the need for residential treatment is not likely to be significantly ameliorated by short-term, system-focused programs. Traditionally, the efforts of the long-term milieu settings have been aimed at restructuring complex and ingrained pathologic influences that have become embedded in family dynamics and have led to maladaptive behaviors in youngsters. The psychodynamic milieu approach emphasized the nuances of relation-ships and meanings ascertained from every interaction with other young people and with adults. This enhanced awareness of a child's impact on others through the marginal life-space interview, together with enhanced awareness of one's own wishes and thoughts as provided by the milieu and individual therapy, may offer the best means for helping a young person return successfully to the community. Although it is increasingly difficult to support young people in long-term milieu therapy, the concerns initially expressed by Anna Freud and her Viennese colleagues, continued in the work of Bettelheim, Ekstein, and Redl, suggest that attention to a child's understanding of self and experience and focus on the interplay of dynamics between the child and the social milieu continues to offer an important means for therapeutic change. This remains true, even at a time when pressure for "mainstreaming" children with special needs together with financial constraints and reliance on psychopharmacology have altered more traditional understanding of the provision of residential psychodynamic treatment for troubled young people.
The concept of borderline diagnosis is defined and the goals of residential treatment are delineated. The specific aims and techniques of psychotherapy are then outlined. Concomitant work with parents is utilized. The importance of working through during termination is noted.
Variables related to aggression were explored in a population of psychiatrically disturbed male adolescents in a residential treatment setting. The Marlowe-Crowne Social Desirability Scale, Daydreaming Questionaire, Byrne Repression-Sensitization Scale, and the Buss-Durkee Hostility Inventory were administered to high and low aggressive patients. Multivariate analyses of the data indicated that high aggressors were significantly lower in their social desirability needs and significantly higher in their daydreaming, hostile, attitudes and sensitization than were low aggressive patients. These findings were discussed relative to a greater understanding of aggression in emotionally disturbed adolescents and implications for treatment.
This paper chronicles a comprehensive evaluation of 6 residential facilities for young offenders located within the region of Waterloo. Two kinds of research methodologies were employed in the investigation. One was primarily quantitative in nature, involving the completion of standardized scales for each of the youths who participated in the study (N = 129). The other was qualitative in nature, and involved interviews with a small sample of "graduates" from the centres (N = 9), and some of their parents and guardians (N = 4). Residential treatment was associated with significant improvements on the 2 measures developed specifically for the evaluation: a measure which focused on the specific goals which had been assigned to youths while in the program (Catalogue of Goals for Youth in Residence), and the global index of youth functioning which was empirically generated from residential case files (Inventory of Work Life and Social Skills). Qualitative interviews with program graduates and selected parents and guardians generally confirmed the positive evaluation of the impact of residential facilities on youths and served as the foundation for a series of recommendations for programmatic modifications and improvements.
Descriptive data derived from initial assessment interviews and from standardized 3-month progress reports are presented on 1684 homeless, chronically mentally ill veterans who were contacted at nine sites in a national Department of Veterans Affairs outreach program. Levels of involvement in the program were modest, with only 16% of those screened having over 10 clinical contacts and 24% still involved after 3 months. Demographic and clinical characteristics were weakly associated with continued involvement, but those admitted to residential treatment were 5.4 times more likely to be involved in the program than those not admitted. Admission to residential treatment appears to be the strongest determinant of clinical engagement of the homeless mentally ill.
The MMPI profiles of 268 clients presenting for residential treatment of cocaine addiction were examined. The results revealed clinically significant elevations on the Pd and Ma scales of this instrument. In addition, elevations approaching clinical significance were found on the D, Pa, and Pt scales. These results are discussed in terms of conducting treatment within the context of an Alcoholics Anonymous/Narcotics Anonymous framework, as well as the implications for relapse prevention planning.
To study residential treatment outcome, a follow-up questionnaire sent to families of former child patients was used to assign them to categories of "good", "fair," or "poor" overall adjustment. The three groups were compared on variables such as presenting symptoms, duration of psychotherapy, amount of drug therapy, and prognosis on discharge; several therapist variables were also studied. Findings, some unexpected, are discussed.
A retrospective review of the clinical charts of 97 adolescents who had received residential treatment for heroin dependence was conducted to determine predictors of heroin use. The average age for the adolescent patients reviewed was 17 years. Almost half of the adolescents (48%) were female and over half of the adolescents (53.6%) used heroin intravenously. Both males and females had substantial heroin habits, but differing amounts of use. Boys used an average of six bags of heroin per day and girls used an average of four bags of heroin per day. Using gender, age, number of heroin dependence symptoms, and other substances as predictors, 64.21% of the adolescents were correctly classified as injectors or noninjectors of heroin. Heroin appears to be a significant drug of abuse among these predominately white, middle class, suburban adolescents.
In this study the factorial validity and the reliability of DSM-IV related ADHD symptom ratings made by care professionals working in residential treatment centres were determined in a sample of 412 residential youngsters. Three concurrent models of the ADHD disorder were investigated, a one-factor model comprising all 18 symptoms, a two-factor model with the Inattention and Hyperactivity/Impulsivity symptoms, respectively, combined and a three-factor model comprising Inattention, Hyperactivity, and Impulsivity symptoms, respectively. An analysis of the covariance structure shows acceptable fits for both the two- and the three-factor models, slightly favouring the three-factor model. The internal consistencies, the test-retest reliabilities, and the inter-rater reliabilities turned out to be good to excellent for all scales based on each of the three concurrent models.
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This paper addresses the need for a coherent conceptual therapeutic approach to guide work with disturbed children and adolescents in residential treatment centers. The paper identifies changes in the population currently in care; examines the two dominant approaches that historically have shaped the standard treatment models used by most residential centers; and discusses four longstanding debates that have complicated the development of a consistent therapeutic approach for residential programs. It concludes with a description of The Sanctuary Model. Integrating a variety of treatment approaches, this trauma-based systems approach to care was first used with adult inpatients traumatized as children. It is now being introduced by a major social agency into three of its residential centers to provide a systematic treatment model for use in their schools, living units, and treatment sessions.
In view of the growing concern over the number of disturbed children in residential treatment centers, identification of the kinds of children best treated in such centers is important. A review of the literature reveals that criteria for placement are inadequate and information on outcomes insufficient for guidance on the placement problem. Implications and recommendations for practice and research are delineated.
Severely or profoundly handicapped young children who lived in a residential treatment center were subjects in a modified time-sampled observation study of social behavior, state, and physical context. The study was conducted for 3 successive years. Although system-level changes in the ecology of the institution over the 3 years did not appear to affect the social-interaction indices, the developmental ages of the children were positively related to social opportunities and social behavior.
This longitudinal study investigated the effectiveness of a one and one-half year long residential treatment program for 26 boys aged 11-15 with histories of sexually aggressive behavior. The clients were assessed with self-report and staff-report measures at the beginning and end of treatment and at several time points in between; also, aggressive acts were tabulated during a one-year follow-up period. There was evidence of improved functioning on 10 of the 12 measures. During the follow-up, 27% of the sample committed an aggressive act, and 8% committed a sexually aggressive act. On most of the measures, improvement occurred gradually over the course of treatment, and on some measures most of the improvement occurred late in the placement.
This paper describes methods being used to implement and assess the effects of a trauma-focused intervention in residential treatment programs for youths with emotional and behavioral problems, and histories of maltreatment and exposure to family or community violence. Preliminary baseline profiles of the therapeutic environments and youths are also presented. The intervention, referred to as the Sanctuary Model (Bloom, 1997), is based in social psychiatry, trauma theories, therapeutic community philosophy, and cognitive-behavioral approaches. Within the context of safe, supportive, stable, and socially responsible therapeutic communities, a trauma recovery treatment framework is used to teach youths effective adaptation and coping skills to replace nonadaptive cognitive, social, and behavioral strategies that may have emerged earlier as means of coping with traumatic life experiences.