Fact Sheet: Children in Residential
Treatment Centers
I. Tens of thousands of children with mental
health needs are being placed in expensive,
inappropriate and often dangerous institutions.
The number of children placed in residential
treatment centers (or RTCs)[1]
is growing exponentially.[2]
These modern-day orphanages now house more than
50,000 children nationwide.[3]
Children are packed off to RTCs, often sent by
officials they have never met, who have probably
never spoken to their parents, teachers or social
workers.[4]
Once placed, these kids may have no meaningful
contact with their families or friends for up to two
years.[5]
And, despite many documented cases of neglect and
physical and sexual abuse, monitoring is inadequate
to ensure that children are safe, healthy and
receiving proper services in RTCs.[6]
By funneling children with mental illnesses into the
RTC system, states fail—at enormous cost—to provide
more effective community-based mental health
services.[7]
A. RTC placements are often
inappropriate.
RTCs are among the most restrictive mental health
services and, as such, should be reserved for
children with the most extreme mental health
needs.[8]
Too often, however, child-serving bureaucracies
hastily place children in RTCs because they have not
made more appropriate community-based services
available.[9]
Parents who are desperate to meet their kids’ needs
often turn to RTCs because they lack viable
alternatives.[10]
To make placement decisions, families in crisis
and overburdened social workers rely on the
institutions’ glossy flyers and professional
websites with testimonials of saved children.[11]
But all RTCs are not alike.[12]
Local, state and national exposés and litigation
“regarding the quality of care in residential
treatment centers have shown that some programs
promise high-quality treatment but deliver
low-quality custodial care.”[13]
As a result, parents and state officials play a
dangerous game of Russian roulette as they decide
where to place children, because little public
information is available about the RTCs, which are
under-regulated and under-supervised.
To make it worse, far too many children are
placed at great distance from their homes. For
example, most District of Columbia children in RTCs
are placed outside the District—many as far away as
Utah and Minnesota.[14]
Many families, especially those with limited means,
find it impossible to have any meaningful visitation
with their children.
B. Evidence is limited on the
effectiveness of RTCs.
Children frequently arrive at RTCs traumatized by
the process that delivered them there. They are
often forcibly removed from their homes in the
middle of the night by “escort companies.”[15]
Other times, children are placed in RTCs not by
their parents or doctors, but by overburdened
child-serving state agencies, who know little about
the children’s individual needs.[16]
Even more appalling, many children’s conditions
do not improve at all while at the RTC.[17]
In fact, there is little evidence that placing
children in RTCs has any positive impact at all on
their mental health state[18]
and any gains made during a stay in an RTC quickly
disappear upon discharge, creating a cycle where
children return again and again to RTCs.[19]
There are many reasons why RTCs fail to deliver
the results they promise, but most center on the
type of services provided, the environment they are
provided in and the lack of family involvement.
First, the reality of what occurs within an RTC
is often quite different from the highly
individualized, highly structured programs that are
advertised. The RTCs often provide less intense
services and the staff are often under-trained.[20]
Children spend much of their day with staff who are
not much more qualified than the average parent and
they spend less time face-to-face with psychiatrists
than they would if they were being served in
appropriate community settings.[21]
The environment is also problematic because
children in RTCs enter a situation where their only
peers are other troubled children—a major risk
factor for later behavioral problems.[22]
Research has demonstrated that some children learn
antisocial or bizarre behavior from intensive
exposure to other disturbed children.[23]
Children are usually far from home in RTCs, often
out-of-state.[24]
Removed from their families and natural support
systems, they are unable to draw upon the strengths
of their communities and their communities are
unable to contribute to their treatment. Few
children thrive when they are hundreds or thousands
of miles from their parents, friends, grandparents
and teachers. Few can flourish without the guidance
of consistent parenting. Yet, we expect that our
most vulnerable and troubled youth will miraculously
turn around in just such a situation. Instead, this
isolation further reduces the efficacy of treatment
and increases its cost.[25]
The fact that children and their families are far
from one another creates a host of problems. For
one, it makes family therapy difficult or
impossible. As a result, when children leave the RTC,
they return to an environment that has not changed.
Also, because the RTC environment is inherently
artificial—children are not asked to negotiate the
obstacles that occur within their family setting or
deal with the difficulties that trigger their
behaviors in their neighborhoods or schools—the
child does not gain new skills to better negotiate
life outside of an institution. As a result, neither
the children nor their parents learn better ways to
overcome the obstacles that led to the RTC
placement. Without family involvement, successes are
limited.[26]
Among the rare children who are able to overcome
these obstacles, few can sustain the gains they have
made. In one study, nearly 50% of children were
readmitted to an RTC, and 75% were either
renstitutionalized or arrested.[27]
C. Children suffer because there is no
watchdog.
The RTC industry is largely unregulated.[28]
RTCs need only report major unusual incidents (or
MUIs), but the interpretation of what constitutes an
MUI and the reporting requirements vary widely.[29]
Some RTCs fail to report MUIs at all—with little
consequence.[30]
Vulnerable kids are placed far from home where
parents, social workers, or the state can offer
little oversight or protection. Worse, many of the
facilities limit children’s ability to have contact
with their parents for extended periods, further
restricting the parents’ ability to monitor the
facilities.[31]
D. Children are abused in RTCs.
Children placed in RTCs have been sexually and
physically abused, restrained for hours,
over-medicated and subject to militaristic
punishments; some have died.[32]
The following are just a few documented examples of
tragic occurrences at RTCs:
-
Medication is often used (and overused) to
control behavior.[33]
Children have been permanently disfigured
because of over-medication.[34]
- In some programs, the children’s shoes are
confiscated to keep them from running away.[35]
- There have been reports of behavioral
‘therapies’ being misused. As one author noted,
“Such therapies do little more than
systematically punish children, all under the
guise of treatment . . . .”[36]
- Sexual abuse by staff members and other
residents is all too frequent.[37]
In one case, a 13-year old girl performed sexual
favors for staff members in return for snacks
and carryout food.[38]
At one RTC, four boys were accused of trying to
sodomize another with a cucumber.[39]
At another, a 19-year-old woman was charged with
sodomizing a 14-year-old girl.[40]
- Physical abuse is also too frequent an
occurrence. For example, a 13-year-old boy was
forced against a wall and slammed to the floor
by employees of an RTC.[41]
- Children are often restrained—sometimes for
hours on end. The overuse of restraint has
resulted in child deaths.[42]
E. Tragic outcomes at great public
expense.
RTCs have grown to a billion-dollar, largely
private industry.[43]
Residential treatment care is exorbitantly
expensive—costing up to $700 per child per day.[44]
Annual costs can exceed $120,000.[45]
Most of the time, the public foots the bill for
these services.[46]
In fact, nearly one fourth of the national outlay on
child mental health is spent on care in these
settings.[47]
II. Other Interventions Work Better for Less
Home- and community-based services are much more
therapeutically effective than institutional
services, and are also markedly more cost-efficient.
As the Surgeon General reported, “the most
convincing evidence of effectiveness is for
home-based services and therapeutic foster care” and
not for RTCs.[48]
A comprehensive system of care would dramatically
reduce the number of children in RTCs.[49]
Community-based alternatives produce better
short- and long-term results and are less disruptive
to children and families. These alternatives provide
intensive mental health treatment, mobilize
community resources and help children and their
families develop effective coping mechanisms. Some
models endeavor to “wrap services around” the child,
while others emphasize multi-systemic therapy and
crisis intervention. Randomized clinical trials
found greater declines in delinquency and behavioral
problems, greater increases in functioning, greater
stability in housing placements and greater
likelihood of permanent placement.[50]
In Milwaukee, a wraparound project that has served over 700 youth
involved in juvenile justice has shown similar
promise; use of residential treatment has declined
60%, use of psychiatric hospitalization has declined
80%, and average overall care costs for target youth
have dropped by one third.[51]
Notes
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