AACP Newsletter, Volume 15, Number 3, Summer 2001

Residential Treatment for Youth: Do No Harm!

A few months after the tragedy of 10 year old Candace Newmaker’s re-birthing death in Evergreen, Colorado, come reports of further brutality against our most vulnerable and troubled children.

In June 2001 in Fountain Hills Arizona, a 14-year-old boy was taken from a residential treatment facility dehydrated and delirious and was pronounced dead when he arrived at the hospital. Prior to staff calling 911 they had forced him, along with other residents, to stand in the Arizona sun in temperatures that were regularly over 100 degrees. They were forced to wear black sweats and were punished if they asked for food or water by being forced to eat mud. These teenagers were often beaten. The "sergeants," or staff members, stomped on the boys chests and arms with boots if they didn’t perform tasks required of them. On one occasion a staff held a knife to the throat of a boy.

Earlier, at a school for troubled teens in Prince Georges County Maryland, a 17-year-old boy died of asphyxia as a teacher cut off his airway in the act of restraining him.

More recently, at a Christian school for troubled youth in Newark Missouri, five staff members were arrested and charged with felony child abuse. Their punishment for youth who were deemed disrespectful was to stand in cow manure pits in depths of a few inches to chest high.

These incidents are the latest in a steady drum beat of reports of egregious behavior on the part of staff members of some residential programs for troubled youth. These facilities go by a variety of names: attitude adjustment schools, behavior modification camps, social service shelters, wilderness survival camps. Others present themselves as psychiatric residential treatment facilities.

These programs claim to help troubled youth, but they often operate with minimal, ineffectual or absent psychiatric oversight. Reports of abusive practices in these facilities come from all over the United States, but more often from states with weaker laws protecting the rights of adolescents.

• How common are such incidents?

• Do they occur in violation of an agency’s policies, or do they result from practices that should be considered child abuse but are seen by program leaders as valid treatments for behaviorally disordered youth?

• Why do parents seek out such programs for their troubled sons and daughters?

• What are our obligations to seek oversight and regulation of residential programs for troubled youth and to educate parents and the public about risks and questionable practices in these facilities?

These are a few of many unanswered questions that trouble advocates and professionals concerned about the humane treatment of children and youth with psychiatric disorders that manifest as troublesome behavior.

What we do know is that there are many programs for such youth around the country. Some have contracts within their home states for serving difficult to manage youth and others receive reimbursement from private insurance carriers. Oversight of these contracts appears to be inadequate in many cases.

Many such programs are responsible only to the parents for the way they serve children and youth. Many programs tell parents to stay out of contact with their children for a period of time and provide parents with explanations of the treatment that may not represent what their child experiences.

Too often, prior treatment is viewed as failed treatment. Records are not obtained and prior therapists are disrespected or shunned if they try to coordinate.

There is no one regulatory agency that has responsibility for such facilities in any state as programs fall outside of usual regulatory frameworks for psychiatric facilities or schools. Deaths, serious harm and frank abuse have been reported on by journalists, starting with the 1998 Hartford Currant article on death and injury from restraint and seclusion.

To date, the medical and nursing professions have had little to say about troubled facilities and the reports of tragic incidents arising from them. Our professions have not defined best practices for addressing behavioral symptomology in such programs.

A psychiatrist speaking on behalf of a program that had a recent death stated in a legal setting that such incidents are rare, but can be unfortunate side effects of restraint, and are unavoidable.

At the very least, states should develop regulatory policies defining the various forms of residential care and assuring that all residential programs in their state are covered by some regulatory system. Regulatory policies should be placed in law and should hold the program administration accountable for assuring the safety of each youth in their care. Regulations should define the boundary for staff between allowable physical interventions and behavior with youth that is frankly abusive.

Psychiatrists and nurses should be on the forefront of advocating for such reforms and assurances for our youth.

The issue of residential treatment should be looked at from the perspective of community psychiatric, or community nursing practice.

What have we learned from nearly twenty years of practicing values and principles articulated for the Children and Adolescent Service System Program (CASSP) and the System of Care (SOC) reform movement it spawned?

The core values of the SOC reforms were the following:

Services should be

1) family centered
2) child and adolescent focused
3) community based and well coordinated
4) culturally competent

Sending youth across the country to a residential program, or limiting parental access to their children in a local program, is the antithesis of a family centered practice. Parents must be included in the assessment of each child, involved in regular contact with their child and central to planning the child’s reentry into their life outside the institution.

Programs that offer rigid programming, or frankly misuse behavioral paradigms, are not providing individualized and tailored care as is becoming a standard "best practice" for ever more child care communities around the country.

To provide a quality service, psychiatrists, nurse practitioners and other mental health professionals should have a strong hand in overseeing the treatment process.

Children and youth taken out of their communities, when those communities have seemed unable to help a youth modify their behavior, are not optimally served. They are deprived of the opportunity to learn social adaptations in the context of family, culture and all that is familiar to them.

When care is placed in the hands of a single entity, when information is not obtained from prior providers, and when parents are excluded from meaningful participation in treatment, the power and control of the staff over a resident in the facility is extreme and unlike most other situations except prisons.

This gross inequity of power is, understandably, fertile ground for abusive practices. The facility becomes the new culture for the child. Treatment becomes for the child the game he or she needs to master in order to survive, or curry favor so as to get privileges.

This is the essence of institutionalization that was recognized as harmful by the movement toward community based and culturally competent care. Regulations based on best practices might include a definition of what specific circumstances demand residential placement. They might assure that this aspect of care is brief, limited only to a period when it meets standards of medical necessity, and is well integrated into community based services.

The CALOCUS would be an ideal tool for such a level of care determination process as it offers alternatives to residential placement when intensive treatment is indicated. Regulations based on best practices should assure that parents be full participants in the care of their child in a residential treatment facility.

Best practices based regulations would demand documentation of critical incidents and would create a certainty of outside investigation of incidents involving death or serious injury. They would create a quality assurance protocol for licensed agencies providing residential care that would address such issues as treatment effectiveness and individualization, resident rights and humane practices and acceptable interventions for troublesome behavior.

Clearly more examination of the network of residential treatment, schools and other programs is warranted by the AACP and the International Society of Psychiatric-Mental Health Nurses (ISPN).

On the heels of two more tragic deaths and police action against residential care staff we would hope that the discussion might look more broadly at the phenomenon of residential care for children and youth. We would encourage an examination of the role of residential care as a treatment option and social intervention, and its impact on the life of a developing youth.

Charley Huffine, MD, AACP Immediate Past-President
Wanda Mohr, RN, ISPN
Carol Bush, RN, ISPN

http://www.wpic.pitt.edu/aacp/Vol-15-3/Youth.html