Some additional context - The first thing I see lacking in this presentation is the question of "who decides what is the most appropriate level of care" and involving the youth in that decision making process. Interestingly, she uses a really good analogy for the effect of residential treatment, that of an amputation. I think overall, this presentation provides a real good glimpse into the mind of the child welfare field and how Girls & Boys Town sees themselves.
Of all tyrannies,
a tyranny exercised for the good of its victims may be the most oppressive. It may be better to live under robber barons than under omnipotent moral busybodies. The robber baron's cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end, for they do so with the approval of their own conscience
http://www.cwla.org/execdir/edremarks050423.htmTemple University Remarks. March 23, 2005
Residential Treatment: Finding the Appropriate Level of Care
By Shay Bilchik, President and CEO, Child Welfare League of America
Good afternoon, ladies and gentlemen. I am very pleased to be here today. This distinguished university is home base for some very distinguished individuals, including your Provost, Ira Schwartz, with whom I share the distinction of having held the same position at the U. S. Department of Justice as Administrator of the Office of Juvenile Justice and Delinquency Prevention - although about a decade apart in time. In fact, although some very nice things have been said about my tenure at OJJDP, the truth of the matter is that the stage was set for my good work by the outstanding work of some of my predecessors, particularly Provost Schwartz.
Beyond your Provost there is one other individual I want to mention before I begin my formal comments: Professor Laurence Steinberg, whose research Justice Kennedy quoted extensively in the recent Supreme Court decision about juveniles and the death penalty. As a longtime advocate for youth, I am grateful to Dr. Steinberg and his colleagues.
And one last note about your faculty - a special thank you to Dean Icard and Associate Dean Jay Fagan, who along with Provost Schwartz, invited me to be with you today. In short, it is a pleasure to spend time in this vibrant community of learners and teachers.
I'd like to share with you a kind of a fable. The story goes that the devil once held a yard sale, and offered all the tools of his trade to anyone who would pay their price.
There they were spread out on the table, each one with its label -- hatred, envy, despair, greed, child abuse, addiction -- all the weapons of destruction that everyone knows so well.
But off to one side, apart from the rest, lay a harmless looking, wedge-shaped instrument marked "DISCOURAGEMENT." It was old and worn looking, but it was priced far above all the rest.
When asked the reason why, the devil explained. "Because I can use this one so much more easily than all the others. No one knows that it belongs to me, so I can use it to open doors that are bolted shut against the others. Then, once I get inside, I can use any tool that suits me best."
I am using this story to introduce my topic of residential care for two reasons. First, because residential care is a somewhat discouraged system, in today's social services environment. (And right now, the whole of that system needs lots of encouragement.) And second, because it deserves to be restored to its rightful place in the array of services - of tools, if you will - which we use to do our work - some call it God's work -- of redirecting precious lives: of healing and making whole.
I have two goals for the next 40 minutes or so: first, to tell you what I think is militating against the optimal use of residential care today, and then to suggest what is working and can work. I will try not to spend too much time on the negative, because I am hopeful. In spite of the challenges, I see a growing honesty about the shortcomings of all our systems and a growing openness to collaborative, creative solutions.
Systems are resilient, just as children are resilient. As I talk about what we do, about agency programs and interventions, I will try to keep connecting those back to real children and families. They are the reason for the work we do. What we want for them, after all, is not complicated.
* We want every one of our children to have someone in their life who loves them and who they love.
* We want every child to have the opportunity to develop skills that will allow them to find meaningful, truly meaningful work in their life. And,
* We want every child to have hope: to wake up each and every morning knowing that there is something to look forward to, that today or the next day or the day after that will bring something good into their life.
These are the things we want for ourselves, for our own children, and for the children in the child welfare system. So, what do we have in our toolbox to counter the evils like child maltreatment and family dysfunction, which stand in our children's way? Every community needs an array of top-flight child welfare options that includes:
* family support, to strengthen families and prevent maltreatment
* early intervention and family preservation
* shelter care
* receiving homes and assessment centers
* kinship care
* residential care, including group homes
* day treatment
* foster care, including family foster care
* therapeutic foster care (AKA specialized foster care or treatment foster care)
* and, of course, aftercare, linked with an integrated network of community-based supports for referral and follow-up. I'll have more to say about that in a few minutes.
Although residential care is just one piece of this array, it is a significant piece. It is utilized not only in child welfare, but also in education, juvenile justice, mental health, and support for the disabled. We estimate that about 50% of our 900+ CWLA member agencies are residential care providers, although for many that function is part of a wider service array. Residential care accounts for 25% of the children's mental health budget nationwide. A CWLA staff team calculated in the mid-90s that across America, 10,000 agencies were serving 225,000 young people in some kind of residential setting.
We think these are still fairly reliable numbers, although in this, as in other matters having to do with residential care, we don't have a lot of statistics we can hang our hats on. Many of the studies that have been done involved inadequate samples and insufficient rigor. Some have lacked control groups, or properly matched controls. Some of them show positive outcomes for children while others show little change, or even negative results. And one thing research shows clearly is that we need more research, and more rigorous research. But we have also learned a great deal from the research that has been done to date.
And if we don't have a lot of answers in this area, it is partly because we have sometimes asked the wrong questions.
Here is a question I hear a lot:
Is residential care and treatment good for children? This is not a fair or complete question.
* Which children?
* What kind of care and treatment?
* At what point, or points, on the continuum of services?
* And perhaps above all, what's best for the family - whether natural or created - to enable them to provide safety and nurturance?
Now we're beginning to get somewhere. The answer, of course, in every case, is: It depends.
Yet a remarkable amount of policy has been made on the untested assumption that residential treatment should always be the last resort, or that alternatives are always preferable. In point of fact, alternatives aren't always even less expensive. That's a point worth making because the attractiveness of the previous assumptions derives largely from the untested assumption that home-based services always cost less.
If we are to test our assumptions, we know we have to start with the individual young person in the context of that young person's family and extended family. To know anything about what is right for that child and those other family members, we need to start with intelligent and sensitive assessment. And because we know that every child is unique, we have to be sure that every community has the complete array of options I listed a moment ago. That way, once we know what an individual child needs at a specific point in time, we will have that service in our toolbox.
It was the great Abraham Maslow who said: "If the only tool you have is a hammer, all your problems are going to look like nails." Conversely, if you have an exquisite array of precise tools fitted for every task, in the hands of sensitive, well trained professionals, you are equipped to meet the individual needs of each unique child and family. Since these are precious human lives we are dealing with, we need the equipment appropriate for both artists and carpenters. Our profession is both an art and a craft, so we need a combination of both sets of tools. And in the long-term view, the combined use of these tools may end up costing us less and being more effective.
Now it is my belief that we have been asking the wrong questions, to a great extent, because we have had the wrong mental model - or, perhaps more accurately, because an old model has persisted in spite of our professional best efforts. The paradigm that causes the trouble is the one that organizes interventions on a vertical axis, with family support and prevention at the top and residential care at the bottom. And because language is the primary tool that shapes our thinking, we unconsciously perpetuate that thinking whenever we use expressions like "penetrating deeper into the system."
Research suggests that one of the reasons we find it hard to demonstrate success for residential placements is that we usually wait too long to pull this particular tool out of the toolbox. We assume that children have to fail in several other placements before we employ it. A new CWLA position statement that is still in draft form calls this "progress by failure." And the result of progress by failure is that while we are making sure the more intensive options are not used too soon, we are almost guaranteeing that they will be used too late.
I said "children fail in placements," just now, because we talk that way. In fact, very often, the adults have failed them by not matching the environment to their needs. As a system, we sometimes hew rigidly to the "progress by failure" method in spite of the clear-cut research evidence that good outcomes usually occur in inverse proportion to the number of placements. We stick with a low-level intervention not only until it fails, but until we can prove that it has failed. This creates a system far more adept at recognizing risk, weakness, and pathology than at recognizing and building on strengths, in individuals and in families.
This vertical model is reinforced by the federal emphasis on least restrictive placements, dating from PL 96-272 in 1980. It was understood at that time that this meant the least restrictive appropriate placement, but somehow that nuance has been lost over time.
We need to get a different model into our own heads and the heads of our policymakers. It is the one that arrays all our possible interventions on a dynamic horizontal axis, where residential treatment can be the proper choice at any point. Residential treatment might be the first stop for a particular child. It might be used to prepare the child and the family for adoption, as has been done successfully in some programs. For some children, it might be needed at more than one point along the continuum. For many it may not be appropriate at any point.
One of the reasons we don't have a lot of good research on the efficacy of residential care is that foundations and the federal government are less interested in funding research on residential care than on other interventions. I'm sure this is a response to the unconscious image of residential care as a kind of cul de sac in the system. Then, of course, less evidence leads to still less funding, so the circle gets vicious. This isn't a nice way to treat a good treatment modality.
Because children funnel down into residential treatment, the children who arrive there arrive with increasingly complex and recalcitrant problems. And because state budgets are squeezed and this kind of care is not usually a high priority, providers are asked to treat more children and more challenging children, who have had more previous placements, in less time, with less staffing, less training, and fewer resources of every kind. Suffolk University and the Children's League of Massachusetts documented this dilemma for 45 agencies in 1999. To cite just a few examples, from 1996 to 1999 the number of children they saw increased by 115%, and the number of those diagnosed with bipolar disorders increased by 152%. We have every reason to believe the situation is even more bleak today. It would not be hard to become discouraged in a landscape like this.
So let me turn to the brighter side. We are finding more programs reporting positive results from rigorous research. Girls and Boys Town (formerly Boys Town) is one. The WAY Program at Children's Village in Dobbs Ferry, NY and the statewide IARCCA Outcome Project in Indiana are two others. Canadian and Israeli studies [Blackman, Eustace, & Chowdhury 1991; Weiner & Kupermintz 2001] have also shown highly positive outcomes. Pennsylvania has a number of good programs, including KidsPeace, Devereux, Youth Service and Choice Services here in Philadelphia, Pathways, Lutheran Children and Family Services, and the Children's Aid Society....to name a few. I was handed a fairly new piece of research when I arrived here today, on the effectiveness of the Silver Springs - Martin Luther School. The evidence of our ability to be effective is mounting.
Research has identified several characteristics of effective residential care programs. Since the need for residential care is not going away, no matter how unpopular it becomes, our best hope is to build on these characteristics. I will focus on four, which will all be familiar to you from other contexts.
Research tells us that effective programs:
1. value and engage families, and are committed to find or forge permanent connections for every child, even when parents are not able to be those connections
2. use competent, individualized assessment of strengths and needs and ongoing measurement of progress
3. offer a flexible array of positive, competency-centered therapies, and
4. begin planning for aftercare from the day of admission, interfacing with the communitywide network of services in other relevant areas, including the schools.
Families
First and foremost, value families. Research shows that the gains children make in residential care are lost when they return to their communities unless we have engaged their parents from the beginning. Families and extended families need to be involved respectfully and creatively, as the foremost authorities on their own children. The Children's Bureau's analysis of the Child and Family Service Reviews from all 50 states showed a clear pattern of failing to adequately involve families in the child welfare system as a whole. This is one of the areas where every state had less than satisfactory outcomes. They particularly noted a failure to engage fathers.
On the plus side, the reviews showed better outcomes for those states where families were engaged -- where, for example, workers put a priority on family visits and spent reasonable amounts of time with parents, where they worked to keep siblings together, and where they used family group conferences effectively.
When helpers and family members respect each other, both are more likely to stick around and be there for the child. That's important because the evidence shows that stable relationships with dependable, caring adults are one of the most important factors in any successful program. Successful programs break down mental and physical barriers between in-home and out-of-home services, both by bringing the family into the agency and by taking the agency out into the community. They value the ethnic and cultural heritage of the families they serve, and to the greatest extent possible, their staffing reflects that. And also to the greatest extent possible, they follow a no-reject, no-eject principle that promotes safety, stability and treatment continuity for each child.
Let me return to one of the three simple goals I started with: that every child should have someone to love who loves them back. The best child welfare programs operate on the knowledge that no child should leave residential care or any other form of foster care without permanent connections; without at least one person who is totally committed to their well-being. The young people who arrive at the bottom of the system, as it is currently envisioned, may not be easy to love. Their parents may be "character builders." But somebody has to love them, and the more people, the better.
Are any of you familiar with The Gus Chronicles? Charlie Appelstein invented Gus Studelmeyer as a stand-in for kids in care everywhere, and uses him to help workers and administrators see our system from the kid's point of view. Gus compares being separated from your family to having an arm taken away. Every day when you look in the mirror you see a hole where your arm used to be. Seeing other kids with two arms makes you angry and resentful. Gus says that "you become so obsessed with getting your arm back that you forget how painful it was when it was attached." You might be fitted with a new arm, and everyone around you may think it's wonderful, but it doesn't feel like your own. So eventually, you find the one you were born with - and the pain of a dysfunctional family begins again.
If we can avoid radical surgery, though - and I know we can't always - families can heal together over time. Or non-family members can fill family roles.
Berisha Black is a young California woman who was in foster care for 15 years, and who co-presented a workshop at our recent national conference. As she phrased it, everybody needs "a whole embrace" of people who care. The first person who offered her a permanent connection that she was able to accept was the woman she now calls her Grandmother. She came into her life when she was almost 18, and angry. Says Berisha, with a kind of quiet amazement: "She loved the mess out of me." Later, with her adopted grandmother's support, Berisha was able to reconnect with her biological father.
It is never too late to become Somebody's Someone. Regina Louise is another California foster care graduate. She wrote a book by that title, and she also wowed the crowd at our conference. She tells the story of reconnecting with a foster mother who had loved her as a teenager, and being officially adopted when she was past 40. Sooner is better, but it is never too late!
Assessment
I spoke earlier about the artistry and the array of tools required to shape top-quality services. Assessment tools are among the most important items in our toolbox, and the ones that need to be employed first. An open-minded, sophisticated assessment of each individual young person should be able to determine the right level of services, and delivery setting, along the horizontal continuum for each child. Monitoring of progress through an individualized care and treatment plan should be able to tell what is working before things go terribly wrong - both on the level of the individual child and on the program level. Based on the individual needs of unique children and youth, residential settings with their controlled environments may be best equipped to do their initial and/or ongoing assessments. That may be an excellent reason not to wait until all else has failed to employ them.
A meaningful assessment leads to decisions in three dimensions: supervision, treatment, and child development.
* Supervision criteria determine what setting is best suited to protect and nurture the child and support her or his development - and protect caseworkers and staff.
* Treatment needs, including medical, mental health, substance abuse, and behavioral requirements, are a matter for clinical assessment. This requires a review of the child's history as well as the presenting issues.
* Developmental assessment captures external and internal competencies.
All three dimensions need to be assessed for the family system as well as the child. Assessments and outcome measures both need to take account of the family and be meaningful to the family. They need to be long-term, if they are to yield useful data. Residential care, like all our interventions, should be part of a long-term, continuous strategy of family stabilization in which past, present, and future choices are all inter-related.
Ideally, measures are standardized and designed to be shared across systems, in a community partnership where foster care and residential care service providers, referral agencies, funders, public schools, in- and out-patient mental health providers, and juvenile justice agencies plan and deliver services together.
One of our CWLA residential agencies, the Crittenton Center in Los Angeles, reports a success story in which assessment was the key. When the young woman they call Laurie arrived at Crittenton three years ago, she was an angry, frightened girl with a two-day old baby and a belligerent attitude. Social workers were not sure they would ever be able to reach her.
While the calm structured milieu and the skilled staff members did their work, assessment revealed that she had a very specific learning disability and was stuck at about a fourth-grade academic level. Her attitude was largely a mask for the frustration she had experienced in school. Using the precise remediation instruments the agency had available to them, they developed an individual education plan that involved many hours of one on one tutoring. Exhilarated by her first taste of success, Laurie herself devoted hours and hours to study, while she was also learning how to parent her tiny daughter. The agency smoothed the way for her to return to school. She has graduated from high school, she is living and working on her own, her daughter is safe and happy, and the Crittenton agency is continuing to monitor their progress. This is just one success story among many - and we don't hear them, or tell them, nearly often enough.
Treatment modalities
Once a child's and family's strengths and needs have been assessed and it is determined that a residential setting is the right placement at this point in time, our challenge is to match the treatment, as well as the environment, to the needs. As you know, residential facilities cover a broad span. I could easily give you a list as long as the previous one, including short-term diagnostic care, secure treatment, detention, and supervised transitional living. What's more, definitions vary from state to state.
Some state agencies respond to surveys by saying they have no children in residential care, because they call their facilities group homes and they don't include group homes in their definition. CWLA acts to encourage uniformity, through its National Resource Center for Child Welfare Data and Technology, its National Data Analysis System, its work with state agencies and the Children's Bureau, and its many publications on the subject. It's a slow process.
Sometimes states use the same terms to denote different things. In most states, though, the array of services really is less than optimal. Skilled workers may use the most exquisite standardized instruments to determine precisely what is needed and then not be able to provide it. No wonder so many become discouraged and leave when they experience slot driven placements and a system with too little capacity.
To avoid discouragement, we need to join together in advocating for a full array of services. We have to win over the public, our lawmakers, the corporate sector, and everyone else who can potentially be part of the solution. Even in these hard times, we can point to communities that have found creative ways to fund comprehensive service networks, and we can muster economic arguments to show their long-term cost-effectiveness. Most of all, we must emphasize the least restrictive appropriate service to meet the needs of each child and family, investing in time-limited intensive services at the outset if assessment shows that this is the best bet for dealing with trauma.
Assessment is the way in which we understand the uniqueness of each child and family. Matching the identified needs and strengths with the best possible interventions is the way we demonstrate our respect for that uniqueness. Earlier I talked about a horizontal continuum, which serves us much better than a vertical one. In fact, though, we really need a dynamic model that is flexible and non-linear, like healthy young people themselves. Human development is not a strictly linear process.
For example, a while ago I listed family preservation near the beginning of the continuum and residential care toward the middle. But who says a family has not been preserved when a child is in appropriate, family-centered residential care? A dynamic model would have room for simultaneous interventions, as opposed to just sequential ones. The wrap-around model does that, and so does multi-systemic therapy.
The test of a good program is not what happens in the 5 months or 10 months that the child is in treatment, but what happens in the 50 or 60 years that he or she is outside of it. That is why the more permeable we can make the boundaries between institution and community - while still preserving the unique strengths of the institution - the better the outcomes for individuals, families, and society.
Aftercare
Outcome assessment follows from the initial assessment and continues after the child leaves placement. And that brings me to the fourth element of success: aftercare. One of the things we see clearly when we visualize our interventions on a horizontal axis is the importance of the start and end points: both prevention/early intervention and aftercare. In some cases, decreased funding and shorter stays have had the salutary effect of requiring agencies to begin working intensively with families and community resources as they plan for discharge from the day of admission.
A four-year study reported in the American Journal of Orthopsychiatry [Leichtman, Leichtman, Cornsweet, and Neese, 2001] showed significant improvements for young people who stayed in residential treatment just three to four months. This requires a different set of staff attitudes than those of traditional group care. It means that entrances and exits are part of a carefully phased case plan. And of course, it means that families, and older youth, must play a leading role in planning for the transition and following through during the transition period.
Effective transitions require a healthy, functioning network of community services. Nothing could be further from the old model of residential care that "rescued" children by separating them from their families and their communities. Today's multi-service agencies are frequently at the hub of a rich network of community connections. Staff members cultivate working relationships and prepare the web of supports that each child - or child and family -- will need for a successful transition back to everyday life. Then they stay involved for at least a year after children and youth exit care.
Taking the agency out into the community is one of the best opportunities for residential care to change its ugly duckling image and avoid discouragement. Successful programs invite the community in for educational programs and festivals. They send young people out into the community as volunteers, as well as to attend school and take advantage of cultural and recreational activities. The last thing a modern residential agency wants to be is that creepy fortress up on the hill.
The IARCCA Outcomes Project, which grew out of a challenge from the Indiana Council of Juvenile and Family Court Judges, tracked 19 of its member agencies with a wide range of services over 5 years. They found that youth in residential care made more gains in several important areas than those in home-based foster care or shelter care. 86.9% had positive educational outcomes at discharge and 86.8% had sustained them a year later.
Just as schools are among the most important partners for child and family success, universities are key partners for agencies. As permanent, established institutions that command a high degree of respect, you are vital members of any community collaboration. You have numerous opportunities to advance the level of professionalism in the field and to bring research to bear on both practice and public policy. Agencies may need your help to improve research designs - for example, through the more frequent use of standard measures and comparison groups, and by assisting in statistical analysis. Future research should clearly specify program features and isolate which treatment variables produce positive outcomes that are sustained when youth return to their communities.
The challenges for residential care are many. I spoke earlier today about a funding and policy environment that threatens our services for children and families, while it increases the stressors that tend to fracture families. Old Nick's toolbox is full. But as I said in my opening, I still have hope. We can not afford to succumb to discouragement.
So what is the position we should be advocating as we make our case for a full range of services? I want to share with you some language from a draft - almost final - position statement the League has developed with tremendous input from our member agencies and others in the field. I will share only a few of the most relevant excerpts that reflect much of what I have presented today. They are broken down into the following action steps around policy and service delivery:
Policy
* Conduct initial and on-going coordinated assessments where the operative question is not: where do the child and family fit into the system, but rather which services in the system best fit the child and family's strengths, needs and permanency plan at the time?
* Promote the choice of most appropriate and least restrictive service for children and families, investing in time-limited intensive interventions at the outset and throughout the course of care if assessment dictates this is the best choice for dealing with trauma and/or keeping families together over the long haul.
* Revise policy and practice to acknowledge that some children and families will require services at various levels of intensity over time, and that this may be a decidedly non-linear process.
* Retain an emphasis on family empowerment and family connections at all levels of service, while recognizing that optimum connections may not mean that every parent and child lives together full-time, or without on-going support.
* Ensure the provision of care and support to families after the course of intensive services, as a way of preventing costly future interventions to the greatest extent possible.
* Blend services so there are step-up, step-down and wrap-around options at all levels of intervention, and in particular so that the boundaries between home-based and out-of-home services are eliminated.
* Develop outcome measures, including cost-benefit measures, not limited solely to discrete services but also related to long-range family stabilization and the real cost of services across time.
* Develop rate reimbursement methodologies that include all direct and indirect costs associated with providing quality care, treatment and services.
Service Delivery
* Implement programs and practices that actively support Family Centered Services that maintain permanent family connections for all children.
* Develop new, structural partnerships between providers of residential services, referral and funding agencies, foster care and post-adoption services, public schools and educational collaboratives, and inpatient and outpatient mental health providers to allow for greater access to services along the continuum at any given point.
* Increase capacity to provide services to those children and families with the most intensive needs.
* Commit resources to post-discharge continuity of care and provision of family supports for at least one year after children exit residential programs.
* Develop more flexible methods of providing services for the duration of residential placement, with much more of a presence in family homes, local schools and locations where community-based services are provided.
* Develop universal outcome measures to assess the effectiveness of residential services, including in the following areas: clinical, functional, placement effectiveness, and consumer satisfaction.
These action steps present us with significant challenges. They are made more difficult by the fact that we are taking them on at a time of great adversity. In this regard, I share with you an old Asian saying: "When fate throws a dagger at you, there are only two ways to catch it -- either by the blade or by the handle."
It is my belief that we can catch the dagger of adversity by the handle and turn a potential moment of crisis into an opportunity to emerge stronger for the sake of our children.
Thank you very much. I would be happy to entertain questions.
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