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) is growing exponentially. These modern-day orphanages now house more than 50,000 children nationwide. 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. Once placed, these kids may have no meaningful contact with their families or friends for up to two years. 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. By funneling children with mental illnesses into the RTC system, states fail—at enormous cost—to provide more effective community-based mental health services.
A. RTC placements are often inappropriate.
RTCs are among the most restrictive mental health services and, as such, should be reserved for children whose dangerous behavior cannot be controlled except in a secure setting. Too often, however, child-serving bureaucracies hastily place children in RTCs because they have not made more appropriate community-based services available. Parents who are desperate to meet their kids’ needs often turn to RTCs because they lack viable alternatives.
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. But all RTCs are not alike. 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.” 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. 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.” 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.
Even more appalling, many children’s conditions do not improve at all while at the RTC. In fact, there is little evidence that placing children in RTCs has any positive impact at all on their mental health state 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.
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. 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.
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. Research has demonstrated that some children learn antisocial or bizarre behavior from intensive exposure to other disturbed children.
Children are usually far from home in RTCs, often out-of-state. 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.
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.
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.
C. Children suffer because there is no watchdog.
The RTC industry is largely unregulated. RTCs need only report major unusual incidents (or MUIs), but the interpretation of what constitutes an MUI and the reporting requirements vary widely. Some RTCs fail to report MUIs at all—with little consequence. 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.
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. The following are just a few documented examples of tragic occurrences at RTCs:
Medication is often used (and overused) to control behavior. Children have been permanently disfigured because of over-medication.
In some programs, the children’s shoes are confiscated to keep them from running away.
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 . . . .”
Sexual abuse by staff members and other residents is all too frequent. In one case, a 13-year old girl performed sexual favors for staff members in return for snacks and carryout food. At one RTC, four boys were accused of trying to sodomize another with a cucumber. At another, a 19-year-old woman was charged with sodomizing a 14-year-old girl.
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.
Children are often restrained—sometimes for hours on end. The overuse of restraint has resulted in child deaths.
E. Tragic outcomes at great public expense.
RTCs have grown to a billion-dollar, largely private industry. Residential treatment care is exorbitantly expensive—costing up to $700 per child per day. Annual costs can exceed $120,000. Most of the time, the public foots the bill for these services. In fact, nearly one fourth of the national outlay on child mental health is spent on care in these settings.
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. A comprehensive system of care would dramatically reduce the number of children in RTCs.
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. 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.