The Residential Treatment Option

The primary goals for each child for whom we are responsible are safety, permanence, and continuous well-being. The optimal environment for achieving these goals is the child’s family, when that family is stable, able to keep the child safe, and committed to the child’s continuous well-being. If the child’s family is unable or unwilling to meet these bottom-line conditions, other relatives who can and will are the second-best choice. In the absence of suitable relatives, an appropriate adoptive family is the child’s last, best hope for safety, permanence, and continuous well-being, understanding that every child, regardless of age or disability, can and should have the opportunity for permanence in a stable family that is committed to his (her) continuous well-being. The issue is never the child’s inability to live in a family. The only issue is whether we identify an appropriate family for the child to live in.

Given the above value cluster, three realities are important to emphasize. First, the longer a child is away from his family, the less likely he is to ever return. Second, the further a child is away from his family and support system, the less likely he is to ever return. Third, the more times a child is moved, the less likely he is to ever return to his family, regardless of the setting to which he is moved or the reason for the move.

Although residential treatment may, at times, be necessary and appropriate for a specific child, it is inconsistent with the primary goals. First, the child’s safety is by no means assured. Second, permanence cannot be achieved in the setting. Third, the child’s continuous and long-term well-being are only partially achieved. Even if the child “adjusts well” to the institution, the primary goals are not being furthered.

Additionally, the “transition” of a child from residential treatment into foster care does not represent permanence or adequate attention to his continuous well-being. It is, at best, an interim step toward achieving the primary goals. Although it may be necessary, keeping the foster care stay focused and brief is as important as keeping the residential treatment experience focused and brief. It’s like keeping a fish out of water: Just getting him closer to the lake may be the right direction; but he is still deteriorating. The child will only thrive when he is safe, has permanence, and his continuous well-being is assured.

Given the above, a child’s going into residential treatment is a bad outcome. It represents a failure of the community to adequately identify, diagnose, and treat his developing maladjustment. His move into residential treatment is an extreme measure that is best managed by preventing its happening. If that has not or cannot be done, several points are critical. First, know specifically the behavior and emotional symptoms for which residential treatment is the only available response. Second, determine exactly what “treatment” will be provided to reduce the behavior and symptoms and the relationship between that treatment and the reduction. Next, determine, in advance, how quickly the reduction is expected to happen and how you can tell if the treatment is achieving the expected outcomes. Now, monitor the child’s therapeutic progress at least weekly, charting the change in behavior and symptoms. The treatment provider should be able to tell you, in advance, the outside limits for each level of behavior and symptom reduction. The exception to this is a child diagnosed with a major mental illness, understanding that only a small portion of children in residential treatment have such a diagnosis.

If the child does not make significant progress during any four-week period, the treatment must be adjusted, with new or revised strategies initiated. If the child has not made substantial progress within 90 days, the treatment is unlikely to ever work. For most children, 90 days is sufficient to reduce behavior and symptoms for the child to return to his family, with community supports.

Children should never be placed in residential treatment unless it is absolutely necessary and the treatment is expected to reduce the problem behavior and symptoms significantly within 90 days.

Assuming that treatment is progressing as expected, in a timely course, a child should never be removed from residential treatment until the treatment goals have been met.

A child should never remain in residential treatment past the point where the treatment goals have been reached. If the child is actually doing well, he should already be home.

Among other things, the above means that a child should never be moved into residential treatment until the plan for his coming home is in place. Further, while he is in residential treatment, the plans for his returning home need to be continuously reviewed and updated to fit his current condition and situation. The return point is when the treatment he actually is receiving in the treatment facility can be duplicated in the community. If he is doing well in the institution, he is likely not receiving any useful treatment and needs none in the community. If the behavior and symptoms that justified residential placement are reducing, he can and should go home when there is a match between residential treatment services and community treatment services. This requires that those child-specific community treatment services are put in place concurrent with his residential treatment.

Do not place children in residential treatment unless you do not have or cannot develop a community alternative.

If you do move children into residential treatment, be specific about behavior and symptoms that are to reduce, the activities that will cause the reduction, the time limits for the reduction, and how you will determine the effectiveness of the treatment.

While the child is in residential treatment, build a child-specific treatment capacity for him in the community into which he can return.

Return the child to the community at the point when the community is prepared to do as well as the residential facility.

The primary goals remain safety, permanence, and continuous well-being. If residential treatment is not a necessary and carefully defined step toward those outcomes, it is not in the child’s best interest. Just remember that the fish needs returned to the lake as quickly as possible. It is urgent; and every day a child is away from his permanent family is an increasing crisis. Every day in his life matters.
By Gary A. Crow, Ph.D. April 2, 2017