Residential Group Treatment for Children and Adolescents

Introduction

This literature review examines the placement of children and youth within residential group treatment programs. As reflected in the sources reviewed, while there has been little direct attention focused on the use of groups and group treatment within residential placement settings for children and adolescents, a number of factors associated with residential placement may be significant and meaningful to future efforts to examine group treatment, group dynamics, and group living experiences within residential programs.

Initially, an overview is provided of current information available on the use of residential placement as a treatment modality for meeting the service needs of children and adolescents. This is followed by a discussion of current perceptions regarding residential placement and the problems associated with it. Finally, an overview is provided of ongoing policy, practice, and research issues associated with residential group care.

Overview of the Current Status of Residential Placement

According to Whitaker (2000a), group care services provided for children within residential settings have been described as a component of the child welfare system within the United States. Such services are designed to provide 24-hour care for a child in a residential facility designed as a therapeutic environment. Within this setting, treatment services, educational services, and group living are integrated on the basis of an individual plan for each child who cannot be effectively helped in his or her own home or with a substitute family (Whitaker, 2000a). As further delineated by Braziel (1996), residential treatment centers and community-based group homes most often represent the primary forms of group care offered under the auspices of residential placement. The settings in which such services are offered include community-based apartments, group homes, campus-based facilities, foster care homes, and other self-contained facilities, including secure units. Within these settings, as noted by Braziel (1996), a range of services is typically offered, including counseling, education, recreation, health, nutrition, daily living experiences, independent living skills, reunification services, and aftercare/post-placement services. There has been an increasing effort to improve the linkages between the child or adolescent in residential care and his or her family and community.

As described by Melton (1998), residential placement services are most often provided under public, voluntary nonprofit, and proprietary auspices within child welfare, child mental health, and juvenile justice systems — often to the same populations of youth. According to Melton, the divisions existing between such services are largely based on arbitrary regulatory and payment structures rather than real differences in purpose, type of services, clientele, or source of referral. As explained by Whitaker (2000a), while the diversity among such programs is minimal, the children and adolescents receiving services through residential placement programs tend to represent clients from all or most of the major children's service systems — that is, child welfare, juvenile justice, and mental health. Historically, efforts to limit the use of residential care in one service system area for the purposes of deinstitutionalization have most often been accompanied by an increase in residential placements in another area of the system (Whitaker, 2000a). Thus, as noted by Whitaker, there has been a growing awareness of the need for a cross-system perspective in relation to residential placement for children and adolescents.

As the literature suggests, it is difficult to obtain accurate population estimates of children and adolescents placed in residential care within the United States. Based on more recent information, a national study commissioned by the U.S. Children's Bureau provides a total population estimate of approximately 500,000 children and adolescents in out-of-home care in the mid-1990s (USDHHS, 1997). As found within the report provided by the U.S. Department of Health and Human Services (USDHHS), the majority of those children and adolescents placed within residential care settings were served in family foster care arrangements, compared to the approximately one-fourth of all children in out-of-home care who were served in residential group care facilities.

Melton (1998) suggested that such estimates represent an inaccurate accounting of the actual numbers of children and adolescents served in residential placement. As further explained by Melton, there is a "hidden sector" within residential care most often represented by children and adolescents placed within private psychiatric settings as well as those in the custody of the juvenile justice system who are placed within residential group care settings. As noted by Whitaker (2000a), such findings underscore the importance of developing an accurate, comprehensive, national, up-to-date database for all children and youth in residential group care.

While children and youth adjudicated within the juvenile justice system have been identified as a "hidden population" receiving residential group care services, some information is available that helps clarify population estimates for this group. Based on information provided by Smith (1998), during the late 1960s and early 1970s, the Statistics Division of the National Criminal Justice Information and Statistics Service of the Law Enforcement Assistance Administration (LEAA) — which later became the Bureau of Justice Statistics (BJS) — and the Children's Bureau initiated a joint effort to develop a means for obtaining information regarding the census of public juvenile facilities. The resulting census, known as the Children in Custody (CIC) census, included public facilities holding juveniles awaiting court action as well as those already adjudicated. As reported by Smith, while previous efforts to obtain statistical information on children and youth in the juvenile justice system focused only on reception or diagnostic centers, training schools, ranches, forestry camps, and farms, the new census also allowed for the collection of information on juveniles within detention centers and shelters, halfway houses, and group homes.

Using data gathered from the CIC census series between 1971 and 1995, Smith (1998) reported that while the numbers of public and private juvenile facilities in the United States had been decreasing since 1987, there were more such facilities in 1995 than there were in 1975. There was also an increase in the number of private facilities relative to public facilities, even though 58% to 63% of the juveniles in correctional facilities were held in public facilities. A smaller percentage were held in private facilities because the majority of private juvenile facilities are ranches, forestry camps, farms, halfway houses, and group homes, which generally have smaller populations than the detention centers and training schools that constitute the majority of public juvenile facilities (Smith, 1998).

As reported by Smith (1998), the percentage of all detained juveniles held in detention centers increased steadily from 15% in 1975 to 23% in 1995. The percentage of all private facilities that were ranches, forestry camps, farms, halfway houses, and group homes decreased from 90% in 1975 to 75% in 1995. Smith indicated that there were 74,270 juveniles in custody in the United States on June 30, 1975, and 107,637 on February 15, 1995 — representing a 45% increase. According to Smith, the increase in the number of males held in custody in juvenile justice residential placements largely explains the overall increase between 1975 and 1995.

As Smith documented, there were only 725 more females held in 1995 than in 1975, while there was an increase of 32,642 males held in juvenile facilities over the same period. The data thus indicate that the proportion of juvenile female residents decreased from 23% in 1975 to 17% in 1995.

As also reported by Smith (1998), the average length of stay for juveniles discharged from long-term residential facilities decreased over this period. Approximately two-thirds of the juveniles held in public facilities since 1983 were held in long-term facilities. The average length of stay for those juveniles discharged from public, long-term facilities decreased from just over six months in 1986 to just under four months in 1995 (Smith, 1998).

Smith (1998) identified other trends significant to the group care of juveniles in residential placement within the juvenile justice system. One notable trend is that minority juveniles make up an increasingly larger segment of all juveniles held in custody. As reported by Smith, in 1979, there were 13,752 African-American juveniles held in custody, compared to 43,268 in 1995 — representing more than a threefold increase in 15 years. Similarly, in 1979 there were 4,395 Hispanic juveniles in juvenile justice residential programs, compared to 18,653 in 1995 — representing a more than fourfold increase. The proportion of African-Americans in juvenile facilities grew from 28% in 1979 to 40% in 1995, and for Hispanics the proportion grew from 9% to 17% over the same period. According to Smith, these proportions exceed the proportion of these groups in the general juvenile population. Hispanic juveniles aged 10 to 17 made up 8% of all juveniles in that age group in 1980 and 13% in 1995, while African-American juveniles made up 15% of the general juvenile population aged 10 to 17 in both 1980 and 1995.

Smith (1998) also documented another important trend related to juveniles in juvenile justice residential placement settings since 1987. The proportion of youth held in juvenile facilities for violent offenses increased between 1987 and 1995 for both males and females. Findings indicated that males were more likely than females to be in custody for violent offenses, ranging from 20% in 1987 to 31% in 1995, compared to 6% in 1987 to 13% in 1995 for females. From 1987 to 1995, males were consistently and increasingly more likely to be in custody for delinquent acts — including violent, property, alcohol/drug, and public order offenses and probation violations — rising from 77% in 1987 to 82% in 1991 and 83% in 1995. Alternatively, females were most likely — but less so each year — to be held in juvenile residential programs for nondelinquent reasons, including status offenses, nonoffender actions, and voluntary admissions, with percentages of 62% in 1987, 61% in 1991, and 55% in 1995.

As explained by LeCroy and Ashford (1992), residential placement and treatment services have come to represent both an expensive and a common intervention for children and adolescents with serious behavioral and emotional disorders. While less costly than psychiatric hospitalization on a per diem basis, residential treatment proves to be more expensive overall because of extended stays (Burns & Friedman, 1990; LeCroy & Ashford, 1992). The average annual costs associated with residential treatment and placement services have been estimated to range between $50,000 and $75,000 per child. Consequently, an increasing complaint voiced in relation to residential placement is that a large proportion of the limited funds allocated to the service needs of children and adolescents are potentially committed to supporting residential treatment for a few, with little money left for the development or funding of community-based services (Burns & Friedman, 1990). As explained by Handwerk, Friman, Mott, and Stairs (1998), despite the fact that residential placement represents both a massive and an expensive treatment modality, little research has been conducted that documents the effectiveness of residential treatment for the children and adolescents who receive it.

Current Perceptions on Residential Placement

As suggested by Whitaker (2000a), in spite of the fact that residential placement has continued to be extensively used within professional fields serving children and adolescents, there has been a long-standing sense of distrust of residential programs. Whitaker explained that such views are deeply rooted in American culture and history, emerging from a basic distrust of institutions and their capacity to care for and nurture children. This distrust arose during the mid-19th century when reformers advocated for alternative placements for children and adolescents other than the large congregate child care institutions that existed at that time. The health conditions found in early institutions were found to be horrendous, and efforts arose to rescue children from such conditions. As noted by Whitaker, this period in child welfare and services became known as the "placing-out" movement, which served as the catalyst for the creation of new, sectarian child care institutions — many of them reflecting the fears of recently arrived immigrant and Catholic families who perceived such efforts as an attempt to deprive children of their cultural and religious birthright.

Similar concerns and advocacy efforts began to resurface in the mid-20th century when child and youth advocates once more strongly promoted the need for alternatives to residential placement. In 1975, Morris Fritz Mayer — recognized as a leading advocate for high-quality residential programs — used the term "pariah care" to describe the conditions of residential centers that then existed (Mayer, 1975, as cited in Whitaker, 2000a). Mayer and others promoted increased recognition of society's marginalization and stigmatization of acting-out youth and the group services designed to meet their needs. Similarly, Wolins (1974) called attention to the fact that most residential programs during that period were no longer staffed by professionals, who had reportedly become increasingly discouraged by the perceived lack of effectiveness associated with such programs. As professionals left residential placements and funding was steadily withdrawn from such programming, residential placements for children and adolescents began to deteriorate, with little evidence of ongoing efforts to promote the investment necessary for innovative and effective treatment programming within residential care.

According to Whitaker (2000a), after the first White House Conference on Children in 1909, there was growing agreement that children and youth in need of out-of-home placement should be served by the family foster care system rather than in residential and group care settings. There was also an emphasis on ensuring that truly dependent children were placed in foster care rather than in residential placement. Whitaker noted that by the mid-20th century, less than 10% of children in group care settings fit the description of "true orphans" or dependent children — reflecting the fact that the greater proportion of those considered dependent children were now being served in family foster care. This represented a complete reversal from what had been occurring in child placement at the beginning of the century. According to Whitaker, the focus in relation to group care settings then shifted toward their development as specialized treatment programs for children with emotional disturbance and/or conduct problems, for whom family foster care was deemed insufficient or inappropriate.

Within the literature, it is possible to identify at least five specific historical and current perceptions regarding residential placement and group treatment for children and youth. The first concerns the degree to which residential placement and group treatment represents a helpful treatment method. Early accounts of residential placement experiences (e.g., Polsky, 1965; Schur, 1973) suggested that children and adolescents received treatment that was negligent and/or abusive while in residential placement. Other reports suggested that there were incongruities between the treatment prescribed in residential programs and the treatment actually delivered (Jessness, Allison, McCormick, Wedge, & Young, 1975; Kazdin, 1985; Quay, 1977). Similarly, the National Academy of Sciences panel, commissioned to evaluate evidence on the efficacy of residential placement programs for juvenile offenders, concluded that most evaluation studies were of limited value because little treatment was delivered, and the treatment that was delivered often bore little resemblance to the treatment prescribed (Martin, Sechrest, & Redner, 1981; Sechrest, White, & Brown, 1979). Concerns regarding the helpfulness of residential placement were further fueled by court rulings that mandated the right to treatment after finding residential programs deficient in providing meaningful treatment services to children and youth (e.g., Donaldson v. O'Connor, 1974).

Another area of concern evidenced within the literature involves the relationships between supervising adults and the children and adolescents they serve in residential placements. Such relationships have tended to be perceived as adversarial, servile, or collusive, as fostered by the early work found in Goffman's (1964) Asylums, Sykes's (1958) The Society of Captives, and Clemmer's (1940) The Prison Community. Each of these works helped to suggest and foster the belief that the treatment received from custodians in residential placement programs was deeply harmful and painful. Similarly, later works suggested that children and adolescents who entered residential placement programs suffered from problems with authority and found themselves in worse shape upon release due to the lack of freedom they were subjected to while in care (e.g., Empey & Stafford, 1991). Overall, there was concern regarding how children and adolescents in residential care fared in future relationships after their experiences with adults who readily — and at times harshly — enforced rules (e.g., Lundman, 1984; Polsky, 1965).

A third major concern in relation to residential placement is the degree to which it produces an inexorable sense of isolation from family and friends (e.g., Eisikovits & Guttmann, 1988; Empey & Stafford, 1991; Kiesler, 1982). The all-encompassing nature of residential life, the presence of institutional barriers to outside contact, and first-hand as well as case descriptions of residential life have emphasized the isolation and disconnection that children and youth experience in relation to family and friends (e.g., D'Amato, 1969; Polsky, 1965; Schur, 1973; Trieschman & Whittaker, 1972; Trieschman, Whittaker, & Brendtro, 1969).

A fourth concern — less commonly cited but evidenced in the literature — is the degree to which residential placement limits children and youth's development of a sense of personal control. Isolated from their homes, families, and friends, children and adolescents in residential care are at risk in terms of their own sense of control over life events and may be less prepared to handle the future challenges of daily living (e.g., Gold & Osgood, 1992; Sykes, 1958). The importance of this concern is underscored by research showing that a reduced sense of control has a strong relationship to maladjustment within placement (Gold & Osgood, 1992; Martin & Osgood, 1987). Research has also provided evidence suggesting that residential programs decrease intrinsic motivation to engage in the prosocial behaviors that such programs intend to promote (e.g., Lepper & Greene, 1978). Although this concern is widely cited in criticisms of behaviorally oriented programs, there have been few tests of the applicability of this research beyond laboratory settings. Only by directly comparing youth in and out of placement can we determine whether external reinforcement actually interferes with their sense of control.

Even though residential placement programs have shown significant changes in the last 20 years, the early negative images associated with these programs continue to prevail. Some of the reported changes include a movement away from the traditional training school format with mostly custodial shift-work staff toward a smaller group-home format with a family-type atmosphere and trained staff who live with the youth (e.g., Lerman, 1975; Lundman, 1984). While these changes were intended to improve residential treatment as well as the prevailing negative images associated with residential programs, little evidence exists to suggest they have been effective.

Conclusion and Future Research Directions

Whitaker (2000a) concluded that there remains a dire need for a thorough review of the functions, place, and purpose of residential group care services within an overall continuum of care. The questions raised by Whitaker were recommended as a framework for future research initiatives regarding residential group care settings and services:

— Under what conditions should any of the varieties of group care be considered a treatment of first or last resort?

— In its multiple forms, what is the effectiveness of group care in ameliorating specific behavioral problems and improving life outcomes among youth and in preventing their reintroduction into deeper-end services?

— What is the relationship between the varieties of residential group care that exist and therapeutic fostering, multisystemic therapy, wraparound services, and similar community-based interventions?

— Of the varieties of residential group care, what relative proportions of each should exist in an overall continuum of care, and what factors should direct a youth and family to one or the other?

— What are the critical ingredients in the varieties of successful residential care programs? How can these be empirically validated, captured in treatment protocols and standards, and monitored through quality assurance procedures?

— How should "success" be measured across the varieties of residential care provision? What is a proper metric for assessing benefits and costs relative to nonresidential alternatives?

— How can the treatment needs of children and youth be balanced and integrated within the continuum of residential placement options? What implications does each option raise specific to group residential settings?

— Are there possible offsetting benefits to some of the presumed negatives associated with residential placement — such as separation from family, community, and culture — including the intensity of the treatment provided, the physical safety of the child, or the protection of the community?

— Are there situations in which long-term residential care and treatment is warranted? If so, for what types of children? How should such treatment be articulated with family, community, and cultural supports?

— Do models of residential care and treatment exist in other cultural contexts that show potential for adaptation in the United States?

As concluded by Whitaker (2000a), until such information is documented through sustained research efforts, little will remain known regarding residential group care for children and adolescents. The field must commit to the kind of rigorous, cross-system inquiry that has long been directed at other components of the child welfare and mental health service continuum.

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