Perspectives on Factors Impacting Youth’s Reentry into Residential Care: An Exploratory Study

Multiple placements in therapeutic residential care is expensive, and is associated with poor outcomes; thus, identifying barriers to successful reintegration into the home and community school settings is essential for developing appropriate post-discharge supports, and reducing societal costs. Participants were seven youth (four female; three White/Caucasian, one Black/African American, one Hispanic/Latino, two multi-racial) recently readmitted to a therapeutic residential care program and five of their primary caregivers (four female; four White/Caucasian, one Black/African American). Through semi-structured interviews with caregivers and youth, this exploratory study investigated (1) the perceptions of preparedness for the youth’s successful transition from therapeutic residential care to the home setting, (2) the post-discharge factors that contributed to the youth’s return to care, and (3) the lessons learned about the youth’s transition from therapeutic residential care to home. The results of this exploratory, qualitative study revealed rich information about youth and their caregivers’ perspectives about their experiences prior to returning to care, such as the importance of healthy relationships (family and peers), transition planning, and post-discharge supports at the individual, family, and school levels.     

The Impact of Community Mental Health Programs for Australian Youth: A Systematic Review

Australia has undergone significant youth mental health reform over the past 10 years, leading to numerous studies examining the effects of community-based mental health care programs for Australian youth. However, no synthesis of this literature currently exists. Therefore, this systematic review aimed to: (1) describe the types of community-based mental health programs that have been delivered to Australian youth in the past 10 years; and (2) examine their impact in improving young people’s mental health symptomology and psychosocial functioning. A systematic search of the peer-reviewed literature was conducted. Studies were included if they evaluated the extent to which such programs improved mental health symptomology (e.g., depression, anxiety, substance use) and/or psychosocial outcomes (e.g., social functioning, school engagement, employment) for Australian youth aged 10–25 years. Thirty-seven studies were included. Four types of community-based youth mental health care programs were identified: therapy (n?=?16), case management (n?=?9), integrated ‘one-stop-shop’ (n?=?6) and lifestyle (n?=?6) programs. The majority of therapeutic programs were effective in reducing mental health symptomology. Case management and integrated approaches consistently yielded significant improvements in both symptomology and psychosocial outcomes. Lifestyle programs were effective in alleviating depressive symptoms, but inconclusive for other outcomes. This review provides support for youth-friendly, systemic, multidisciplinary and integrated assertive outreach models of community mental health care to improve outcomes for young Australians experiencing mental health concerns. Several recommendations for future research are provided to strengthen the local evidence-base supporting community mental health programs to ultimately enhance young people’s life trajectory.

     

Ethnic Differences in Children’s Entry into Public Mental Health Care via Emergency Mental Health Services

For children and youth making a mental health crisis visit, we investigated ethnic disparities in whether the children and youth were currently in treatment or whether this crisis visit was an entry or reentry point into mental health treatment. We gathered Medicaid claims for mental health services provided to 20,110 public-sector clients ages 17 and younger and divided them into foster care and non-foster care subsamples. We then employed logistic regression to analyze our data with sociodemographic and clinical controls. Among children and youth who were not placed in foster care, African Americans, Latinos, and Asian Americans were significantly less likely than Caucasians to have received mental health care during the three months preceding a crisis visit. Disparities among children and youth in foster care were not statistically significant. Ethnic minority children and youth were more likely than Caucasians to use emergency care as an entry or reentry point into the mental health treatment, thereby exhibiting a crisis-oriented pattern of care.     

Implementation and Evaluation of Evidence-Based Psychotherapeutic Practices for Youth in a Mental Health Organization

The current initiative and program evaluation study is a demonstration of the research to practice process in youth-focused psychotherapy. We collaborated within a community-university partnership to create practice and research infrastructure in order to develop, implement, and evaluate two new models of service founded on evidence-based psychotherapeutic practice parameters. The two new service models incorporated validated interventions to address behavior problems in elementary age children, and depression in adolescents, which were delivered in separate but similarly run intensive outpatient programs within a mental health setting. We utilized a rigorous training, technical assistance, fidelity monitoring, and outcome measurement strategy to promote the integrity and quality of services provided. The resultant programs were delivered with acceptable to high fidelity and effects on youth and parenting measures collected during program and from pre to post showed a decrease in targeted problems in youth and positive benefits for families. This initiative and program evaluation adds to the accumulating research-to-practice literature in children’s mental health.     

Important Elements of Aftercare Services for Youth Departing Group Homes

Aftercare services have been suggested to improve the outcomes of youth who depart group homes. The purpose of this study was to collect views from social service agency leaders about the aftercare supports they believed were most important for youth departing group homes. This project used a survey method and gathered views from 38 agency leaders who were 28–66 years of age, with an average of 21 years of experience working with residential care programs in 23 states across the United States. Participants ranked seven support domains (i.e., family, education, mental health, relationships, physical health, safety, and independent living) and rated 56 specific aftercare supports based on importance for youth who were departing group homes and returning to their homes/schools prior to high school graduation. Results suggested family, safety, and mental health supports were the most important domains of support for aftercare. Specific aftercare items that were rated critically important included support for self-harm/suicidal thoughts, accessing mental health services, coping with trauma, and managing medication for behavior/mental health. Tables are provided for the complete list of 56 specific support ratings. The findings are summarized and limitations are discussed. Also included are the implications the findings could have regarding future research on the design of aftercare services.     

Mental health policy and the psychiatric inpatient care of children

Recent changes in psychiatric inpatient treatment of children and youth are placed in the more general context of, first, the inpatient treatment of adults and, second, multiple public policies affecting children. For adults, the experimental evidence shows that the majority of psychiatric inpatients could be treated in programs outside the hospital more effectively and less expensively. For children, no such data base exists. Contrary to policy intent, between 1980 and 1985 inpatient care of children and youth increased substantially in residential treatment centers, private psychiatric hospitals, and scatter hospitals (general hospitals without any formal specialized units). Thus, psychiatric inpatient care of children and youth is increasing, dramatically so at largely uninvestigated and more expensive sites. The failure of children's mental health policy is placed in the context of the multiple policy failures for children regarding health, welfare, education, and housing. Recent positive efforts by federal agencies are described, but the need is great for data on efficacy and cost-effectiveness of inpatient treatment of children.     

A comparison of children with serious emotional disturbance served in residential and school settings

The National Adolescent and Child Treatment Study (NACTS) was designed to study children identified and served by the public mental health and special education systems as seriously emotionally disturbed. Children (N=812) and their parents (N=740) participated in the first wave of data collection in this longitudinal study. Subjects lived in six states, with approximately half in psychiatric residential treatment centers and the other half in public school special education programs. A multi-method, multi-source methodology was employed. The sample is characterized by externalizing problems, poor adaptive functioning, and substantial academic deficits. Residential children were more likely to have blended families, were more likely to have previously received residential treatment, and had higher rates of conduct disorder, anxiety, and attention deficit disorder, as measured by the Diagnostic Interview Schedule for Children. The two groups did not differ on intelligence, age of onset, or rates of schizophrenia or depression. The data suggest the presence of greater at-risk factors in the residential group and different paths of entry into special education and residential treatment programs.     

Evaluation of a Trauma-Informed School Intervention with Girls in a Residential Facility School: Student Perceptions of School Environment

In response to the high nationwide prevalence of psychological trauma among court-involved youth who have been exposed to abuse and neglect and the associated far-reaching adverse consequences, there are calls to develop a trauma-informed workforce across the various systems (child welfare, juvenile justice, mental health, and education) designed to serve this population. We describe a pilot test of a modified version of the Heart of Teaching and Learning (HTL) curriculum, an intervention designed to increase trauma-informed practices in education settings. This program was implemented in a public charter school that exclusively serves court-involved youth placed in residential treatment. The intervention was associated with decreases in trauma symptoms experienced by youth. Because student perceptions of teachers were high both before and after implementation of the curriculum, no statistically significant changes were observed. The article concludes with a discussion of the ways in which the curriculum can be used to help prepare a national education workforce capable of implementing trauma-informed evidence-based practices in school settings.     

Treating Transgender Individuals in Inpatient and Residential Mental Health Settings

This article describes the need for specific guidelines regarding how to manage inpatient and residential mental health programming with respect to transgender individuals. The article discusses what is known about transgender mental health and how it is related to sociopolitical factors, how inpatient and residential programs can address the impact of sociopolitical factors on transgender individuals and send a welcoming message to prospective consumers, how programs can attend to policies and procedures in ways that create the best milieu for an inpatient or residential unit that provides care for one or more transgender individuals, and how providers and interdisciplinary teams can meet the unique clinical needs of transgender individuals. These guidelines are designed to assist providers in creating a safe environment that affords quality inpatient and residential mental health care to transgender individuals.     

Integrating Narrative Family Therapy in an Outdoor Behavioral Healthcare Program: A Case Study

Adolescent mental health is a significant societal concern in the United States. Diagnosable mental health disorders have been reported at rates of 10–20 % among children and adolescents and this does not include adolescents experiencing personal and interpersonal distress not meeting diagnostic criteria. Adolescents who do not respond to traditional mental health services are often placed in residential treatment centers or other out-of-home treatment programs. Outdoor Behavioral Healthcare (OBH) is growing as a viable treatment option for adolescents who struggle with emotional, behavioral or substance related problems; however, questions have been raised about how to integrate the family into an OBH treatment setting. This article describes a case study illustrating how techniques from Narrative Family Therapy can be used to accomplish this integration, and offers a view of using Narrative Family Therapy to further involve families in the treatment and post-treatment process in an OBH program.     

Challenges and opportunities in moving toward a public health approach in school mental health

These three outstanding papers are important for the discipline of school psychology, the field of school-based mental health, and more generally for systems of education and mental health for children and adolescents. As the authors emphasize, there is an unprecedented focus on improving programs that remove barriers to learning and enhance development, health, and mental health in youth, in the most universal natural setting—the schools. The authors also correctly highlight that school psychology is uniquely positioned to play a leading role in this reform and change effort. Two interconnected themes of the public health approach—applying the evidence base and moving toward preventive and population-focused interventions—are emphasized in these papers, and while they focus on school psychology, the issues discussed are generalizable to the many disciplines that operate within educational and mental health systems. In the following discussion, I react to the papers' two major themes, discuss realities that should be addressed for progress to be made, and comment on their implications for school psychology.     

An Integrative Review of School-Based Mental Health Interventions for Elementary Students: Implications for Occupational Therapy

Occupational therapy for children and youth experiencing mental health conditions is often overlooked in current school-based services, as the traditional role within the system is often limited to physical health issues. The purpose of this integrative review is to investigate current psychosocial interventions within school settings to understand the effects of services provided and to determine potential roles for school-based occupational therapists. The findings of this review support occupational therapists in facilitating interventions that target mental health in school settings. Psychotherapy presented the strongest evidence for reducing psychosocial symptoms in school settings.     

Mental Health and Incarcerated Youth. II: Service Utilization

The incarceration of mentally ill youth is a serious problem not receiving the same attention as in adults. In this study, we examine the level of prior service utilization in incarcerated youth versus youth receiving community mental health services. We randomly recruited youth from middle South Carolina served by a local community mental health center (CMHC; n = 60), hospitalized in the state adolescent inpatient program (n = 50), and incarcerated in the S.C. Dept. of Juvenile Justice facilities (n = 75). We used a Services History to evaluate episodes of prior utilization of mental health, social service, educational, residential, and volunteer services, as well as the DISC-PC 2.3 to evaluate DSM-III-R diagnoses and symptoms and the CBCL and YSR to evaluate behavioral symptomatology. Incarcerated, hospitalized, and CMHC youth utilized similar levels of educational services and social services. Incarcerated youth had a significantly lower lifetime utilization of outpatient and acute mental health services and significantly higher utilization of out-of-home residential services than the other groups. These services utilization variables, along with gender and age, significantly distinguish incarcerated youth from the clinical groups, with clinical variables not serving to significantly distinguish them. Our results indicate the need to develop programs to prevent the entry of mentally ill/emotionally disturbed youth into the juvenile justice system. Youth who are at risk for incarcenation may benefit from intensive mental health services to prevent out-of-home placement and later incarceration.     

The Integration of a Family Systems Approach for Understanding Youth Obesity,Physical Activity,and Dietary Programs

Rates of overweight in youth have reached epidemic proportions and are associated with adverse health outcomes. Family-based programs have been widely used to treat overweight in youth. However, few programs incorporate a theoretical framework for studying a family systems approach in relation to youth health behavior change. Therefore, this review provides a family systems theory framework for evaluating family-level variables in weight loss, physical activity, and dietary approaches in youth. Studies were reviewed and effect sizes were calculated for interventions that manipulated the family system, including components that targeted parenting styles, parenting skills, or family functioning, or which had novel approaches for including the family. Twenty-one weight loss interventions were identified, and 25 interventions related to physical activity and/or diet were identified. Overall, family-based treatment programs that incorporated training for authoritative parenting styles, parenting skills, or child management, and family functioning had positive effects on youth weight loss. Programs to improve physical activity and dietary behaviors that targeted the family system also demonstrated improvements in youth health behaviors; however, direct effects of parent-targeted programming is not clear. Both treatment and prevention programs would benefit from evaluating family functioning and parenting styles as possible mediators of intervention outcomes. Recommendations are provided to guide the development of future family-based obesity prevention and treatment programs for youth.     

Generalization and Behavior Covariation of Aggression in Children Receiving Stress Inoculation Therapy

Many behaviorally disordered children exhibit aggressive behaviors which often interfere with acquiring prosocial and academic skills. A stress inoculation program was implemented with four behaviorally disordered children to determine whether aggressive behaviors would decrease and generalize to a day school setting. Specific coping behaviors were also recorded to determine whether they increased as a function of this intervention. A multiple baseline design across children was employed with concurrent data collected in the generalization setting. Three of the four children exhibited decreases in aggression and increases in coping behaviors which generalized to the day school. Results are discussed in terms of enhancing generalization and treatment gains with behaviorally disordered youth.     

Direct comparisons between residential and community students on school performance measures in a public school setting

The purpose of the current study was to evaluate the school performance of residential youth who attended a public school setting. Direct comparisons were made between the residential youth and students in the community on a number of school measures. Results from a multivariate analysis of covariance indicated that the residential students had significantly lower grades, participated in significantly fewer extracurricular activities, and exhibited more problematic behaviors such as tardies and absences. These findings were consistent with previous research which found that many residential youth have a number of behavioral, social, and academic difficulties that interfere with school functioning. A number of recommendations were made regarding educational placement for residential youth.     

Workforce Support for Urban After‐School Programs: Turning Obstacles into Opportunities

Organized after‐school programs can mitigate risk and build resilience for youth in urban communities. Benefits rely on high‐quality developmental experiences characterized by a supportive environment, structured youth–adult interactions, and opportunities for reflective engagement. Programs in historically disenfranchised communities are underfunded; staff are transient, underpaid, and undertrained; and youth exhibit significant mental health problems which staff are variably equipped to address. Historically, after‐school research has focused on behavior management and social‐emotional learning, relying on traditional evidence‐based interventions designed for and tested in schools. However, after‐school workforce and resource limitations interfere with adoption of empirically supported strategies and youth health promotion. We have engaged in practice‐based research with urban after‐school programs in economically vulnerable communities for nearly two decades, toward building a resource‐efficient, empirically informed multitiered model of workforce support. In this paper, we offer first‐person accounts of four academic–community partnerships to illustrate common challenges, variability across programs, and recommendations that prioritize core skills underlying risk and resilience, align with individual program goals, and leverage without overextending natural routines and resources. Reframing obstacles as opportunities has revealed the application of mental health kernels to the after‐school program workforce support and inspired lessons regarding sustainability of partnerships and practice.     

The de facto national system of psychiatric inpatient care. Piecing together the national puzzle

National data regarding psychiatric inpatient episodes can be viewed in 2 ways. The normative method surveys the "specialty mental health sector." A more inclusive method includes smaller sites (e.g., the military), all of general hospital treatment (rather than only the psychiatric unit), residential treatment centers, and other residential care. The difference between the 2 methods represents approximately 725,000 episodes, at a direct cost of more than $6 billion. The more inclusive analysis of the years 1980 and 1985 reveals a strong shift to the private sector and an increase in inpatient care of children and youth that might be obscured by limiting national treatment statistics to the specialty mental health sector.     

Wrapping community-based mental health services around children with a severe behavioral disorder: An evaluation of project wraparound

During the past two decades there has been a significant increase in community-based mental health and educational services for children and youth with serious emotional and behavioral problems and their families. However, in the vast majority of programs there are no reliable longitudinal data on the adjustment of the children that are served. Project Wraparound was a community-based individualized treatment program which served children and youth with severely maladjusted behavior and their families by providing intensive home and school-based services. The purpose of this paper is to provide a longitudinal analysis of client and family adjustment data. Data on client adjustment within the home and characteristics of the home environment were obtained at intervals of 3 months, 6 months, and 1 year. Data on client adjustment in school was obtained at four points over a period of 2 years. The results from 19 cases indicate that substantial change occurred on measures of the home environment and client adjustment in the home with no significant change in adjustment in the school. Implications of the findings are discussed.