Development and Implementation of Trauma-Informed Programming in Youth Residential Treatment Centers Using the ARC Framework

This project describes application of an evidenced-based, trauma-informed treatment framework, Attachment, Regulation and Competency (ARC), with complexly traumatized youth in residential treatment. The processes of implementing the ARC model into clinical and milieu programming at two residential treatment programs are described. Particular attention is paid to system-level processes and strategies for embedding ARC in a sustainable manner. Pilot data demonstrated a significant relation between use of ARC and reductions in PTSD symptoms, externalizing and internalizing behaviors, and the frequency of restraints used across programs. Preliminary findings contribute to an emerging empirical basis for the ARC model and are supportive of its clinical utility as a practice in the residential context. Next steps include: a) expanding the study findings by conducting controlled efficacy research, b) examining system level variables as mediators of change, and c) describing the full operation stage of implementation of the ARC framework.     

Complex Histories and Complex Presentations: Implementation of a Manually-Guided Group Treatment for Traumatized Adolescents

It is consistently recognized that children and adolescents who have repeatedly experienced or witnessed violence are at significant risk for a multitude of lasting difficulties across many domains of functioning. Adolescents in residential settings often have extensive trauma histories and experience profound behavioral, emotional, and interpersonal difficulties. Unfortunately, there are few structured trauma-informed treatments that have been implemented in residential settings, and even fewer that have been evaluated. This article describes the core components of Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS), a manually-guided trauma-informed group treatment, and provides clinical examples within residential facilities for adolescents with emotional and behavioral difficulties and extensive victimization histories. Preliminary data on self-reported emotional, behavioral, and posttraumatic stress symptoms are presented.     

Clinical Considerations for the Treatment of Latency Age Children in Residential Care

Children in the United States are exposed to alarmingly high rates of violence and trauma. Notable are the rates of maltreatment among children and the heightened risk for both out of home placement and an array of developmental, behavioral, and psychosocial sequelae. Despite these risks, little information is available on effective interventions and services designed to address the complex needs of youth in residential treatment settings. To effectively respond to their unique developmental, behavioral, and emotional needs, trauma-informed interventions and services must be provided to support optimal outcomes. To this end, this paper delineates the prevalence of children in residential care secondary to chronic maltreatment and other trauma exposures, identifies behavioral and emotional issues through the theoretical framework of complex trauma, highlights the importance of organizational capacity to deliver trauma-informed services, and describes effective clinical interventions that are often used in residential treatment. Clinical considerations and recommendations are also provided.     

Play to the Whistle: A Pilot Investigation of a Sports-Based Intervention for Traumatized Girls in Residential Treatment

Adolescents in residential treatment settings have symptoms that prevent them from participation in normal youth activities, which in turn prevent development of social skills and competencies. A sports-based intervention called “Do the Good” (DtG) was designed for this population using trauma-informed treatment principles. This paper describes the intervention model and presents outcome data. A total of 88 female residential students aged 12 to 21 participated, including 62 students voluntarily enrolled in the sports league and 26 treatment-as-usual (TAU) comparisons. Positive behaviors (e.g., helping peers, perseverance) during games were observed and coded for sports league participants and their coaches. Mental health charts of DtG and TAU participants were reviewed for behavior and symptoms prior to program participation, and again post-program. Girls in the sports league exhibited reductions in restraints and time-outs, as well as internalizing and externalizing symptoms. These data provide evidence that sports-based interventions present a promising adjunctive approach for traumatized youth.     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); mental health services--DoD. Final rule

This final rule is to reform CHAMPUS quality of care standards and reimbursement methods for inpatient mental health services. The rule updates existing standards for residential treatment centers (RTCs) and establishes new standards for approval as CHAMPUS-authorized providers for substance use disorder rehabilitation facilities (SUDRFs) and partial hospitalization programs (PHPs); implements recommendations of the Comptroller General of the United States that DoD establish cost-based reimbursement methods for psychiatric hospitals and residential treatment facilities; adopts another Comptroller General recommendation that DoD remove the current incentive for the use of inpatient mental health care; and eliminates payments to residential treatment centers for days in which the patient is on a leave of absence.     

Systemic Self-Regulation: A Framework for Trauma-Informed Services in Residential Juvenile Justice Programs

Most youth detained in juvenile justice facilities have extensive histories of exposure to psychological trauma. Traumatic stress plays a key role in their mental health and behavioral problems and needs, and in their safety and rehabilitation and the security and effectiveness of detention facilities. We provide an overview of the barriers to successful provision of mental health services for youths in juvenile justice facilities, including those involving youth, parents, and juvenile justice residential facility staff and administrators. Next, we discuss the relevance and potential utility of approaching mental health needs using posttraumatic stress disorder (PTSD), and more broadly posttraumatic dysregulation, as an organizing framework. Examples of how a posttraumatic dysregulation perspective can enhance juvenile justice residential facility milieus and services are presented, with an overview of traumatic stress intervention models that have shown promise, or potentially could be deployed, in developing and sustaining trauma-informed juvenile justice facilities.     

AMERICAN BAR ASSOCIATION POLICY REQUIRING LICENSURE,REGULATION, AND MONITORING OF PRIVATELY OPERATED RESIDENTIAL TREATMENT FACILITIES FOR AT‐RISK CHILDREN AND YOUTH

Well‐meaning parents send an estimated 10,000 to 14,000 at‐risk children each year to unregulated private residential treatment facilities, which for as much as $3,000 to $5,000 per month promise to modify troublesome behaviors and make bad kids good. The facilities that compose this booming, billion‐dollar business are generally not regulated, licensed, or monitored by state or federal governments; too many aspects of this alternative care system for youth are rife with mistreatment, including physical, sexual, and mental abuse by facility staff. This American Bar Association policy resolution urges state, territorial, and tribal legislatures to pass laws that require the licensing, regulating, and monitoring of residential treatment facilities that are not funded by public or government systems but offer treatment to at‐risk children and youth for emotional, behavioral, educational, or other problems or issues.     

Child Maltreatment,Placement Strategies,and Delinquency

The current study examined the criminal justice experiences of foster care youth living with relatives, foster families, and living in congregate care; dependents receiving in-home care; and non-dependent youth. Specific attention was directed at uncovering whether form of maltreatment, placement type, and/or placement instability were related to delinquency. A prospective analysis of official record data followed children in Los Angeles County from the time of a first admission to the Department of Children and Family Services (DCFS) to potential involvement in the criminal justice system (N = 1,235). The study also utilized a matched control design in which DCFS cases were compared to non-dependent controls (N = 1,235). The most consistent predictors of delinquency were placement instability and age at placement. Youth who were older at placement and youth with at least one placement change were more likely to be arrested for violent and non-violent crimes as well as be charged by the district attorney than younger youth with no placement changes.     

WHEN IT HAPPENS IN A FAMILY: AIDING PARENTS OF SUBSTANCE‐ABUSING ADOLESCENTS*

This article first summarizes key data on the scope of teen substance abuse and the lack of teen access to needed treatment services. It then describes how and why attorneys may be helpful to parents who discover their teen's drug or alcohol problem and seek advice and counsel about the legal implications of various actions that can or may be taken. The article explores such issues as parents finding illegal drugs in the house or on their teen's person, various modalities of treatment and how family members are involved, how parents might secure residential evaluations for their youth without the necessity of juvenile court involvement (and why this is important), concerns about placing youth in unlicensed residential treatment facilities, health insurance coverage issues, home drug testing, and how past American Bar Association (ABA) policy on youth drug and alcohol abuse is being followed up with a new ABA project to aid parents of substance‐abusing teenagers and their families.     

Traumatized Youth in Residential Treatment Settings: Prevalence, Clinical Presentation, Treatment, and Policy Implications

Children and adolescents with histories of traumatic exposure comprise a substantial portion of youth in residential treatment programs. However, until recently, little has been known about this specific population. Given the well-documented unique treatment considerations for traumatized youth, it is important to understand how the distinct needs of this population factor into the particular residential treatment setting approach. This paper presents a comprehensive overview of the current understanding of this vulnerable youth population, the impact trauma exposure can have on their clinical presentation and response to treatment, and the available empirical research regarding effective intervention strategies. In addition, policy implications specific to traumatized youth receiving treatment in residential settings are discussed.     

A Clinical-Corrections Approach: The Failure of a Residential Juvenile Delinquency Treatment Center

Abstract With the incidence of violent juvenile crime and the increasingly limited funds for residential treatment of the adolescent offender, one court jurisdiction (16th Judicial Circuit, Kane County, Illinois) attempted to develop and administer its own residential treatment facility within the walls of its detention facility. This article documents the problems encountered in this endeavor and provides recommendations for other jurisdictions which might be tempted to try to balance the fiscal and rehabilitative demands of this growing population by administering their own residential treatment facilities. The problems addressed in this article pertain to the following areas of difficulty: developing a therapeutic milieu; attracting, training, and evaluating a competent child care staff; and implementing a consistent philosophy of change designed to drive all decision-making within the center.     

Adult day care regulation: "Déjà vu all over again"?

We investigate what aspects of adult day care are regulated by licensure and certification requirements, whether differences exist among centers according to their regulatory status, and the relationship between regulatory status and satisfaction. The data come from a national survey of adult day care center. We find that adult day care regulations are primarily structural in nature and that differences do exist among centers by regulatory status. Participants are very satisfied with the centers and their staff overall, especially at centers that are regulated; their satisfaction with milieu is less at regulated centers and with amenities is unaffected. Day care regulations have not been extended to the processes and outcomes of care as nursing home regulations recently have been. The choice that now faces policymakers is between increasing these regulations or relying on market mechanisms to protect day care participants.     

Does Treatment Quality Matter?

Research Summary

The Florida Department of Juvenile Justice has implemented a process to evaluate the treatment quality of interventions provided statewide in all long‐term residential programs. In the current study, we examine the predictive validity of this treatment quality component in the prediction of recidivism of youth (N = 2,397) who completed juvenile justice residential programs from July 1, 2013 to June 30, 2014. We use hierarchical linear modeling to assess the effects of treatment quality (as youth are nested within programs), controlling for demographic and criminal history factors. The results indicate that higher average treatment quality scores of interventions received within a residential program decreased the likelihood of subsequent arrest, conviction, and reincarceration, whereas the highest treatment quality score of any specific intervention provided within the program decreased the odds of reincarceration only.

Policy Implications

In this study, we confirm the importance of fidelity and implementation quality in the provision of crime prevention treatment interventions to serious, deep‐end juvenile offenders. Additionally, our results shed light on the ability of a juvenile justice agency to measure treatment quality in a substantively meaningful way with the use of limited additional resources. The services provided to keep communities safe, prevent future offending, and rehabilitate juvenile offenders must be held accountable for producing such outcomes, and one method of measuring such compliance is to evaluate the quality of the interventions with respect to staff training, fidelity adherence, evaluation, and corrective action processes.     

Probable posttraumatic stress disorder in a sample of urban jail detainees

This study examined the nature and extent of probable posttraumatic stress disorder (PTSD) among men in a substance abuse treatment program in a large urban jail. Specifically, it explored the prevalence of probable PTSD and other psychiatric problems among jail detainees, the types of trauma detainees experienced during different phases of their lives, and how those experiences might have contributed to the development of probable PTSD. Results showed that psychiatric problems were quite serious; nearly one-quarter of the sample reported previous psychiatric hospitalization, and nearly 10% were being currently treated with psychiatric medication. In addition, 21% of the sample met the criteria for probable PTSD, a rate five times greater than that in the general population. The current study suggests that the presence of probable PTSD among male detainees should be incorporated into the creation and implementation of jail-based behavioral healthcare services, including screening, assessment, and clinical interventions. Furthermore, in-custody drug treatment programs should adopt trauma-informed strategies for all program participants as the expected standard of care.     

Déjà vu: from Furby to Långström and the evaluation of sex offender treatment effectiveness

Abstract

The notion that sex offender treatment does not work fuels public outrage and demands for protective legislation. This paper will respond to a recent meta-analysis reporting major weaknesses in research designs that preclude drawing conclusions about the effectiveness of sex offender treatment. Methodological and ethical challenges exist in the investigation of counselling interventions in general and sex offender treatment specifically, and we argue that the medicalization of psychotherapy research may have inherent flaws. Alternatives to dichotomous recidivism outcomes are proposed, including harm reduction measures and reduction of maladaptive behaviours. Future clinical directions for sex offender treatment are explored, including application of risk-needs-responsivity models, a focus on process as well as content and incorporation of principles of trauma-informed care.     

Predicting successful outcomes for serious and chronic juveniles in residential placement

In the past decade, juvenile justice agencies have become more reliant on objective risk scales based on an actuarial approach to assessing risk. Risk assessment scales are used as decision-making guides at multiple points in the juvenile justice system. However, little research has focused on assessment of more serious offenders facing removal from the community. Enormous benefits can be derived, both in public safety and cost savings, from successful interventions with these offenders. Identifying offenders most amenable to intervention and at lowest risk for offending upon leaving placement represents a significant challenge. In this study, a placement risk screen was developed that assesses amenability to treatment in a residential treatment program and later risk for adult criminality. The relationship between suspected risk factors, success in a residential treatment program, and adult offending was assessed in a population of 81 male delinquent youths. Many factors are believed to have a bearing on success in treatment and later offending behavior, but only a small number of these were statistically significant. The results suggest that success in residential placement can reduce future offending, but that youth should first be screened for amenability to the program so scarce resources can be conserved. The proposed placement risk screen can assist juvenile court judges, officers, and residential treatment staff in identifying youth most suitable for treatment and who represent a lower risk to the community.     

Consulting to residential programmes for sexually aggressive delinquents

Abstract

Delinquent adolescent boys, especially those looked after in residential settings, often have a long history of coercive antisocial behaviour. Many have a history of aggression and violence, including serious sexual offences such as rape and indecent assault. In light of the Criminal Justice Act 1991 the residential care sector will come under more pressure to accommodate sexually aggressive recidivistic delinquents. However, few staff who work in residential settings with delinquents have received training in the management and treatment of sexually aggressive behaviour. Time spent in residential care settings may therefore do little to reduce the risk of sexual aggression. This paper proposes that the assessment and management of risk is central to the effective rehabilitation of this group of young people. Based on work carried out at Glenthorne Centre a risk assessment strategy is presented consisting of several different strands: an analysis of organisational decision-making; identification of sources and types of information to inform decisions; the development and implementation of a risk assessment protocol; and staff training. A case example is used to illustrate the use of the protocol at Glenthorne.     

EMPLOYMENT AID FOR YOUTH AGING OUT OF FOSTER CARE: EXTENDING ONE-STOP CAREER CENTERS TO INCLUDE A DIVISION FOR FOSTER CARE YOUTH

Every year thousands of children are discharged from the foster care system and find themselves ill prepared for the responsibility of adulthood. Providing enhanced employment opportunities to both current and former foster care youth will allow them to become economically self-sufficient and therefore have an improved transition from foster care. This Note proposes that states incorporate a foster youth employment program in the one-stop career centers mandated by the Workforce Investment Act. Through this program, foster youth will be provided with the tools they need for success while maintaining control over their own future.     

Our Seat at the Table: Mentorship,Advocacy, & Youth Leadership in Qualitative Research

This commentary discusses strategies and models for engaging diverse community partnerships through the Youth of Color Needs Assessment, a community-based participatory research project that elevates the voices and experiences of homeless and unstably housed youth of color in King County, Washington. Building upon the lens and expertise of a young Community Advocate thrust into research, it explores the strengths of youth of color leadership and best practices for trauma-informed, relational support for youth leaders and focus group participants alike. These insights offer a youth-centered model for the field grounded in engagement, sustainability, and ethics for research within and for communities at the margins.     

THE AMERICAN BAR ASSOCIATION ADDRESSES THE NATIONAL PROBLEM OF YOUTH AT RISK

During the 2006–2007 American Bar Association (ABA) year, a special ABA Presidential Youth at Risk Initiative has addressed several important topics: addressing the needs of juvenile status offenders and their families; foster children aging out of the foster care system; increases in girls, especially girls of color, in the juvenile justice system; the need to better hear the voices of youth in court proceedings affecting them; and improving how laws can better address youth crossing over between juvenile justice and child welfare systems. Lawyers are encouraged to use their skills to improve the systems addressing at‐risk youth and their families and to help facilitate coordination of youth‐related community efforts. Learning how to effectively communicate with youth is an important skill attorneys must learn. Through the Youth at Risk Initiative, the ABA has held continuing legal education programs, hosted community roundtables among youth‐serving stakeholders, and developed projects on: juvenile status offenders; lawyer assistance to youth transitioning from foster care; educating young girls on violence prevention, conflict resolution, and careers in law and justice; and provision of useful information to youth awaiting juvenile court hearings. New ABA policy has addressed services and programs to at‐risk youth, assuring licensing, regulation, and monitoring of residential facilities serving at‐risk youth, enhanced support for sexual minority foster and homeless youth, juvenile status offenders, and improving laws and policies related to youth exiting the foster care system.