Professional Psychology: Research and Practice 1998, Vol. 29, No. 6, 582-587
Copyright 1998 by the American Psychological Association, Inc. 0735-7028/98153.00
Understanding the Mental Health Needs of Children and Adolescents in Residential Treatment John S. Lyons, Lisa N. Libman-Mintzer, Cassandra L. Kisiel, and Harry Shallcross Northwestern University, Mental Health Services and Policy Program with the penetration of managed care approaches in child welfare, residential treatment services have come under increased scrutiny. In these circumstances it is critical to understand the clinically indicated use of these expensive interventions. As part of a community-reinvestment strategy of reform within a state child welfare agency, a needs-based assessment of children and adolescents was undertaken. A review of cases revealed that although the level of mental health need for many was significant, a substantial proportion of children in residential placement were not at high levels of risk. On the basis of these data, a process of placement review was designed and implemented for more effective use of residential treatment.
One of the effects of managed behavioral health care has been increased pressure to demonstrate the rational use and anticipated outcomes of mental health services. As managed care initiatives have moved from private sector insurance cover-
age into public sector mental health and child welfare, there has been increased attention on identifying the clinically appropriate use of services. Obviously that attention has tended to focus on either the most expensive or most commonly used services. Within child welfare, residential treatment services represent both an expensive and common intervention for children and adolescents with serious emotional disorders (LeCroy & Ashford, 1992). Although less costly than psychiatric hospitalization on a per diem basis, residential treatment proves to be more expensive because of extended stays. This can result in annual costs between $50,000 and $75,000 per child. At this cost, a large proportion of the limited funds allocated to mental health care can end up supporting residential treatment for a few, with little money left for the development or funding of communitybased services (Burns & Friedman, 1990). As both a ubiquitous and an expensive treatment modality, the question remains as to the effectiveness of residential treatment for the particular children who receive it. To successfully determine the appropriateness of residential care for those children placed in these settings, needs of recipient children must be assessed in a systematic, reliable, and clinically relevant manner. A consensus has developed that a discontinuity exists between children' s mental health needs and the services provided to them (Burns & Friedman, 1990; Julian, Julian, Mastrine, Wessa, & Atkinson, 1992; LeCroy & Ashford, 1992; Pothier, 1988). A small number of studies have laid a groundwork for research assessing children's mental health needs. Segal, King, and Naylor (1995) targeted the lack of a systematic means for creating treatment plans for children only known to clinicians for a short period of time. Eisikovits and Schwartz (1991) critiqued the practice of treating children in residential settings, and stated that vague diagnostic criteria are often used resulting in a failure to match mental health needs to services provided to individual children. Burns and Friedman (1990) also highlighted the need for agreement on characteristics of "severe emotional probl e m s " and a means to accurately describe children with mental health problems. Burns and Friedman conceptualized their recommendation as the first step in the larger effort to reform mental health service delivery based on the needs of children.
JOHN S. LYONS,PhD, is the Director of the Mental Health Services and Policy Program of the Institute of Health Services Research and Policy Studies at Northwestern University. He is a tenured Associate Professor of Psychiatry and Medicine. His research focuses on the use of clinical outcomes to improve service delivery. LISAN. LIBMAN-MINTZERis a graduate student in the clinical psychology graduate program in the Department of Psychiatry and Behavioral Sciences of Northwestern University Medical School. She is currently on internship at the University of Michigan. She was affiliated with the Mental Health Services and Policy Program at Northwestern University at the time of this study. CASSANDRAL. KtSIEL received her PhD in clinical psychology from Northwestern University. She is currently a clinical fellow at Cambridge Hospital Harvard Medical School and a postdoctoral fellow at the Human Resources Institute Trauma Center. She was affiliated with the Mental Health Services and Policy Program at Northwestern University at the time of this study. HARRY SHALLCROSS,PhD, is an independent consultant living in New Jersey. He is one of the founders of managed behavioral health care and currently works with states to facilitate planning for service system design and reform. He was affiliated with the Mental Health Services and Policy Program at Northwestern University at the time of this study. Tim pRESENTSTUDYdescribes aspects of a complex planning process. Jess McDonald, the Director of the Illinois Department of Children and Family Services, had the vision and resolve to commit the department to this process. Patricia Chesler, the Director of Research and Policy, and Joseph Loftus, the Executive Deputy Director, were instrumental in managing this process. Jane Hastings and Linda Hargnett of Chrysallis Consulting played key roles in facilitating training and implementation. Sarah Rosenbloom, Courtney West, and Zachary Oelrich participated in the reviews of cases. The selected residential sites graciously facilitated the review process. We thank each of these individuals for their respective contributions to the work described. CORRESPONDENCECONCERNINGTI-I/SARTICLEshould be addressed to John S. Lyons, Northwestern University, Mental Health Services and Policy Program, Ward Building 9-217, 303 East Chicago Avenue, Chicago, Illinois 60611-3008. Electronic mail may be sent to
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REFORMING RESIDENTIAL TREATMENT IN CHILD WELFARE We have observed that residential settings often supply identical service packages to all resident children regardless of the individual child's level and type of need (Lyons, 1997). Julian et al.'s (1992) study of treatment utilized by children with severe mental illness demonstrates the outcome when children's needs are not well understood and decisions regarding care are not made systematically. In their study of 25 children receiving mental health care through a public mental health agency, the children received services from a total of 140 different providers, which suggests the opportunity for problems with coordination and planning. This body of research substantiates a need for an accurate, rational means of describing and operationalizing the problems of disturbed children. This represents the first step in elucidating their mental health needs. After the information necessary for describing a child's mental health problems has been garnered, criteria to guide level of care decisions may be applied. Elsewhere we have discussed the use of outcomes management approaches at the system planning level (Lyons, Howard, O'Mahoney, & Lish, 1997; Lyons, Shallcross, & Sokol, 1998). Needs-based planning approaches that use reliable and valid assessments of clinical characteristics can be used to inform the planning process about the needs of service recipients. Because most planning to date has focused on the use of utilization data only, inclusion of some clinical data should improve these planning projects. The present article discusses the process and findings of a needs-based planning project in child welfare in the state of Illinois. A Needs-Based P l a n n i n g Project In 1995, the state of Illinois Department of Children and Family Services (DCFS) spent more than $450 million on various forms of mental health services for the more than 50,000 wards of the state. This amount represented nearly one third of the total DCFS budget of approximately $1.5 billion and represents a substantial amount of money for these important services. The perceived problem was that about $350 million of these resources was being spent on long-term residential care and psychiatric hospitalization. In many cases, the system was reported to function as having only two options--no service in the community or long-term residential placement. The problem was reported to be particularly acute in poor urban neighborhoods, which represent the communities of about two thirds of all DCFS wards. The planning objective for DCFS was to determine whether it would be feasible to bring back to the community a subset of children currently in residential placements to free up resources for reinvestment in community services. For such a community reinvestment strategy to work, it would have to be the case that a significant minority of children currently in residential treatment could be returned to the community safely. The growing literature on wraparound services suggests that these community-based services are at least as successful as residential treatment, and significantly less expensive (Brown & Hill, 1996; Rosenblatt, 1996). A random sample of 17 residential treatment providers was drawn from a list of all residential providers for DCFS wards of the state of Illinois. Residential treatment, for this study,
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includes residential placement programs (n = 8), group homes (n = 5), supervised independent living facilities (n = 2), and residential treatment programs for sexual offenders (n = 2). The sample was stratified into three tiers based on program size: large (more than 50 children in residence), medium ( 2 0 50 children), or small (less than 20 children). At each of the large provider sites, a random sample of 30 DCFS cases were examined. At the mid-sized programs, a random sample of 20 files were drawn. At the small programs, a sample of 10-12 files were randomly selected. All data were contained in the children's files at the residential sites. Children's mental health needs were assessed using the Child Severity of Psychiatric Illness (CSP1; Lyons, 1998), a measure that assesses psychiatric symptoms, risk behaviors, and functioning (school, home, and peer) as well as factors that influence level of pathology in these areas (Lyons et al., 1997). The dimensions and anchor points within each dimension were developed through focus groups with child welfare caseworkers and staff as well as members of the provider community. The anchor points differ slightly by dimension, but in general, 0 = no evidence o f that dimension, 1 = a mild degree o f that dimension, 2 = a moderate degree, and 3 = an acute or severe degree o f the dimension. The Risk Factors dimension takes into account
the recency and acuity of each risk behavior, with higher ratings assigned to more recent and acute risk. Pilot studies have demonstrated the CSPI to be a useful decision-support tool as well as an accurate measure of children's mental health needs, mental health service utilization, and outcome (Lyons et al., 1997). Charts were reviewed by trained psychology graduate and undergraduate research assistants under the direction of the project coordinator. Interrater reliability was high ( r = .88). Basic demographic information, including age, gender, length of stay in the residential program, history of psychiatric hospitalization, and diagnosis, were collected as well. The Risk Factors dimension of the CSPI consists of ratings of suicide risk, danger to others, elopement risk, crime delinquency, and sexual aggression. On the basis of this dimension, four distinct risk groups were created for the purpose of determining each child's overall level of risk. Examples of the risk anchors for Suicide and Elopement are included in the Appendix as examples. Four risk groups were used. The norisk group had no history or current suicidality, dangerousness, runaway, crime or delinquency, or predatory sexual behavior. The history of risk group had at some point been either suicidal, dangerous to others, runaway or criminal/delinquent, but had not been involved in any of these behaviors in the 30 days prior to admission. This group had no history of predatory sexual behavior. The recent risk group had engaged in at least one of the following risk behaviors: suicide, dangerousness to others, runaway, or crime/delinquency in the past 30 days but were not acutely at risk for these behaviors. This group had no history of predatory sexual behavior. The acute risk group was currently suicidal, dangerous, at immediate risk for runaway or criminal or delinquent behavior. Any history or recent predatory sexual behavior was included in the acute risk group. O f the sample of 333 children, almost two thirds (66.2%) were male. The children ranged in age from 5 to 21 with a mean age of 14.2 years. More than half (52.8%) were African American, and more than one third (39.3%) were Caucasian.
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The remainder of the sample was composed of a small number of Hispanic, Asian, and Native American children. The mean IQ score was 87.8 with a range from 50 to 136. The majority of children scored between 70 and 100 (70.8%). A small number of children had IQ scores below 70 (6.4%). The remaining children had IQ scores above average (22.8%). This group of children had been in state custody for an average of 4.46 years (Mdn = 3.50 years; range = 0 - 2 0 years). They had spent an average of 1.01 years in their current placement (Mdn = .60 year; range = 0 - 1 4 years). On average, the children had lived in 1.14 previous residential placements (Mdn = 1.00 placement; range = 0 - 1 0 past placements). The anchor points of the Symptoms dimension of the CSPI correspond to five broad diagnostic categories: emotional disturbance, conduct disturbance, neuropsychiatric disturbance, oppositional behavior, and impulsivity. A rating of 2 or greater in any area corresponds to a level of symptomatology great enough to warrant a specific Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IE" American Psychiatric Association, 1994) diagnosis within these broader categories. Most of the children (83.0%) met criteria for a diagnosis in at least one of the five aforementioned categories. Most psychopathology was seen in the following three areas: emotional, conduct, and oppositional. More than half of the children (54.5%) met criteria for an emotional disturbance, 43.2% met criteria for a conduct disturbance, and 48.0% met criteria for an oppositional disturbance. A small minority of the children had diagnosable substance abuse and neuropsychiatric problems. Table 1 presents the distribution of cases by levels of risk. Forty-four children (13.2%) had never engaged in any of the five risk behaviors. One hundred twenty-nine children (38.7%) were at acute risk on at least one dimension. One hundred twelve of the 333 children (33.6%) were found to be either at no risk or with only a history of risk (no risk behaviors in the past 30 days prior to admission) and thus did not necessitate residential placement. The following analyses compare this group of children (low risk) to the children at acute and recent risk (high risk). Table 2 summarizes these comparisons.
Of the 111 girls in the sample, 41.4% were determined not to need residential treatment based on their level of risk. Of the 219 boys, 29.7% were determined not to need residential services. Girls were 71.7% more likely to be inappropriately placed than their male counterparts. The two groups of children were compared on each of the broad CSPI symptom categories using independent sample t test analysis. Results are summarized in Table 2. Children determined to need residential services experienced significantly more neuropsychiatric disturbance, conduct disturbance, oppositional behavior, and impulsivity than children determined not to need residential services (p < .001). Children determined to need residential services also experienced significantly more emotional problems than children determined not to need residential services (p < .05). A Total Symptom Severity (TSS) index was created for all children by summing CSPI ratings on each of the five symptom clusters. An independent sample t test indicated a significant difference between the group needing residential services and the group, not needing such services (p < .001). The mean TSS score for the group needing services (M = 6.89) was 1.5 times greater than the mean score for the group judged not to need residential services (M = 4.45). The two groups of children were also compared on family, peer, and school functioning using independent t test analysis. Results are summarized in Table 2. No significant differences in family functioning were found between the children needing residential placement and those not needing such services. Children determined to need residential treatment were found to have significantly worse peer relationships and school functioning than the children not in need of residential care (p < .001 ). Table 3 presents the percentage of children in each of the four risk categories by type of facility. The difference in risk across facility type is statistically significant (p < .001). The large and small facilities have the highest proportion of no-risk children. Independent living facilities have a majority of low risk children. Sexual offender programs and mid-sized facilities had the highest risk children. Implications and A p p l i c a t i o n s
Comparison of High- and Low-Risk Children Three age groups were created to target possible differences between children ~tt different developmental stages: 12 and under, 13-17, and 18 and up. It was found that those 18 years and up were more likely than younger children to be placed in residential treatment when not currently or recently at risk to themselves or to others. In contrast, children in the 13-17 age group were least likely to be placed without acute or recent risk.
Table 1
Classification of Children and Adolescents by Risk Group Risk group
No. of children
%
No risk History of risk Recent risk Acute risk Total
44 68 92 129 333
13.2 20.4 27.6 38.7 100
Although the majority of children in residential treatment had profiles consistent with residential services, slightly more than one third may be able to be better served in community settings. These children were receiving residential treatment in the absence of any current or recent risk behaviors. Not only are these children not dangerous to themselves or to others, they suffer from less overall psychopathology, less psychopathology across diagnostic categories, and less school and peer dysfunction than those children acutely or recently at risk for any of the five risk behaviors. These children and adolescents appear to be logical candidates to be successfully "stepped down" to communitybased treatment, consistent with the notion of treatment in the least restrictive setting possible (U.S. Congress, 1986, as cited in Pothier, 1988). Thus the findings support the objectives of the community reinvestment strategy for building communitybased services for children living in impoverished areas. Moving those children who can be appropriately treated in community settings affords significant financial savings, especially given the high cost of residential care. Money saved from
REFORMING RESIDENTIAL TREATMENT IN CHILD WELFARE Table
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2
Comparison of High-Risk and Low-Risk Children on Selected Childhood Severity of Psychiatric Illness Low risk Dimension Symptoms Neuropsychiatric Emotional Conduct Oppositional behavior Impulsivity Functioning Family dysfunction Peer dysfunction School dysfunction
High risk
n
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SD
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