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| Rhode Island’s juvenile justice system imposes a fiscal drain on the state budget says Mark C. Dumas, Ph.D., director and co-president of Psychological Centers in Providence. (photo by Tom Croke) | |
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By Phyllis Hanlon
Residential placement has been at the center of controversy for years with opponents calling for community and home-based services and advocates lobbying for positive change within existing models. In recent years, some combination of both has occurred throughout New England.
During the eight years Bette Lewicke, Ph.D., a neuropsychologist at Monadnock Behavioral Health Services in Peterborough, N.H., worked at Crotched Mountain School, she noted some significant modifications in the residential school model, one of the most notable occurring in 2003 when Donald Shumway, former commissioner of Health and Human Services, became president. "He implemented 'gentle teaching' training for all staff," she says. "This is a combination of relationship building, good behavioral techniques and arranging the learning environment."
Following the MANDT system developed in 1975, which promotes dignified and respectful treatment for all, Crotched Mountain removed time-out booths from the classroom and instituted less invasive restraint protocols, according to Lewicke.
Crotched Mountain Principal Archie Campbell cites a shift toward co-housing in which staff and a small number of students live in the same residence. Students also participate in community activities during traditional school hours "for leisure time development, relationship building and on-the-job training at real job placements," says Campbell.
Additionally, Crotched Mountain encourages interaction between non-disabled peers and students to generate awareness and foster relationships and international internships add diversity and "cultural flair" to campus, says Campbell.
According to Mark C. Dumas, Ph.D., co-director and president of Psychological Centers in Providence, R.I., residential placement represents 70 percent of the mental health dollars spent on children and teens nationally. In Rhode Island's case, its juvenile justice system with 225 residents at an annual cost of $100,000 per resident imposes a serious fiscal drain on the state budget. Dumas reports that a pending legislative bill should reduce that number to 150, thus decreasing spending.
Although he agrees that in certain cases, residential placement is the best solution, Dumas says, "Scientific evidence reveals that when you place children with similar problems together, it breeds contagion."
In accordance with the move away from residential placement, Psychological Centers provides statewide community-based mental and behavioral health services, concentrating on multi-systemic therapy (MST) and functional family therapy (FFT). "We focus not only on the child but also on the family as a whole to create systemic changes in the family that are sustainable when treatment concludes," Dumas says.
Connecticut launched several initiatives relating to residential care five years ago, says Karen Andersson, Ph.D., director of Connecticut's Behavioral Health Partnership. She reports that between 2001 and 2004, $30 million was invested in new community-based services with more than $17 million devoted to intensive, evidence-based home care.
By December, Connecticut expects to have 52 therapeutic group homes, up from the current 43. "These are highly staffed, clinically informed sites with five or six kids to a home," she says.
Andersson's agency, which she calls "managed care with a heart," also instituted an authorization and regular review process in December 2006. "Every child in residential care will have to get authorization and will be subject to concurrent reviews," she says. Treatment planning updates will tie in to onsite evaluations.
To help providers become better acquainted with the continuum of community services available and handle the increased workload produced by the new authorization and review process, Connecticut hired a cadre of clinical psychologists in August to act as consultants and technical assistants. "The psychologists will get to know and understand the milieu and work with providers. They will prompt treatment and discharge planning," Andersson says.
In Massachusetts, the shift to a family network delivery system of care as prescribed by the Department of Social Services (DSS) has produced mixed results, according to James V. Major, executive director of the Massachusetts Association of Approved 766 Private Schools (MAAPS). The agency's annual survey finds that residential referrals remained flat during the period from October 2005 to March 2006. "However, day school numbers rose 33 percent," Major says, prompting multiple readmissions. This situation creates more "stuck kids," since children are moved from DSS to the Medicaid budget, he adds.
However, Major praises a November 2006 policy that positively impacts residential schools. "The Department of Education (DOE) and a state agency, Operational Services Division, established a policy to allow schools to increase salaries for professional staff," he says. "There had been a $20,000 difference in salaries, so residential schools had a hard time getting qualified staff. [Now] some schools can hire at competitive rates and be fully staffed with teachers who are fully credentialed."
Jack Weldon, executive director of St. Vincent's Home in Fall River, Mass. believes residential schools must rethink the traditional model while still providing "sophisticated, diagnostic assessment, devising a treatment plan that makes sense for the child and the family, and creating a therapeutic milieu that is trauma informed, knowledgeable and responsive to the needs of the kids." He confirms Major's statistics regarding lower residential numbers, reporting that four years ago, St. Vincent's average daily census was 134; today that number is closer to 25.
Weldon says St. Vincent's has closed one campus, converted its main campus from residential education to other services and created more short-term services. "Recently, we opened a day school and now do more community services, such as step-down," he says. "The 80 percent drop in residential education is offset by new programs and services."
Stephen H. Yerdon, LICSW, executive director of Devereux Massachusetts, reports that residential schools, including Devereux, collaborate with state agencies like Department of Social Services (DSS), Department of Mental Health (DMH) and Department of Education (DOE) to "match philosophy of care for kids."
Substance abuse and more complicated, more acute diagnoses are forcing residential schools to open their doors to new client populations. According to Yerdon, one in 150 children in the Northeast have some form of pervasive developmental disorder (PDD). "A lot of residential schools are providing psychiatric hospital level type of care. Kids are suicidal and very aggressive," he says.
And while wraparound care proves successful when begun early after diagnosis, costs still run as much, or more, than residential care. "It requires a lot to keep children and their families safe and get them appropriate treatment after they've been in residential care," says Yerdon.
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