Model programs make a difference in the lives of children and adolescents with behavioral health disorders.

 

Improvement Comes in Many Ways.

Indicators frequently used to determine whether children are improving in their treatment programs include the following:  

• Reductions in recidivism rates
• Reductions in inpatient lengths of stay
• Improved functioning on specific behaviors or dimensions
• Improved school attendance and/or performance
• Reduction in incarceration and recidivism rates for juvenile offenders
• Increased parent participation and/or support
• Increased youth and/or parent satisfaction with services

 

"Joe" Program A (a Montana residential wilderness program in operation for 4-1/2 years. This program serves 110 adolescents a year from ages 13 to 18.)

Joe, a 16-year-old from Billings, Montana, entered the mental health system at age 11 due to school behavior and truancy issues. Since age nine, Joe has received child protective services because of neglect and physical abuse. His father was incarcerated and his mother was heavily dependent on alcohol and drugs. By age 16, Joe had received a misdemeanor charge for criminal mischief, including shoplifting, "joy riding," and marijuana possession with intent to sell. Joe was referred to Program A after he was tried for "joy riding" and marijuana possession.

During orientation, Joe made two run-away attempts. He was uncooperative and belligerent, and denied having any problems. On the back-country expedition he ran away during the first week. Program staff followed Joe and, after several days, he reluctantly returned to the group. The program requires that the children move together during the expedition, but this proved difficult for Joe, who resisted becoming a part of the group. Joe, however, excelled at some of the more difficult tasks and soon emerged as a leader. Joe was a survivor and quickly adapted to situations that arose in the back-country. He graduated from the expedition as one of the more progressive children.

When Joe moved into the residential component of the program, however, he began to show some of the same behavior patterns he had exhibited in the beginning. Once he began some of the community service work programs, however, he was able to control many of these behaviors. He enjoyed activities more than sitting down and talking, and the concept of contributing to society resonated with him. After leaving the residential component of the program he decided to go to Job Corps, which he completed in six months with training in plumbing. Thus far, he has stayed out of the juvenile justice system and child protective services.

 

"Sam" & "Susan" PROGRAM B (a Florida residential treatment center (RTC) and outpatient day program in operation since 1988. The program serves ages 4 to 18 with 200 per year served by the RTC and 80 per year served by the outpatient day program.)

Currently Program B is treating Sam, a 4-year-old boy in the custody of the Department of Children and Families. In his four years, he has been in 17 foster homes. He was born addicted to cocaine and removed from the home due to neglect and suspicion of abuse. Since that time, he has had no contact with family members. He has shown behavior that is extremely hyperactive and aggressive toward other children. His treatment includes behavioral therapy, medication, and a highly structured educational setting. The treatment objective is to prepare him for foster care placement (therapeutic or regular placement, depending on progress) and participation in the day program if he is from the area. He has been in residence for four months and has shown improvement.

Program B is also currently treating "Susan," a 12-year-old, deaf girl, who was referred to the program by her family. She has a history of sexual abuse by family members. Her diagnoses include thought disorder and borderline intelligence, i.e., she does not qualify as mentally retarded, but her IQ is on the borderline of mental retardation. Due to aggressive behavior, she has a history with the juvenile justice system. Since she has been in residence at Program B, she has been arrested twice for assaulting staff members. After her first arrest, she served 18 days in detention. On the day of her return, she struck a staff member. After her second arrest, she was returned to a highly structured behavioral health program, coupled with family intervention, to control antagonistic behavior exhibited by her family. The treatment goal for this child is to teach her safe behaviors so that she can be returned to her home and the support services in her area. After six months in the program she has shown signs of improvement.

 

"Ted" PROGRAM C (a residential treatment center and day program for juvenile sex offenders in operation since January 1996. The program has 30 RTC beds and 15 day treatment slots. It serves boys ages nine to 17.)

Seventeen-year-old Ted is currently housed by Program C, a residential treatment center (RTC) for juvenile sex offenders. He came to the RTC eight months ago after it was revealed that, while in several foster homes, he sexually assaulted or made attempts to sexually assault female members of the household. Before entering foster care, Ted's family-life was tenuous; his mother died shortly after his birth and his father has been in and out of prison. Through the years, however, Ted has received support from a sister, who is 15 years older than Ted, and from a frail grandmother. For economic and health-related reasons, Ted's family placed him in foster care and with the help of the juvenile justice system, referred Ted to Program C.

During his time at Program C's RTC, Ted has participated in the weekly counseling sessions and his sister and brother-in-law have taken on the role of parents in the family therapy and parental support groups. In addition to the sex-offending behaviors, Ted was diagnosed with depression and obsessive-compulsive disorder during one of the weekly psychiatric visits. With the help of the in-house nursing staff, Ted has adhered to his schedule of medications and has shown improvement. Ted has also shown marked improvement in school and has had regular attendance. He hopes to leave the program at the end of the year and move in with his sister and her husband. After returning to a home environment, Ted will continue to receive day treatment services.

Program C has found several key components of their program to be particularly effective. In their sex-specific group therapy sessions, they spend a great deal of time focused on victim role-playing. This exercise highlights the effects of sex offending on the victim and helps the children understand the victim's perspective. The program also teaches the children about appropriate sexual fantasies and sexual relationships. They teach that sexual relationships should have "CERTS"- consent, equality, respect, trust, and safety.

 

"Juan" PROGRAM D (a multi-site program providing treatment at 18 sites in California and Nevada. Services are provided through community-based outpatient care facilities emphasizing three treatment components -- education, mental health treatment, and rehabilitation.)

Program D is serving Juan, a 9-year-old, Spanish-speaking boy, exhibiting behavioral problems in the classroom. His teacher referred him to the school psychologist who concluded that he needs a mental health assessment. Consequently, he was referred to one of Program D's programs, where he was assessed and assigned to a bilingual therapist and a caseworker. The caseworker will collaborate with the boy, his teacher and the boy's single mother. The therapist will provide an in-class consultation to help the child's teacher manage his behavioral problems and he will also work with both the mother and child until the mother is comfortable managing his behavioral problems. The program, in the case of a single mother, will also provide a male mentor to spend time with the child and serve as a positive male role model.

For services that are not provided directly, Program D participates in several collaborative and interagency arrangements. These arrangements include relationships with the following:

• Child care agencies,
• Emergency service organizations such as the Red Cross,
• Social service organizations such as the Boys and Girls Club,
• Parenting groups,
• Advocacy groups, such as the Alliance for the Mentally Ill,
• Psychiatric hospitals and
• Specialty groups, such as the Latino Psychological Organization and the Asian American Psychological Organization.

Several innovative aspects of Program D are reported by administrators to be particularly effective. Adolescents on probation are often not welcome or treated well by the mental health system. In response to this, Program D has developed a treatment program and a team of staff members specifically for this population. They also have developed a day treatment program for small children who suffer from Post-Traumatic Stress Disorder due to familial abuse. Additionally, they have developed state-of-the-art school programs and services to prevent out-of-home placement or hospitalization.

Because Program D works with impoverished communities, one of the primary challenges faced by this program is reaching their target population. These communities do not have the resources for transportation or childcare services so they have difficulty connecting with services. Another challenge is working cooperatively within a fractured social service system. This program tries to establish a relationship between the child, the family and the counselor. Facilitating this relationship, however, may require contacting two or three uncoordinated entities within the social service system.

 

"Jimmy" PROGRAM E (a Las Vegas, NV, outpatient day rehabilitation program in operation since December 1998 with components emphasizing intensive-community service and home social skills for parents. It serves 35 children ages 5-18 with a separate program for adolescents/pre-adolescents as well as adolescent girls referred through the courts.)

Program E is currently treating eight-year-old Jimmy who has been in multiple foster homes and is now in a group home. He has never known his father and was removed from his home because of maternal neglect. He was referred to the program through the department of child welfare. Initially, he could not participate in club activities because he was aggressive, easily provoked and paranoid. He was placed in a behavioral management program where he was rewarded for controlling his behavior. Jimmy responded immediately to this program, because he had never received any positive reinforcement before. He is now interacting well with the members of the club. He has joined the club basketball team and the child welfare department is looking for a more permanent foster care home for him. Jimmy is still behind in school academically, but they feel that now that his behavioral problems are under control his academic performance in school will improve.

The major strategy of the program is to provide two components of treatment: 1) intensive therapy and 2) structured socialization with intensive supervision. To ensure the provision of both of these components, Program E entered into a partnership with the Boys and Girls Club, where the program is conducted. This arrangement allows the program to provide traditional group therapy, including strengthening social skills and self-esteem, cognitive behavioral therapy, behavioral reinforcement, supervised socialization and opportunities for improved social relationships within the club. During the six hours at the club after school, the children are given the opportunity to participate in a number of therapeutic activities that would not otherwise be covered by Medicaid (their primary funding source). Recreational therapy, computer centers, libraries, tutoring, and homework assistance are all treatment-enhancing resources provided for free by club staff.

 

"Beth" PROGRAM F (a specialized school in Los Angeles, serving children ages 5­21 with special education needs. It has been in operation for six years and serves 111 students.)

Beth entered Program F as a mid-ninth grader. Before entering the program, Beth had extensive absences from her home school and extensive incidences of violent behavior and destruction of property. Her first day in the program, in an attempt to get suspended, she spilled paint all over the school. Her assaulting and destructive behavior continued for the next six months. Beth was assigned a counselor, whom she could contact anytime. Also, she was placed in a special learning center for students who cannot be with their peers. This center was a non-traditional classroom setting in that there were no desks and no structured time frame for the curriculum.

In this setting, Beth was given individual goals and would earn points for achieving those goals. These goals could be academic, e.g., completing a chapter, behavioral, e.g., not cursing at the teacher, or social/interactive, e.g., sitting within three feet of another student all the while respecting their property and personal space. With each achievement, the scope of the goals increased. Academically, this setting was structured such that she would work on one subject for weeks at a time to prevent over- stimulation. As time passed and with each achievement, Beth began to master additional subjects.

Beth also was given the opportunity to engage with younger, handicapped students to gain insight into how those less fortunate or with greater obstacles to overcome could behave positively and be successful. Also, she was given the opportunity to engage in more physical outdoor activities than she would have at a more traditional school. Eventually, Beth was given the opportunity to leave the school environs and enter the community at large. By the time she graduated, Beth was in a more typical learning environment and demonstrating improvement; she had bonded with the staff and her counselor, her attendance had improved, and she became a leader on the student council. After graduation, Beth went on to attend junior college.

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For more information,
see Enhancing Youth Services by the Lewin Group
for the National Association of Psychiatric Health Systems
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