Designing and Testing a Developmentally Appropriate Intervention for Children in a Psychiatric Residential Treatment Facility.

Preadolescent children in residential care have treatment needs that are different from adolescents. An intervention was created using developmental theory to inform decisions about the timing, objectives, strategies, and context best suited to preadolescents in an intensive residential treatment center. Aggressive behavior, seclusions, and restraints data for preadolescents during a 32-month period was used in the analysis. There was a significant decrease in aggressive behavior, seclusions, and restraints for preadolescents during the periods when the developmentally appropriate intervention was used versus the times when they received same intervention as the adolescents.

Polypharmacy in the Management of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: A Review and Update.

Objective: Prescription of multiple medications concurrently for children and adolescents has increased in recent years. Examination of this practice has been undervalued relative to its incidence. This article reviews studies investigating effectiveness of medication combinations for youth with attention-deficit/hyperactivity disorder (ADHD). Methods: A literature search identified studies that combined two or more prescribed medications for the treatment of ADHD. Included studies focused on youth; had study design of randomized controlled trial (RCT), nonrandomized trial, or case review (n > 10); and included an outcome measure of treatment effectiveness. Results: Thirty-nine pertinent studies were identified. All studies combined two medications, with the vast majority including a stimulant (n = 37). The largest group (n = 16) combined stimulant and alpha-agonist, finding greater efficacy than alpha-agonist alone but not stimulant alone in all cases. A few RCTs found benefit from the addition of risperidone or divalproex to stimulant for comorbid aggression. Four studies adding atomoxetine found mixed reports of benefit, including the only small RCT showing no benefit. RCTs with selective serotonin reuptake inhibitors found minimal evidence of benefit for mood or anxiety comorbidities. Conclusion: The best studied combination is stimulant and alpha-agonist; addition of alpha-agonist to stimulant seems effective for residual symptoms of ADHD. Stimulant plus risperidone has the most evidence of efficacy for comorbid aggression or disruptive behavior. Limited support exists for the effectiveness of other medication combinations, including no trials studying three or more medications concurrently. Combinations frequently yielded more side effects, leaving monotherapy preferable if a sufficient treatment response can be achieved.

Positive and Negative Peer Influence in Residential Care.

The potential for negative peer influence has been well established in research, and there is a growing interest in how positive peer influence also impacts youth. No research, however, has concurrently examined positive and negative peer influence in the context of residential care. Clinical records for 886 residential care youth were used in a Hierarchical Linear Model analysis to examine the impact of negative and positive peer influence on naturally occurring patterns of serious problem behavior over time. Negative peer influence, where the majority of youth in a home manifested above the average number of serious behavior problems, occurred 13.7% of the time. Positive peer influence, where the majority of youth manifested no serious problem behaviors for the month, occurred 47.7% of the time. Overall, youth problem behavior improved over time. There were significantly lower rates of serious problem behavior in target youth during positive peer influence months. Conversely, there were significantly higher rates of serious problem behaviors in target youth during negative peer influence months. Negative peer influence had a relatively greater impact on target peers' serious behavior problems than did positive peer influence. Caregiver experience significantly reduced the impact of negative peer influence, but did not significantly augment positive peer influence. Months where negative peer influence was combined with inexperienced caregivers produced the highest rates of serious problem behavior. Our results support the view that residential programs for troubled youth need to create circumstances that promote positive and control for negative peer influence.

The impact of abuse and gender on psychopathology, behavioral disturbance, and psychotropic medication count for youth in residential treatment.

This study examined the relationship between gender, abuse history, and clinical change in a residential treatment program for youth with emotional and behavioral disturbance. Admission data and data collected after 1 year of treatment or at discharge were examined for 1,303 youth. Measures included the Suicide Probability Scale, Child Behavior Checklist, and the Diagnostic Interview Schedule for Children. Data also included medication count, demographic data, and history of sexual or physical abuse or both. At intake, girls scored significantly more pathologically than boys on 9 out of 12 measures. At intake, abused youth indicated more hostility, anxiety, and mood disorder symptoms as well as psychotropic medication usage than nonabused youth. Youth improved significantly on all outcome measures with treatment, although interaction effects indicate some differing treatment responses by abuse history or gender. After treatment, girls still scored significantly higher than boys on 6 of 8 outcome measures, and abused youth, especially youth experiencing both sexual and physical abuse, had significantly higher anxiety, affective, behavior, and eating disorder symptom counts and were on more psychotropic medications than nonabused youth. Although behaviorally focused treatment was associated with improvement on every measure, the most important implication of our study is that a singular treatment approach does not fit all youth completely as reflected by continuing treatment needs in our most troubled youth. Additional symptom-focused treatment and research attention must be given to girls and abused youth in residential care to maximize their therapeutic outcomes.

12-month follow-up outcomes for youth departing and integrated residential continuum of care.

This study examined the 12-month post-departure outcomes for youth who exited a residential treatment program at differing levels of restrictiveness. Study participants were 120 youth who entered an integrated residential continuum of care at its most restrictive level and then either departed the program at the same level or stepped down and departed at a lower level of restrictiveness. Results indicate that youth who stepped down and exited at the lowest level of restrictiveness were the most likely to be living at home or in a homelike setting and experienced fewer formal post-departure out-of-home placements. However, there were no differences in post-departure rates of substance use, arrests, or being in school or having graduated. These results suggest that youth who were served in the integrated continuum and departed at the lowest level of restrictiveness had more positive outcomes at 12-month post-discharge.

Psychotropic medication management in a residential group care program.

This article presents a psychotropic medication management approach that is used within a residential care program. The approach is used to assess medications at youths' times of entry and to facilitate decision making during care. Data from a typical case study have indicated that by making medication management decisions slowly, systematically, and based on behavioral data, it is possible to make changes to psychotropic treatment that have a positive effect on youth behavior and psychological well-being.

Patterns of movement for youth within an integrated continuum of residential services.

This study examined patterns of movement for youth receiving services within a continuum of intensive and restrictive residentially-based programs. Data were collected for 701 completed episodes of care within a three-program residential continuum of care over a 5 year period, and examined time within program, movement between programs, in-program disruptive behavior, and discharge status. Results showed that most youth either remained in a stable placement in the least restrictive of the programs, or followed a pattern of placements that systematically moved them from more restrictive to less restrictive settings. Of note, transitions from more restrictive to less restrictive programs correspond to deescalating levels of problem behavior; and over 80% of the youth were stepped down to either family-based or independent living situations at the time of departure. Findings support the notion that a continuum of intensive residential services can serve the needs of youth with significant emotional and behavioral needs.

Breaking the cycle of intergenerational abuse: the long-term impact of a residential care program.

OBJECTIVE: The number of youth in residential care programs who have been abused is high. The relationship between childhood abuse victimization and adult intimate partner violence (IPV) is well documented. This study compared the rates of IPV 16 years after individuals had participated in a long-term residential care program with individuals accepted to the program who did not participate. The IPV rates for these two groups were also compared to national normative data. METHOD: Information on adult functional outcomes was obtained from former residential care and comparison youth via a confidential survey that was administered either by telephone or by mail. Analysis was limited to respondents who were currently married or involved in a marriage-like relationship (n=131; 92% male). RESULTS: The IPV rates for the sample were 9.3% for those who stayed in the residential program less than 18 months and 6.5% for those who stayed more than 18 months, neither of which were significantly different from the national norm of 8.4%. The IPV rate for the comparison group was 26.1%, which was significantly higher than the national norm. Regardless of length of program stay, respondents who were maltreated in childhood had a 14.5% IPV rate, which was significantly lower than the estimated 36-42% rate projected for individuals with similar backgrounds. CONCLUSION: We conclude that time spent in a treatment-oriented residential care program was associated with lower adult IPV rates. Specifically, the skills taught in a long-term, treatment-based residential program (e.g., healthy interpersonal relationships, self-government) may have a long-term beneficial impact for adolescents at high risk of adult IPV.

Hope as an outcome variable among youths in a residential care setting.

This study investigated changes in hope among 155 youths (ages 10 to 17 years) placed in a residential treatment facility over a 6-month period. The child and adolescent participants met criteria for a range of emotional and behavioral disorders and received interventions hypothesized to improve hopeful thinking. Hope scores significantly improved over 6 months of treatment. The positive changes in hope were not moderated by ethnicity or sex. For Agency hope scores (i.e., willpower), those with higher levels of psychopathology at admission demonstrated significantly more improvement in agency thinking over the course of 6 months.

Gender differences in adolescents in residential treatment.

Gender differences for adolescents in residential care were examined for a sample of 2,067 youths in a large residential facility. At admission, female youths were more troubled than male youths, as shown in significantly higher Diagnostic Interview Schedule for Children (DISC) diagnoses and comorbidity rates, higher internalizing and externalizing Child Behavior Checklist scores, and significantly higher Suicide Prevention Scale hopelessness, negative self-evaluation, and suicide ideation scores. Girls had higher rates of depressive and anxiety diagnoses on the DISC at both admission and 1 year. Both genders demonstrated significant reductions in both externalizing and internalizing problem behaviors over the first year in the program. Girls had significantly higher rates of internalizing problem behavior but showed a significantly greater reduction in these behaviors than did boys. At departure, girls were rated as being more successful than boys by clinical staff. Youths did not differ by gender in their behavior on a 6-month follow-up success scale. Implications for prioritizing research addressing the needs of female adolescents in residential care are discussed.