Therapeutic residential care: A necessary option for foster youth with greater needs

The tide of opinion in the U.S. child welfare arena has been turning against institutional settings for foster youth for some time. A spate of reports of child abuse and improper disciplinary techniques in residential facilities for young people has intensified calls for the elimination of residential care as an option for foster youth. But as all who are intimately involved in the child welfare world know, therapeutic residential care is a critical part of the continuum of services that must be available for foster youth.

Media investigations have targeted abusive behavior by staff at poor-quality residential facilities around the country, with a spotlight on a for-profit company called Sequel. Concern and outrage reached a fever pitch when a 16-year-old boy died at a Sequel home in Michigan after being restrained for 12 minutes. The Imprint and the Texas Observer co-published a harrowing account of Residential Treatment Centers (RTC’s) in Texas, documenting horrific instances of abuse at multiple centers around the state.

Unfortunately, some commentators, like the author of the report on Texas RTC’s, are using reports of abuse and violence to support ending all residential care rather than getting rid of bad providers. These critics of residential care miss two basic points. First, there are children who, for a variety of reasons, are not having their needs met in a family setting. These are the children who bounce from foster home to foster home, spend nights in agency offices or hotels, or even end up sleeping in cars with their caseworkers. Many have endured years of trauma, including physical and sexual abuse, severe neglect, and living in dangerous and chaotic conditions. Some have cognitive or neurological issues caused by drug exposure in utero or severe neglect. Some have violent outbursts, many are verbally aggressive, and many have difficulty in making attachments. These children need treatment delivered in a residential setting before they can function safely and thrive in a family setting.

Perhaps some of these youths could heal and thrive in a home with professional therapeutic foster parents, an option which is gaining increasing popularity. These foster parents are highly-trained and paid to take care of children with complex needs full-time. This is an option that deserves more attention but its growth is probably limited by both the lack of willing and qualified candidates and the expense.

Residential care abolitionists also miss the importance of quality. Residential programs can range from outright abusive to very high quality and highly successful in achieving positive outcomes for their clients. In an op-ed in The Imprint, Dana Dorn and Kari Sisson of the Association of Children’s Residential Centers explain that “High-quality residential interventions have the ability to change lives for the better and are a critical part of the continuum of behavioral health services. They have well-trained and supported staff who provide individualized, trauma-informed, youth-guided, family-driven care in environments that are safe, welcoming and encourage healthy relationships.” The authors stress that providers who are incompetent or “prioritize profits” over people should not be allowed to stay in business.

Opponents of residential care often use faulty reasoning to make their point. They often state that children who attend residential care have worse outcomes than those in family care without explaining that it is the most traumatized, troubled kids with complex histories who are placed in residential facilities. Those children would be expected to have worse outcomes than their peers because they have often had the worst past experiences by the time they finally have access to treatment.

The State of Washington provides a cautionary tale of what can happen when residential care in a state almost disappears. Budget pressures stemming from the 2008 recession dovetailed with the growing sentiment against residential options, as described in an excellent article in The Imprint by Elizabeth Amon. Between 2009 and 2019, over 200 residential beds in 13 locations disappeared. Unfortunately, the state lacks enough appropriate placements for youth with psychiatric, behavioral and developmental needs. These young people end up staying overnight in offices, emergency one-night foster homes, hotels, and cars–or sent to out-of-state facilities including some operated by Sequel. Not only are these arrangements anti-therapeutic, but they are extremely expensive, as Amon points out.

In Texas, where the Imprint focused on the poor quality of many RTC’s, child welfare administrators are worried about the declining number of residential centers. Every year, at least one RTC stops contracting with the state due to inadequate reimbursement, which means they cannot pay workers enough to retain them. As a result, the number of Texas foster children sleeping in offices and hotels spiked last year, according to an article in the Austin American-Statesman. These were mainly teenagers with trauma histories and/or significant behavioral and mental health issues, according to a state official.

In New Mexico, the Department of Children, Youth and Families (CYFD) contracts with ten residential treatment centers in the state, but that is not enough to care for all the foster youth who need therapeutic residential care, as the Secretary told the Santa Fe New Mexican. As a result New Mexico still sends children to out-of-state facilities. The Secretary has requested more funding for additional therapeutic residential care resources.

In Maryland, the Baltimore Sun and WYPR reported last February that dozens of children were spending weeks or even months in psychiatric units of hospitals without a medical reason because social workers had nowhere else to place them. Often these children were placed in psychiatric units after experiencing a crisis in a foster home. Most of these children are not ready to move to a foster home upon discharge and need a higher level of supervision and therapeutic care. But there are waitlists for the roughly 350 spots at Maryland residential treatment facilities, and for out-of-state facilities as well. These long hospital stays are destructive and traumatic to the children as well as extremely expensive.

Last January, I wrote about similar problems in Oregon, New York, California, and Illinois. Residential critics miss the point. If states don’t have quality residential facilities, or any residential facilities at all, they will send their kids to facilities run by operators like Sequel, put them up in offices, hotels, temporary placements or cars, or leave them in hospitals. That’s why only three out of 40 states and territories sending children to Sequel facilities have severed ties with the company, despite its awful track record.

Those who oppose all residential care for foster youths are blind to the challenging problems of some foster youth, the life-changing potential of quality therapeutic residential care and the vast differences between high and low-quality residential facilities. We need to make sure quality residential services are well funded and regulated to keep children out of offices, hotel rooms, abusive or out-of-state facilities, and hospitals. Legislators at all levels of government must recognize the need for adequate funding of this crucial service necessary to heal the wounds of our most fragile foster youth.