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JTSP • 29
A Multi-Center Study of Private
Residential Treatment Outcomes
Ellen Behrens, Ph.D.
Canyon Research & Consulting
Kristin Sattereld, M.D., Ph.D.
University of Utah
Correspondence should be addressed to Dr. Ellen Behrens, E-mail:
Ellen@canyonresearchandconsulting.com
Abstract
This paper presents the results from a multi-center study on
outcomes for youth treated in private residential treatment programs.
The sample of 1,027 adolescents and their parents was drawn from nine
private residential programs. Hierarchical linear modeling indicated
that both adolescents and parents reported a signicant reduction in
problems on each global measure of psycho-social functioning from the
time of admission up until a year after leaving the program (e.g., Total
Problems Scores, Internalizing Scales, and Externalizing Scales of the Child
Behavior CheckList, CBCL, and Youth Self-Report, YSR). Furthermore,
youth and parents reported that the youth improved on all syndromes
between the point of admission and discharge (YSR and CBCL syndrome
scales: Anxious/Depressed, Withdrawn/Depressed, Somatic Complaints,
Thought Problems, Attention Problems, Aggressive Behavior, Rule-
Breaking) and that most of the syndromes remained stable and within the
normal range for up to one year after discharge from treatment.
PRIVATE RESIDENTIAL TREATMENT OUTCOMES
30 • JTSP
A Multi-Center Study of Private Residential
Treatment Outcomes
Since the early 1990’s hundreds of private residential programs have
been established in the United States. Outcomes of youth treated in
these programs are largely unknown (Friedman, Pinto, Behar, Bush,
Chirolla, Epstein … & Young, 2006). Previous research has focused
almost entirely on public residential treatment programs (RTPs) (Curry,
2004; Curtis, Alexander, & Longhofer, 2001; Hair, 2005; Leichtman,
Leichtman, Barbet, & Nese, 2001; Lieberman, 2004; Whittaker, 2004). In
fact, there is virtually no published outcome research on private RTPs.
This paper attempts to build a research corpus expressly for private RTPs
using a large-scale, systematic exploration of treatment outcomes.
It can be argued that private RTPs and public RTPs are fundamentally
different. They developed independently and therefore have different
histories, professional associations, client services, and client populations.
Public RTPs originated in the 1940s, with the work of Bruno Bettleheim,
Fritz Redl, and David Wineman (Cohler & Friedman, 2004). The primary
professional association representing public RTPs is the American
Association of Children’s Residential Centers (www.aacrc-dc.org), which
was founded in the 1950’s. Clients in public RTPs are typically referred
through public avenues (i.e., juvenile justice system, child protection
agencies, or public mental health systems) (Curtis, et. al., 2001; Epstein,
2004; Hair, 2005) and funded with public money. Public RTP clients are
predominantly males and disproportionately selected from ethic minority
backgrounds (Asarnow, Aoki, & Elson, 1996). A literature search of
the PsycInfo database produced dozens of research studies conducted
at public RTPs, enough to warrant a few literature reviews published
in referee journals (e.g., Curry, 1991, Epstein, 2004; Hair, 2005, Little,
Kohm, & Thompson, 2005).
In contrast, private RTPs were established in the late 1980’s and early
1990’s (Young & Gass, 2007) with the most rapid growth occurring after
2000 (Santa & Moss, 2006). Private RTPs were founded by a different
and loosely organized network of individuals including John Santa, John
Reddman, Kimball Delamare, and John Mercer (Santa & Moss, 2006). The
National Association of Therapeutic Schools and Programs (NATSAP),
founded in 1999, is the major association representing professionals
in private RTPs. Private RTPs are typically for-prot entities. Private
RTP services typically feature adventure activities, challenge courses,
art therapy, and equine programs (Young & Gass, 2007). Services are
most often funded by parents or, in some cases, by insurance companies
(Friedman et al., 2006; Young & Gass, 2007). The large number of co-
educational and female-only programs suggests that female youth are
well represented within private RTPs. Unlike public RTPS, private RTPS
are costly for families, ranging from $5,000 to $12,000 a month (Young
& Gass, 2007), which largely circumscribes the client base to families of
a high socio-economic status. In contrast to the large body of research
PRIVATE RESIDENTIAL TREATMENT OUTCOMES
JTSP • 31
on public RTPs, only one published outcome study has been conducted
at a private RTP , specically at The Menninger Residential Treatment
Program, an intensive, short-term program. The primary measures
for the study of 123 youth were the Child Behavior Checklist (CBCL)
(Achenbach, 2001) and the Youth Self-Report (YSR) (Achenbach, 2001).
The study found that parents and youth reported a signicant decline in
problems from admission to 3 months post-discharge with maintenance
of gains up to 12 months post-discharge (Leichtman et al., 2001).
The ndings of Leichtman and colleagues stand in contrast to the
large body of literature on public residential treatment. Though a critical
mass of studies have found that 60%-80% of adolescents improve during
stays in public RTPs (Curry, 1991; Curtis et al., 2001; Epstein, 2004;
Hair, 2005; Wells, 1991), many others have found that treatment gains
come slowly, are spotty, and leave quickly. For instance, The National
Adolescent and Child Treatment Study found that youth treated for
“serious emotional disturbance” in public RTPs took three years to
move from clinical to normal range of functioning (Greenbaum, Dedrick,
Friedman, Kutash, Brown, Lardieri, & Pugh, 1996). In addition, based on
published outcomes, reviewers have concluded that residential treatment
is most appropriate for higher functioning, less vulnerable youth (Connor,
Miller, Cunningham, & Melloni, 2002; Epstein, 2004; Gorske, Srebalus,
Walls, 2003; Wells, 1991). Numerous other reviews of public RTPs
conclude there is “no evidence” of lasting benets for youth who received
treatment: a signicant portion of adolescents who function well at
discharge subsequently experience a decline when transferred to a lower
level-of-care (Curry, 1991; Epstein, 2004; Hair, 2005; Little, Kohm, &
Thompson, 2005). The U.S. Department of Health and Human Services
(1999) concluded after a review of the research conducted in public RTPs,
“Given the limitations of current research, it is premature to endorse the
effectiveness of residential treatment for adolescents.” In part because
of this pronouncement, public policy shifted from RTP placements to
community-based services. Bennett Leventhal and D. Patrick Zimmerman
(2004), guest editors for a special issue of the Child and Adolescent
Psychiatric Clinics of North America on (public) residential treatment, open
the issue by stating,
…the role of residential treatment seems to have little or no
place in the continuum of care for children with mental disorders.
Facilities for the intensive, long-term treatment of children and
adolescents with serious and persistent psychiatric illness seem to
have disappeared or quietly slipped in the shadows of available
services. The public sector has seen dramatic downsizing or closures
of most long- and short-term inpatient psychiatric treatment centers
for children and adolescents. (p.7)
The poor outcomes reported for public RTPs are based on a
research corpus that has been sharply criticized for methodological
PRIVATE RESIDENTIAL TREATMENT OUTCOMES
32 • JTSP
PRIVATE RESIDENTIAL TREATMENT OUTCOMES
aws. Reviewers have criticized this body of work for its poor samples,
retrospective designs, unstandardized measures, and unsophisticated
statistical analyses (Curry, 1991; Curtis et al., 2001; Epstein, 2004, Hair,
2005). The majority of studies used only one informant, even though
multiple informants have been shown to be necessary (Rend, 2005),
and many studies use self-styled measures that lacked normative data
and psychometric rigor (Hair, 2005). Sample sizes for studies of public
RTPs also tend to be very small. Additionally, relatively few studies
used advanced statistics to control for error or explore the impact of
moderator and predictor variables.
Method
The present study was designed to systematically explore youth
outcomes in private RTPs and to simultaneously address some of the
aws noted in the public RTP research corpus. The study used a multi-
center design, with repeated standardized measures, prospective data,
a large sample, and two informant groups. The Western Institutional
Review Board (www.wirb.org) approved consent/assent forms and issued
Certicates of Approval for the study. The research questions were:
1) What are the characteristics of adolescents treated in the private
RTPs?
2) How do adolescents function during and after treatment in private
RTPs?
2a) How does adolescent functioning vary across the selected
treatment outcomes (e.g., total problems, internalizing problems,
externalizing problems, aggressive behavior, anxious/depressed
symptoms, withdrawn/depressed symptoms, somatic complaints,
social problems, thought problems, attention problems, aggressive
behavior, and rule-breaking behavior)?
2b) Do youth outcomes vary according to age, gender, or number of
presenting problems?
Participants
The sample consisted of 1,027 adolescents who, along with their
parents or guardians (hereafter referred to as “parents”), agreed to
participate in the study and who completed measures at admission,
discharge, and 6- and 12-months after discharge from the program
(regardless of discharge status). Students were admitted to one of nine
programs located in the Eastern and Western United States, between
August 2003 and August 2005. Demographic information (i.e., ethnicity,
parental income, gender, age) provided by the residential programs
indicated the sample was representative of students enrolled in the
programs during the same time period.
Description of the residential programs
The nine participating programs were private, out-of-home, licensed
(when applicable), therapeutic placements for adolescents and were
JTSP • 33
member programs of the National Association of Therapeutic Schools
and Programs (NATSAP). The RTPs were Academy at Swift River, Aspen
Ranch, Copper Canyon Academy, Mount Bachelor Academy, Stone
Mountain School, Pine Ridge Academy, SunHawk Academy, Turnabout
Ranch, and Youth Care (www.aspeneducation.com). The contribution
of each of the residential programs to the sample was relatively equal,
ranging from 9% to 16%. This sample consisted of a mean of 55% of
adolescents admitted to the residential programs during the identied
time period. Though the participating programs were owned by one
parent company, Aspen Education Group, curriculum and programming
were developed “on-site.” This individual development resulted in
signicant diversity of curriculum and programming. The participating
programs varied in terms of size (ranging from 15-bed programs to
120-bed programs), location (Massachusetts, Utah, Arizona, Oregon,
North Carolina), treatment philosophy (therapeutic boarding school
or residential treatment, the latter of which is more clinically focused
and designed for more severely impaired adolescents), and services
(e.g., equine assisted therapy, neurofeedback, adventure therapy, partial
community placements). The diversity of the participating programs is
reective of the broader private residential treatment industry.
Design and measures
Since no control or comparison group was available, a single-group,
pretest-posttest design was used. The primary measures were the
Child Behavior Check List (CBCL) and the Youth Self Report (YSR)
(Achenbach, 2001). The CBCL and YSR are two related and widely used
measures of adaptive and maladaptive psychological and social functioning.
The CBCL and YSR syndrome scores, Internalizing and Externalizing
Scores, and Total Problem Score have excellent reliability (alpha values
range from .78 to .97 for the CBCL scales and from .71 to .95 for the
YSR scales) and validity (e.g., Achenbach, 2001; Bérubé & Achenbach,
2006). The CBCL is a parent-report measure of adolescent functioning
that consists of 113 items. The YSR is a youth self-report measure that
consists of 112 items. The measures have the same item format and
scales, which makes them highly compatible. Items are rated on a three-
point scale and are primarily objective or behaviorally anchored (e.g.,
“cries a lot”, “gets teased”, “dgets”, “truant”). The CBCL and YSR yield
11 scales:
Eight (8) Syndrome scales: Anxious/Depressed, Withdrawn/
Depressed, Somatic Complaints, Thought Problems, Attention
Problems, Rule-Breaking Behavior, Aggressive Behavior,
Three (3) Aggregate or broad-band, scales: Internalizing
(problems that are mainly within the self), Externalizing (problems
that mainly involve conict with other people and their expectations
for the child), and Total Problems (the sum and severity of all the
problems reported on the measure).
PRIVATE RESIDENTIAL TREATMENT OUTCOMES
34 • JTSP
PRIVATE RESIDENTIAL TREATMENT OUTCOMES
High scores on a scale indicate clinical deviations from the norm and
the presence of numerous and severe problems. Each raw-scale score
can be converted into a T-score, percentile rank, and range (Normal,
Borderline Clinical, and Clinical). This study used raw scores for statistical
analysis, as recommended in the CBCL and YSR manual, because T scores
are truncated (Achenbach, 2001). The corresponding range for each
syndrome’s mean raw score was reported for informational purposes, to
provide a benchmark relative to the normative data.
Background questionnaires were completed by both parents and
adolescents at admission and discharge, and then again at the six and
12 month marks after discharge. The questionnaires evaluated psycho-
social history (e.g., psychotropic medication use, legal problems, grade
point average, matriculation in school, presenting problems and program
evaluation) and satisfaction with the RTP. Residential program staff
completed a brief form for each participating adolescent that indicated
discharge status and problems that had been the focus of treatment.
Results
Characteristics of the sample
The mean age for all participants was 16 (SD = 1.2) with 55%
being male. Most participants were Caucasian (87%), with small
percentages of other ethnic groups. The median annual family income
was >$100,000. Almost all (97%) of the adolescents were placed in
treatment by their parents. The overwhelming majority of youth had
previous treatment at other levels of care (94%). Specically, 80% had
received outpatient treatment in the prior year, 70% had recently been
prescribed psychotropic medications, and 31% had at least one psychiatric
hospitalization. Only 22% of the youth had a legal record. The mean grade
point average for participants was 2.0 on a 4.0 scale (D).
At the admission mark, “Total Problems” raw scores were 74 on the
CBCL and 63 on the YSR, placing youth problems at the 97th percentile
according to parents and the 91st percentile according to youth. This
nding is salient: when treatment began, the adults and adolescents
indicated that the adolescents were functioning worse than more than
90% of the adolescent population.
While in the residential program, the majority of adolescents were
treated for multiple problems (82%). The most common treatment foci
within the sample were disruptive behavior disorders (50%), substance
use disorders (40%), and mood disorders (34%). The average length
of stay was 10.5 months for those discharged with maximum benet
and seven months for those who were discharged with partial benet
or against program advice. The majority of the sample discharged with
staff approval: 54% of students were discharged with maximum benet,
JTSP • 35
19.8% discharged early but with approval, 17.3% discharged against
program advice, and 8.2% were transferred to a different program. At
the discharge mark, mean parental and youth satisfaction with treatment
was 4.4 and 4.3, respectively, on a scale ranging from one (poor) to ve
(excellent).
Change in functioning during and after treatment
Table 1 contains the mean raw scores and ranges of functioning on the
CBCL and YSR scales. Both adolescents and parents reported a dramatic
decline in youth problems from admission to discharge, on all scales of the
YSR and CBCL. Furthermore, scores changed from either the clinical or
borderline clinical range at the admission mark to the normal range at the
discharge mark and for up to one year after that, on all of the aggregate
scales of the CBCL and YSR. For example, as shown in Figure 1, parent
report of total problems decreased from the 97th percentile (Raw Score
73.82, Clinical Range) at admission to the 72nd percentile (Raw Score
31.14, Normal Range) one year after treatment. The complementary data
from adolescents was similar: youth-reported total problems decreased
from the 91st percentile (Raw Score 63.5, Clinical Range) at admission
to the 60th percentile (Raw Score 38.5, Normal Range) one year after
treatment.
Table 1
Raw Score Scale Means and Range of Functioning
Admission Discharge 6-Months
Post 12-
Months
Post
Aggregate Scales
Internalizing CBCL 19.09, CL 7.96, N 7.88, N 7.99, N
YSR 18.15, B 10.41, N 10.37, N 10.49, N
Externalizing CBCL 28 .19, CL 8.34, N 11.13, N 11.12, N
YSR 24.52, CL 12.52, N 14.23, N 15.06, N
Total Problems CBCL 73.82, CL 27.81, N 30.94, N 31.14, N
YSR 63.50, CL 36.37, N 38.49, N 38.35, N
Syndrome Scales
Anxious/Depressed CBCL 8.49, N 4.00, N 3.52, N 3.42, N
YSR 7.97, N 4.84, N 4.61, N 4.87, N
Withdr awn/Depressed CBCL 6.95, N 2.63, N 2.91, N 2.91, N
YSR 5.36, N 2.87, N 3.15, N 2.87, N
Somatic Complaints CBCL 3.64, N 1.34, N 1.45, N 1.66, N
YSR 4.81, N 2.70, N 2.62 , N 2.75, N
Notes. CL = Clinical Range of Func tioning, spans the 98th to 100 th percent ile, B = Borderline Clinic al
Range of Functioning, spans the 95th to 97th percentile, N = Normal Range of Functioni ng, below the
95th percent ile. CBCL ns = 252- 650, YS R ns = 139-773. ( Table 1 Cont inued on page 34)
PRIVATE RESIDENTIAL TREATMENT OUTCOMES
36 • JTSP
PRIVATE RESIDENTIAL TREATMENT OUTCOMES
Private Residential Outcomes, p. 23
Figure 1.
CBCL and YSR Mean Raw Total Scores Over Time
Table 1
Raw Score Scale Means and Range of Functioning
Admission Discharge 6-Months
Post 12-
Months
Post
Syndrome Scales
Social Problems
CBCL 5.25, B 2.14, N 2.00, N 2.06, N
YSR 5.30, N 3.43, N 3.39, N 3.31, N
Thought Problems
CBCL 5.53, B 2.21, N 2.05, N 2.10, N
YSR 6.81, N 4.25, N 4.37, N 4.41, N
Attention Problems
CBCL 10.10, B 4.73, N 5.24, N 5.27, N
YSR 8.72, N 5.76, N 6.12, N 5.09, N
Rule Breaking Behavior
CBCL 13.80, CL 3.93, N 5.24, N 5.27, N
YSR 13.07, CL 5.77, N 7.26, N 7.63, N
Aggressive Behaviors
CBCL 14.39, B 4.41, N 5.33, N 5.31, N
YSR 11.45, N 6.75, N 6.98, N 7.43, N
Notes. CL = Clinical Range of Func tioning, spans the 98th to 100 th percent ile, B = Borderline Clinic al
Range of Functioning, spans the 95th to 97th percentile, N = Normal Range of Functioni ng, below the
95th percent ile. CBCL ns = 252- 650, YS R ns = 139-773.
(Continued from p age 34)
JTSP • 37
Paired samples t-tests were used to examine change in YSR and
CBCL aggregate and syndrome scale scores from the admission mark to
the discharge mark.. All scales of the YSR and CBCL showed signicant
in-treatment changes (Table 2). As shown in Table 1, all syndrome raw
score scales reduced to the normal range by discharge or, in the case of
those scales that were already in the normal range at admission, reduced
to levels further within the normal range at discharge.
One year after the discharge mark parents reported on some other
important indicators of outcomes. Eighty-nine (89%) percent of the youth
remained at home and had not been placed in any type of out-of-home
care (i.e., residential treatment, boarding school, short-term psychiatric
hospitalization). Eighty-six percent of parents reported their child was
“somewhat better” or “much better” in response to the question,
“Currently, how would you describe your child’s problems in comparison
to when s/he entered the program?”
Note. ** = p<.001. CBCL ns = 215, YSR ns = 420
PRIVATE RESIDENTIAL TREATMENT OUTCOMES
Table 2
T-tests for Syndrome Scale Scores at Admission and Discharge
Measure t test value
Aggregate Scales
Internalizing CBCL 21.19**
YSR 12.75**
Externalizing CBCL 17.65**
YS R 13.12* *
Total Problems CBCL 25.22**
Y S R 17.9 8 * *
Syndrome Scales
Anxious/Depressed CBCL 14.37**
YSR 11.15**
Withdrawn/Depressed CBCL 11.47**
YS R 14 .71**
Somatic Complaints CBCL 9.60 **
Y S R 11. 3 9 * *
Social Problems CBCL 13.94**
SR 10.41**
Thought Problems CBCL 11.81**
YSR 10.45**
Attention Problems CBCL 18.09**
YS R 14. 31* *
Rule Breaking Behavior CBCL 22.82**
Y S R 12.17 * *
Aggressive Behaviors CBCL 21.10**
YS R 13. 56**
38 • JTSP
Hierarchical linear modeling was used to evaluate changes in global
functioning over time (admission through 12 months after discharge)
and to explore if functioning was related to gender, age, or number of
presenting problems. Hierarchical linear modeling is ideal when, as with
this study, the goal is to model change over time but there are unequal
time intervals and missing data (Hedeker & Gibbons, 1997), and when
the goal is to determine if outcomes vary for different groups within the
sample. Two-level, growth curve models were conducted using HLM6
(Raudenbush, Bryk, & Cheong, & Congdon, 2004) (Table 3). Growth
models were estimated separately for Internalizing, Externalizing, and
Total Problems scales using raw scores for the CBCL and YSR. Predictor
variables were age, gender and number of presenting problems. Models
were run separately for each predictor to maximize the available data.
Because the major focus for the study was the trajectory of outcomes
over time, attention was primarily on the linear and quadratic trend
components rather than the intercepts. The linear trend isolated
outcomes at admission and discharge. The quadratic trends isolated
outcomes during the year after discharge. Table 3 displays chi-square
tests that showed signicant variability among subjects in their intercepts,
linear slopes, and quadratic trends, (p < .05). Attempts to account for
the reliable variance in linear and quadratic components with the youths’
age, gender, or number of presenting problems were unsuccessful. Taken
together, the HLM models indicated that youths’ problems improved
signicantly from admission to 12 months after discharge and that these
trends did not differ based on gender, age, or number of problems.
Table 3
Growth Model Mean Scores for Internalizing, Externalizing, and Total Problems of
the CBCL and YSR
Intercept Linear Slope Quadratic Component
Internalizing CBCL 7.21* -1.96* 1.66*
YSR 8.29* -1.55* 1.51*
Externalizing CBCL 7.74* -2.87* 3.23*
YSR 10.44* -1.51* 2.52*
Total Problems CBCL 25.29* -7.45* 7.30*
YSR 30.46* -4.72* 5.33*
Note. * = p<.05
PRIVATE RESIDENTIAL TREATMENT OUTCOMES
JTSP • 39
Repeated-Measures ANOVAs were computed for all syndrome scales
of the YSR and CBCL, using Greenhouse-Geisser corrections, to test
whether changes made during treatment were maintained after leaving
the program, on each syndrome (Table 4). The within-subjects variable
was time, which was measured by comparing scale scores obtained at
the discharge mark to those obtained at six months and 12 months after
discharge from the program. The hypothesis was that there would not
be signicant change over time, rather that gains made during treatment
would be maintained. As seen in Table 4, time was not signicant for
most of the syndrome scales.
Table 4
Repeated Measures Analysis of Variance with Time as a Within Subject Variable
Syndrome Scales MS df F p Partial eta sq
Anxious/Depressed
CBCL 3.50 1.94, 317.30 .69 .50 .004
YSR 4.70 1.85, 168.52 .50 .59 .005
Withdrawn/Depressed
CBCL 9.13 1.93, 314.75 2.58 .08 .016
YSR 6. 58 1.88, 173.33 1.79 .17 .019
Somatic Complaints
CBCL 1.30 1.97, 321.76 .75 .47 .0 05
YSR .78 1.95, 179.19 .23 .79 .002
Social Problems
CBCL 3.43 1.87, 305.12 1.22 .29 .007
YSR 2.72 1.77, 163.03 .57 .55 .006
Thought Problems
CBCL 1.59 1.93, 315.36 .60 .54 .004
YSR .78 1.82, 170.36 .08 .91 .001
Attention Problems
CBCL 55.23 1.92, 313.61 7.76 .001 .045
YSR 29.79 1.88, 72.92 5.19 .008 .053
Rule Breaking Behavior
CBCL 349.04 1.96, 319. 41 27.02 .000 .140
YSR 184.10 1.79, 164.88 15.42 .000 .144
Aggressive Behaviors
CBCL 135.24 1.90, 309.73 10.58 .00 .060
YSR 60.17 1.94, 178.41 4.49 .01 .046
These ndings indicate that neither the youth nor their parents thought
that the youth had changed signicantly during the year after discharge from
the treatment program in terms of anxiety, withdrawal, somatic complaints,
social problems, and thought problems. However, both parents and youth
reported that the youth had changed (worsened) signicantly in the year
after discharge in terms of rule breaking, aggression, and attention. Note
that the effect sizes, measured with partial eta square values, were very
small for each of these scales, which indicates that there was only a small
proportion of total variability. Thus, though statistically signicant, the
PRIVATE RESIDENTIAL TREATMENT OUTCOMES
40 • JTSP
increase in rule-breaking, aggressive behaviors, and attention problems
during the year after discharge was very small. Raw mean scores (Table
1) for the syndrome scales indicate that after discharge, parents and youth
reported only a one-to-two point increase in those problems (on scales
that have a ceiling of 30-34 points) and that the scores remained well
within the normal range.
Discussion
This study represents the rst large-scale attempt at a systematic
exploration of long-term treatment outcomes in private residential
treatment. The 1,027 adolescents who participated in the study were
sampled from nine private RTPs that varied widely in their approach and
services. The variety among these private RTPs was intended to reect
private residential treatment in general. The typical client in these private
RTPs was a white, upper middle- to upper class, 16-year-old male or
female with prior treatment failures who was functioning below average
academically and had multiple psycho-social problems. The most common
youth problems were disruptive behavior, substance use, and mood
disorders.
This present sample was fundamentally different from the samples
reported in public residential treatment studies (Curtis et al., 2001;
Epstein, 2004; Hair, 2005). Public residential treatment clients are
primarily males, disproportionately selected from ethic minority
backgrounds, and referred by public authorities. In this private RTP
sample clients were equally likely to be male or female, unlikely to be
from ethnic minority backgrounds, and were placed in treatment by their
parents. These demographic data lend credence to the claim that private
and public residential treatment programs have distinct services and
populations.
Adolescents in this study had serious psychological and social
problems. At admission, both adolescents and parents reported that
the adolescents’ problems were worse than adolescents in the normal
population (97.5% and 91%, respectively). Additional study variables point
to high levels of distress among the adolescents in the sample such as
an extensive treatment history (94% had prior treatment at least one
level-of-care), a high rate of multiple problems (82%), and a 10.5 month
average length-of-stay for those discharged with maximum benet.
Both adolescents and parents reported a signicant decline in
problems during treatment, on every measured outcome of global
psycho-social functioning (CBCL and YSR Total Problems, Internalizing,
and Externalizing Scales), as well as at the syndrome level (YSR and
CBCL syndrome scales). Perhaps the most meaningful nding was
that functioning changed from the clinical or borderline clinical range
at the admission mark to the normal range at the discharge mark and
remained in the normal range during the year after discharge, on all of
the aggregate scales of the CBCL and YSR (Internalizing, Externalizing,
PRIVATE RESIDENTIAL TREATMENT OUTCOMES
JTSP • 41
and Total Problems Score). In the year after discharge, adolescents also
maintained gains on syndrome scales, with relatively minor recurrence
of problems with rule breaking, aggression, and attention. These long-
term positive outcomes stand in contrast to the outcomes reported for
public residential treatment program about which numerous reviewers
have concluded that there is no evidence of lasting benet (Curry, 1991;
Epstein, 2004; Hair, 2005).
This study’s data suggest that treatment outcomes generally do not
vary according age, gender, or number of problems. These null ndings
stand in contrast to the ndings in the public RTP research corpus. A
critical mass of research suggests that youth with relatively numerous
and severe problems are less likely to benet from treatment in public
RTPs (Connor et al., 2002; Curry, 1991; Epstein, 2004; Gorske et al.,
2003; Hussey & Guo, 2002). This nding, however, did not bear out in the
present study. In the present study, favorable outcomes were obtained
for youth even though co-morbidity rates and problem severity were
very high. Furthermore, the public RTP research corpus suggests that
outcomes vary by gender and age of the youth (Connor et al., 2002;
Epstein, 2004; Lyons & McCulloch 2006). In the present study, males
and females as well as younger and older adolescents had comparable
outcomes. Perhaps one explanation for these null ndings in the present
study lies within the differences between private and public residential
treatment clientele and services. This is a hypothesis that warrants
further empirical study.
Given that this sample had co-morbid conditions, had failed at prior
levels of care, and was largely in the severe range at admission, the
shift in scores toward the normal range during and after treatment is
noteworthy and speaks to the clinical signicance of the change. Perhaps
a point of comparison will help to interpret these data. Two of the most
acclaimed evidenced-based treatments for youth with behavioral and
substance abuse problems, Multi-systemic Therapy (MST) and Functional
Family Therapy (FFT), show high rates of problematic functioning
after treatment. The primary outcome indicator used to establish
the effectiveness of MST and FFT was recidivism. Research suggests
that recidivism rates were reduced with MST by 25% - 70% and FFT
by 25-80% (Fonagy, Target, Cottrell, Phillips & Kurtz, 2002; NREPP).
Though primary outcome indicators were different for those studies
than the present study, a lesson can be derived. Even treatments already
deemed as “evidence-based” do not “cure” all youth. In fact, a signicant
portion of youth who complete the “best of the best” evidence-based
programs, have serious problems that persist. In this context, the clinical
signicance of the present study’s ndings is remarkable: youth who came
to private residential treatment had the most severe of problems, but a
year after discharge function within the normal range.
A number of issues warrant further research attention. First, this
study did not use a control group. The lack of experimental designs (i.e.,
PRIVATE RESIDENTIAL TREATMENT OUTCOMES
42 • JTSP
control groups, random assignment to different conditions) in residential
treatment outcome research is a common occurrence due to the
practical and ethical constraints involved in leaving seriously disturbed
adolescents untreated or treated at a lower level-of-care. In this age of
outcome-based contracting and evidence-based practice standards, it is
clearly desirable to use more robust, experimental designs when possible.
Curry (1991) has suggested some creative and practical alternatives to
classic experimental design that use within-program and across program
comparison groups. Private residential treatment research would also
benet from process-focused studies that attempt to attribute change to
specic components of treatment. Private residential care is so multi-
facetted and complex that it is less an intervention and more a tapestry
of interventions (Fahlberg, 1990). As such, attempts to tie program
components to outcomes would have profound clinical implications.
PRIVATE RESIDENTIAL TREATMENT OUTCOMES
JTSP • 43
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Disclosure Statement: Aspen Education Group provided funding for this study.
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