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Prior services used by youths referred to mental health facilities: A closer look
Prior Services Used by Youths Referred to Mental Health Facilities: A Closer Look
Kathleen Wells Dale Whittington Bellefaire/Jewish Children’s Bureau Cleveland, Ohio
This study examines the service use history of youths referred to one private, nonprofit mental health agency over a 1Zmonth period. One hundred eleven youths were study subjects. Services studied included those in the mental health, welfare, and juvenile justice systems. Study data were obtained from individuals who were knowledgeable about these youths. Data were validated against service use data recorded in youths’ case records. Analyses revealed extensive prior use of services, use of services across systems, sex and racial differences in type and duration of services used, and use of less restrictive mental health services before more restrictive services. Some issues raised by findings are delineated.
Mental health policy makers, service providers, and child advocates alike are concerned about the increasing number of youths in mental health group care facilities (i.e., psychiatric hospitals, residential treatment centers, and group homes). For example, in 1984 there were 48,375 youths in private psychiatric hospitals, representing a fourfold increase in admissions since 1981 (Miller, 198.5, cited in Weithom, 1988). Over the same period of time the number of children under 18 in the population decreased by 1.6% (U.S. Census Bureau, 1988, cited in Weithom, 1988). These figures suggest that the increase in the number of youths in psychiatric hospitals cannot be explained by an increase in the number of adolescents in the population. In 1981 there were 17,703 children and youths under 18 in residential treatment centers (28.3 per lOO,OOO),twice the rate found in 1969 (Taube & Barrett, 1985). Requests for reprints should be sent to Kathleen Wells, BellefaiMewish 22001 Fairmount Blvd., Shaker Heights, Ohio 44118.
243
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This increase is particularly disturbing in light of the principles of family primacy and treatment in the least restrictive environment possible, on which current mental health policies are based (e.g., The Education for All Handicapped Children Act, 1975) and in view of the interests of youths’ liberty and privacy that are at stake. A number of hypotheses have been offered regarding this discrepancy between a mental health policy that favors deinstitutionalization and an increased use of institutional and other mental health group care services. These hypotheses include an increase in the proportion of the adolescent population that is disturbed (Egan, 1985); an increase in the admission of youths who previously would have been placed in institutions in the child welfare and juvenile justice systems (Weithom, 1988); an increase in the admission of youths for whom mental health group care facilities are inappropriate (Knitzer, 1982); an increase in the number of for-profit psychiatric hospitals for adolescents; insurance policies that favor inpatient over outpatient treatment; and a widespread preference for a medical approach to youths’ problems (Weithom, 1988). It is difficult to evaluate the merit of any of these hypotheses because we do not have adequate epidemiological data (Weithom, 1988), system use data, or well-defined clinical criteria for entrance into mental health group care programs (Wells, 1990). We even lack a basic description of the mental health, welfare, and juvenile justice system services used by youths across the life course, and of the factors associated with youths’ movement from one service to another. We undertook the present study to begin to provide basic descriptive information relating to services that youths have used throughout their lives. The specific study questions under investigation were as follows: 1. What mental health, welfare, and juvenile justice system services have youths used across the life course? 2. What is the extent of service use across the life course?
3. To what extent do youths move from welfare and juvenile justice system services to use of mental health system services? 4. Are less restrictive mental health services used before more restrictive services? 5. What services are used first? What is the relationship between the type of service used first and the duration of subsequent service use? 6. What are the characteristics of the current referral?
In addition, we explored duration of services used.
sex, racial,
and age differences
in type and
Method Study Subjects To answer study questions we collected information about all youths referred to mental health group care programs at one mental health agency
Youths Referred to Mental Health Facilities
215
from June 1985 through May 1986. Referred youths were included as subjects in the study if they had never been referred to the agency previously, were between 10 and 17 years old, had an IQ of 66 or more, and were not actively psychotic. One hundred seventeen youths fell into the study cohort; 111 were included in the study sample. Respondents Information was provided by the one adult who knew each youth well and had had responsibility for him or her for at least the year before the referral. Seventy-nine percent of the respondents were biological, adoptive, or stepmothers; 6% were biological fathers; 5% were grandmothers; 5% were foster mothers; and 5% were adults who knew the youth well but did not fall into the other categories. Data Collection
Procedures
Respondents were interviewed by one of two interviewers. Ninety of the interviews took place in respondents’ homes; the remaining 21 took place in an agency office. Interviews were conducted within one week of a youth’s referral to the agency. Each respondent was told that information was being obtained to conduct a study and to help provide information needed to evaluate the youth’s application to the agency. Each respondent was told that the interviewer was not involved in making the decision regarding the youth’s placement. The Interview The interview included questions with prestructured response formats and one standardized measure, The Parent Version of the Child Behavior Checklist (Achenbach & Edelbrock, 1983). Interview questions focused on the youth’s demographic status, current problems, the crisis that led to his or her referral to the agency, and the youth’s use of mental health, welfare, and juvenile justice system services from birth to the present time. Mental health services included psychiatric hospitals, psychiatric wards of general hospitals, residential treatment centers, group homes, day treatment, and outpatient therapy. Welfare services included foster care, receiving centers, and emergency shelters. Juvenile justice system services included correctional facilities and detention homes. For each service that was used, the respondent stated the name of the facility and the month and year in which the youth was admitted and discharged. In addition, respondents were asked whether the court or county had ever declared the youth dependent, neglected, abused, delinquent, or unruly.
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The Child Behavior Checklist (Achenbach & Edelbrock, 1983) is a standardized measure of child behavior problems. It has been found to be reliable and valid for the groups studied (Achenbach & Edelbrock, 1983). It comes with normative data for children who have not been referred to a mental health facility over the last year. This measure was included to allow a description of the severity of the behavioral problems of the sample. Because of the prestructured response formats used for questions and items on the Child Behavior Checklist an assessment of interrater reliability was not necessary. The Case Record Review All data provided by respondents were checked against a second source of information. The data for youths in custody of a county department of human services (n = 56) were checked against county records. The data for all other youths (n = 55) were checked against case records sent to the agency as part Data that could not be reconciled of the agency’s routine intake process. were excluded from the study. Results Sample Characteristics The average age of the study youths was 14.5 years. Sixty percent were girls, 75% were white, and 50% had a family income from wages of less than $14,000 per year. One third of the youths’ families had received no income from wages over the last 12 months. Eighty-six percent of the youths came from families in which their biological parents did not live together. Only 17%, however, lived in their most recent family home with neither a biological nor an adoptive parent. Fifty-one percent of the study youths were in the custody of a county department of human services. Nearly 90% of the youths scored in the clinical range on the Child Behavior Checklist (Achenbach & Edelbrock, 1983). There were no statistically significant associations among age, sex, and race in the sample. Question I: What mental health, werfare, and juvenile justice system services have youths used across the life course? Ninety-six percent of referred youths had used at least one service. As Table 1 reveals, the most frequently used service was outpatient therapy (83%); the least frequently used was day treatment (~1%). Ninety-three percent of referred youths had used at least one out-of-home placement. Some out-of-home placements (i.e., psychiatric hospitals and wards, group homes, foster homes, and detention homes) were used two or
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Youths Referred to Blental Health Facilities TABLE 1 Percentage of Youths Using Services, by Use Category Use Category 5% n
Type of Service Psychiatric Hospital Psychiatric Ward Residential Treatment Group Home Day Treatment Outpatient Foster Home Receiving Center Emergency Shelter Detention Home Note.
50 44 27 17 1 89 32 20 28 27
Ever Used 47 41 25 16
%
Multiple Usea 40 43 21 41 0 52 63 20 25 63
107 subjects used at least one service.
aPercentage
of youths using a service who used it two or more times.
TABLE 2 Percentage of Youths Using Any Out-of-Home Placements, by Times Used Categorp Times Used 0 1 2 3 4 5 6-9 10 - 1.5 16-23
% 7 22 14 18 9 6 14 7 2
Note. n = 111 aPlacements” refers to placements of any duration in psychiatric hospitals, psychiatric Bards, residential treatment centers, group homes, foster homes, receiving centers, emergency shelters, and detention homes.
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TABLE 3 Percentage of Youths Using Out-of-Home Placements Lasting Two Weeks or Longer, by Use Category
Type of Placement Psychiatric Hospital Psychiatric Ward Residential Treatment Group Home Foster Home Receiving Center Emergency Shelter Detention Home
n 49 31 24 15 29 13 6 11
Use Category 1 2-3 61 37 65 36 83 17 67 33 34 52 9 28 100 0 45
45
4-9 2 0 0 0 14 0 0 9
Note: n refers to number of subjects who had used a service two weeks or more.
more times by more than one-third of the referred youths who used them. Table 2 shows that nearly one-quarter of the sample had used six or more prior out-of-home placements. Yet, when out-of-home placements lasting less than two weeks were excluded from the analysis, it became clear that extensive multiple use (i.e., use of a service four or more times) of long-term placements occurred only for foster homes and detention homes. These data are displayed in Table 3. We also calculated the percentages of referred youths using each service who were boys and girls, whites and blacks, and younger than 11.5 years, between 11.5 and 13.9 years, between 14.0 and 16.5 years, and older than 16.5 years. A greater percentage of girls (56%) than of boys (29%) used psychiatric hospitals; a greater percentage of blacks (55%) than of whites (16%) used residential treatment; and a greater percentage of whites (88%) than of blacks (55%) used outpatient therapy. These associations were tested with a chi-square test for goodness of fit. The associations between sex and prior use of a psychiatric hospital (X2 (1, N = 111) = 7.88, p < .Ol), between race and prior use of residential treatment (X2 (1, N = 104) = 14.47, p < .Ol), and between race and prior use of outpatient therapy (X2 (1, N = 104) = 12.28, p < .Ol) were all statistically significant. Additional chi-square analyses revealed that these results were not due to the co-occurrence of demographic variables. Question 2: What is the extent of service use across the life course? The median age of first use of any service was 10 years. Once they had entered the system, referred youths spent a median of 25 months in care.
Youths Referred to Mental Health Facilities
239
When out-of-home placements were considered alone, referred youths spent a median of 6.7 months in out-of-home placement. As Table 4 reveals, referred youths spent the most time in foster homes (a median of 18 months) and the least in emergency shelters (a median of less than 1 month). Boys spent more total time than girls in residential treatment, detention homes, and foster homes. The greatest discrepancy occurred for residential treatment: boys spent a median of 22 months in treatment (with a range of 5 to 82.25 months) and girls spent a median of 5 months in treatment (with a range of .3 to 45 months).
TABLE 4 Statistics, Duration of Service Use
Type of Service
N
Psychiatric Hospital Psychiatric Ward Residential Treatment Group Home Outpatient Foster Home Receiving Center Emergency Shelter Detention Home All Types
50 44
Median Months 3 1
27 17 89 32 20 28 27 107
7 3 10 18 2
D, - Dga 1 - 16
aRefers to the first and ninth decile of the distribution of total months spent in a type of service.
Whites spent more time than blacks in psychiatric wards. Whites spent a median of 1.8 months in treatment (with a range of .l to 7.25 months); blacks Blacks spent a median of .9 months (with a range of .03 to 3.15 months). spent more total time in residential treatment than whites. Blacks spent a median of 25 months in treatment (with a range of .3 to 82.25 months); whites spent a median of 4 months (with a range of .3 to 68 months). By and large, there were too few subjects to allow us to assess differences in use of specific services as a function of a referred youth’s current age. Age at first use of any service, however, was found to correlate with total months used services to a statistically significant degree (r = -.54, p < .Ol). The younger a youth was at first service use, the more time he or she was likely to spend using services across the life course. Moreover, there was a group of referred youths who used services at an Seventeen percent first used services at early age and used them repeatedly. age 5.5 or younger. Nine was the median number of services used by this
Wells and Whittington group, compared to 4 for the rest of the sample, and 5.5 was the median number of out-of-home placements used by this group, compared to 3 for the rest of the sample. Question 3: To what extent do youths move from use of weLfare and juvenile justice system services to use of mental health system services? The majority of referred youths (58%) use services in more than one system: 34% used both welfare and mental health services; 10% used both juvenile justice and mental health services; and 14% used services in all three systems. No youths used only welfare and juvenile justice system services. Thirty-nine percent of referred youths used services in only one system: 36% used mental health system services only, 2% welfare system services only, and 1% juvenile justice system services only. Four percent used no services in any system. There was no clear pattern with respect to order of use. Question 4: Are less restrictive restrictive ones?
mental health services used before more
Sixty-six percent of referred youths used both a less restrictive mental health service (i.e., outpatient therapy and/or day treatment) and a more restrictive service (i.e., psychiatric hospitals, psychiatric wards, residential treatment centers, or group homes). Eighty-two percent of that group had used outpatient therapy, at least once, before either a psychiatric hospital or ward, a residential treatment center, or a group home. Question 5: What services are used first ? What is the relationship between the type of service usedjirst and the duration of subsequent service use? Forty-nine percent of referred youths used nonrestrictive mental health services as their first service, 24% used out-of-home mental health placement services first, 15% used out-of-home welfare placement services first, and 13% used out-of-home emergency services first. These data are displayed in Table 5. When we tested differences in total months spent in all services by youths first using each of the four types of services listed in Table 5, through a oneway analysis of variance, the means differed to a statistically significant degree (F (3, 100) = 8.29, p < .Ol). Youths who used an out-of-home welfare placement service first spent more time using services (M = 69.8) than youths first using nonrestrictive mental health services (A4 = 32.8). out-of-home emergency mental health placement services (A4 = 27.4), or out-of-home services (M = 22.5).
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Youths Referred to Mental Health Facilities TABLE 5 Percentage of Youths Using Services, by Type of Service First Used Type of Service First Used Nonrestrictive Mental Health Services Outpatient Therapy Out-of-Home Emergency Services Receiving Center Emergency Shelter Detention Home Out-of-Home Mental Health Placement Services Group Home Residential Treatment Psychiatric Ward Psychiatric Hospital Out-of-Home Welfare Placement Foster Home
5%
% 49
49 13 6 4 3 24 2 4 10 8 1.5 15
Note: n = 107
We categorized the services youths used first by their age at first use. The results revealed that 1) of the 21 youths who began service use at age 5 or younger, the greatest percentage (78%) used foster homes first; 2) of the 82 youths who began service use between ages 6 and 16, the greatest percentage (51%) used outpatient treatment first; and 3) of the 4 youths who began service use at age 17 or 18, the greatest percentage (75%) used a psychiatric hospital first. Question 6: What are the characteristics of the current referral? We examined characteristics of the current referral in terms of the most recent service used, the number of months between the crisis that triggered the current referral and the referral, and the restrictivity of the current referral compared to the restrictivity of the most recent service used. As Table 6 reveals, the most frequently used recent service was the Sixty-four percent of respondents psychiatric hospital or ward (41%). reported that youths had been “in crisis” for seven months or more. Twentyone percent reported that the youths had been “in crisis” two years or more. For 50% of referred youths the current referral was less restrictive than the most recent service, for 45% it was more restrictive, and for 5% it was the same.
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252
TABLE 6 Percentage of Youths in Two Referral-Characteristic n
Characteristic Months in Current Crisis? <3 3-6 7 - 12 13 -24 > 25
months months months months months
Most Recent Type of Serviceb Psychiatric Hospital/Ward Residential Treatment/Group Home Day Treatment/Outpatient Foster Home
Receiving Center/Emergency Shelter Detention Home
Categories
90
23 17 32 15 23
21 15 29 14 21
44 7 20 7 12 7
41 7 20 7 11 7
atI = 110. bn _ - 107. If more than one service was used before the referral, the most restrictive was counted.
service
Discussion
This study assessed neither the quality nor the appropriateness of the services used by referred youths, nor did it take into account constraints on service use imposed by the systems of care in the communities in which referred youths received services. In addition, the study did not assess the impact on distribution and accessibility of services resulting from policy changes that have occurred over the period (1969-1986) covered by the study. Nonetheless, this descriptive study has some strengths. It focuses on all the mental health, welfare, and juvenile justice system services used across the life course by a relatively large number of adolescent referrals to mental health group care programs at one mental health facility. Although the data were retrospective, they were provided primarily by mothers who knew the youths well. The data were confirmed through a review of youths’ case records. Moreover, the major study findings, which are summarized below, carry some implications for understanding the increased use of mental health group care services by adolescents. The findings also suggest issues important to improving the care and treatment of children and youths in need of services.
Youths Referred to Mental Health Facilities Major study findings are summarized
253
below.
Summary of Findings First, referred youths used a variety of services across the life course. Ninety-six percent used at least one service, 93% used at least one prior outof-home placement, and almost 25% used six or more prior out-of-home placements. Second, referred youths spent a considerable amount of time using services; 25 months was the median. The time spent, however, varied tremendously by service type. For example, the middle 80% of youths who used foster care used this service from 1 to 61 months. Third, the majority of referred youths (58%) used services in more than one system. There was no clear pattern with respect to order of use but, within the mental health system, less restrictive services generally were used before more restrictive services. Fourth, differences in sex, race, and age emerged in both the type of services used and time spent in services. For example, a greater percentage of blacks (55%) than of whites (16%) had used residential treatment; blacks also spent more time (a median of 22 months) in treatment than whites (a median of 4 months). Fifth, the earlier a youth started using services, the more time he or she spent using services across the life course. In addition, a small but significant group of referred youths began using services at a young age and used them repeatedly. Implications Understanding the context for use of mental health group care. It is not easy to explain the increase in the proportion of youths in mental health group care facilities. Prior treatment of admitted youths, in light of the number of youths who use these services repeatedly, is only one consideration; the issue cannot be understood fully without attention to the type, severity and chronicity of their emotional problems, the criteria for admission to programs of all types, the available alternatives to public and private hospitalization, funding mechanisms that may favor one service over another, and how all these factors change over time. In understanding this issue, however, the data reported in this study also point to the importance of evaluating the changing adequacy of the community and family environments in which troubled youths have lived. This sample of disturbed and largely poor adolescents has used multiple services over the last 10 to 15 years. Their families have been unable on their own to provide the support these children needed. During this time, the proportion of children and youths living in poverty has increased, substantiated reports of child abuse have increased, the number of children
Wells and Whittington and youths living in single parent families have increased (Burt & Pittman, 1985). and some of the major federal social programs designed to support families have been dismantled (McGowan, 1985). These changes may have placed a greater number of children and youths at risk for removal from their homes; and they may have made it more difficult for the children and youths to return, once removed, than in the past. Considered within this broad context, it is not surprising that some economically (and culturally) impoverished seriously emotionally disturbed youths are using out-of-home placements and using them repeatedly. We need to examine existing policies, programs, and research agendas to assess how welfare and mental health concepts, programs, and systems can be integrated. The problems of seriously emotionally disturbed and poor youths cannot be addressed separately from their families’ needs for food, housing, education, medical care and employment. Adequacy ofServices. In view of the early use of services by this sample and the strong relationship between age at first use and subsequent use, it is clear that the community and placement services that were provided were either inadequate or insufficient. Youths in this sample have failed in the systems serving children and youth, or perhaps can best be described as system-induced fai1ures.l Various initiatives have been proposed to improve services for seriously emotionally disturbed youth (cf. Stroul & Friedman, 1986). Only those which relate directly to our study data will be elaborated here. First, it is clear that the range of services that were available were inadequate, as evidenced by the few referred youths in this study who used day treatment and by the failure of any respondents, in the pilot study for this study, to identify use of intensive in-home or after-care services. Admittedly some of these services may be used more frequently now than they were over the last decade by this sample. Furthermore it is not clear how many youths in this sample would have profited from such services if they had been available. Nevertheless it is clear that less restrictive, family-based, and after-care services must be expanded. Indeed, in light of the seeming intractability of some problems experienced by youths and their families, we may need to not only expand the type of services that are available but also to reconceptualize the services that are needed. It is also clear that the mechanisms for identifying children and families in need of services and then matching them to programs must be strengthened. It is telling that 21% of youth in this sample had been in crisis for two or more years before their referral, that more than one-quarter had been in the foster care system, and that some groups spent much more time using some ‘This study challenges some commonly-held assumptions regarding services used by youths It has become almost a truism in the mental referred to mental health group care facilities. health policy literature that youths referred to mental health group facilities whether they beresidential treatment centers or psychiatric hospitals have not had treatment. This is clearly not the case for this sample.
Youths Referred
to >lental
Health
Facilities
255
services than others. The failure to assess and diagnose children and families in need of services and to provide them with programs designed to meet their specific needs may well contribute to the cycles of out-of-home placement documented in our study. Well-trained staff members must also be employed to work with children The and families at every point where they have contact with a system. amount of time referred youths in this sample have spent using services within and across systems hints at the complexity of their problems and Yet it is estimated underscores their need for treatment by skilled clinicians. that only 10% of public child welfare workers have Master of Social Work degrees (Lieberman, Russell, & Homby, 1988) and there are only 4,000 board-certified child psychologists in this country (Landers, 1989). Finally, the responsibility felt by providers of services for youths in their care must be enhanced. Although to examine the reasons associated with each youth’s movement from one service to another was beyond the scope of this study, impressions derived from the case record review revealed how easily movement can be rationalized by the language of policy, how readily programmatic failure can be explained away through an appeal to the psychodynamics of an individual case, and how difficult a task is faced by staff members who try to follow through with an individual case. A system composed of autonomous, relatively short-term services works against continuity of care in the sense that may be the most meaningful to a child: maintaining a relationship with one and the same clinician who can support growth and development over the long haul. Both the case record review and the serial placements used by our sample suggest that individual facilities should evaluate the appropriateness and the quality of environments to which youths in their care are being discharged. Minimally, we need to heighten the responsibility felt by service providers for at least the next step taken by their young clients. Emergence of a population of chronically disabled young adults. Among the referred youths who have had multiple placements there is also a small group--close to 20% in this sample--who started using services before age 5. We believe that some of these youths have very severe emotional problems, have been abandoned by their parents, have not been able to live with substitute parents, and have spent their childhood and early adolescence cycling through out-of-home placements. Current mental health and welfare policies, with their emphasis on treatment in the least restrictive environment possible, on prevention of placement, and on planning for permanency have worked to deny the existence of such youths. Moreover, many existing mental health group care programs are not well equipped to help these youths. Generally such programs assume that youths have had largely normative socialization experiences, have parents who are available for involvement in their treatment, and have some capacity for object relationship. We need to prevent the accumulation of the emotional, educational, and health-related deficits associated with moving from place to
Wells and Whittington
256
place and to develop new approaches to provide such youths with the longterm support they need (Wells, in press). Such youths also foretell the emergence of a population of chronically disabled young adults in our society; that outcome also must be avoided.
References Achenbach, T. M., & Edelbrock, C. Checklist
and Revised
Child
Printers. Burt, M., & Pittman, K. (1985). Urban Institute.
(1983).
Behavior
Profile.
Manual
for
the Child
Burlington,
Testing the social safety net.
Behavior
VT: Queen
Washington,
City
DC: The
The Education for All Handicapped Children Act, Pub. L. No. 94-142 (1975). Egan, J. (1985). Emerging trends in mental health care for adolescents,
Paper presented before the Select Committee on Children, Youth, and Families, U.S. Congress, Washington, DC. Knitzer, J. (1982). Unclaimed children. Washington, DC: Children’s Defense Fund. Landers, S. (1989, June). Disturbed children slip through legal safety net. APA Monitor, p. 22. Lieberman, A., Russell, M., & Homby, H. (1988). National Survey of Child Welfare Workers. Portland, ME: University of Southern Maine, National Child Welfare Resource Center for Management and Administration. McGowan, B. (1988). Family-based services and public policy: Context and implications. In J. Whittaker, J. Kinney, E. Tracy, & C. Booth (Eds.), Improving practice technology for work with high risk families: Homebuilders’ Social Work Education Project (Monograph
Lessons from the No. 6, pp. 69-89).
Seattle: University of Washington, Center for Social Welfare Research. Stroul, B., & Friedman, R. (1986). A system of care for severely emotionally disturbed children and youth. Washington, D.C.: Georgetown University Child Development Center, CASSP Technical Assistance Center. Taube, C. A., & Barrett, S. A. (1985). Mental Health, United States, 1985. Rockville, MD: National Institute of Mental Health. Weithom, L. A. (1988). Mental hospitalization of troublesome youth: An analysis of skyrocketing admission rates. Stanford Law Review, 40,773-838. Wells, K. (1990). Placement of emotionally disturbed children in residential treatment:
A review of placement
criteria and implications for practice
and research..
Manuscript submitted for publication. Wells, K. (in press). Eagerly awaiting a home. Severely emotionally disturbed youth lost in our systems of care: A personal reflection. Child and Youth Care Quarterly.
Kathleen Wells Dale Whittington Bellefaire/Jewish Children’s Bureau Cleveland, Ohio
This study examines the service use history of youths referred to one private, nonprofit mental health agency over a 1Zmonth period. One hundred eleven youths were study subjects. Services studied included those in the mental health, welfare, and juvenile justice systems. Study data were obtained from individuals who were knowledgeable about these youths. Data were validated against service use data recorded in youths’ case records. Analyses revealed extensive prior use of services, use of services across systems, sex and racial differences in type and duration of services used, and use of less restrictive mental health services before more restrictive services. Some issues raised by findings are delineated.
Mental health policy makers, service providers, and child advocates alike are concerned about the increasing number of youths in mental health group care facilities (i.e., psychiatric hospitals, residential treatment centers, and group homes). For example, in 1984 there were 48,375 youths in private psychiatric hospitals, representing a fourfold increase in admissions since 1981 (Miller, 198.5, cited in Weithom, 1988). Over the same period of time the number of children under 18 in the population decreased by 1.6% (U.S. Census Bureau, 1988, cited in Weithom, 1988). These figures suggest that the increase in the number of youths in psychiatric hospitals cannot be explained by an increase in the number of adolescents in the population. In 1981 there were 17,703 children and youths under 18 in residential treatment centers (28.3 per lOO,OOO),twice the rate found in 1969 (Taube & Barrett, 1985). Requests for reprints should be sent to Kathleen Wells, BellefaiMewish 22001 Fairmount Blvd., Shaker Heights, Ohio 44118.
243
Children’s Bureau,
244
Wells and Whittington
This increase is particularly disturbing in light of the principles of family primacy and treatment in the least restrictive environment possible, on which current mental health policies are based (e.g., The Education for All Handicapped Children Act, 1975) and in view of the interests of youths’ liberty and privacy that are at stake. A number of hypotheses have been offered regarding this discrepancy between a mental health policy that favors deinstitutionalization and an increased use of institutional and other mental health group care services. These hypotheses include an increase in the proportion of the adolescent population that is disturbed (Egan, 1985); an increase in the admission of youths who previously would have been placed in institutions in the child welfare and juvenile justice systems (Weithom, 1988); an increase in the admission of youths for whom mental health group care facilities are inappropriate (Knitzer, 1982); an increase in the number of for-profit psychiatric hospitals for adolescents; insurance policies that favor inpatient over outpatient treatment; and a widespread preference for a medical approach to youths’ problems (Weithom, 1988). It is difficult to evaluate the merit of any of these hypotheses because we do not have adequate epidemiological data (Weithom, 1988), system use data, or well-defined clinical criteria for entrance into mental health group care programs (Wells, 1990). We even lack a basic description of the mental health, welfare, and juvenile justice system services used by youths across the life course, and of the factors associated with youths’ movement from one service to another. We undertook the present study to begin to provide basic descriptive information relating to services that youths have used throughout their lives. The specific study questions under investigation were as follows: 1. What mental health, welfare, and juvenile justice system services have youths used across the life course? 2. What is the extent of service use across the life course?
3. To what extent do youths move from welfare and juvenile justice system services to use of mental health system services? 4. Are less restrictive mental health services used before more restrictive services? 5. What services are used first? What is the relationship between the type of service used first and the duration of subsequent service use? 6. What are the characteristics of the current referral?
In addition, we explored duration of services used.
sex, racial,
and age differences
in type and
Method Study Subjects To answer study questions we collected information about all youths referred to mental health group care programs at one mental health agency
Youths Referred to Mental Health Facilities
215
from June 1985 through May 1986. Referred youths were included as subjects in the study if they had never been referred to the agency previously, were between 10 and 17 years old, had an IQ of 66 or more, and were not actively psychotic. One hundred seventeen youths fell into the study cohort; 111 were included in the study sample. Respondents Information was provided by the one adult who knew each youth well and had had responsibility for him or her for at least the year before the referral. Seventy-nine percent of the respondents were biological, adoptive, or stepmothers; 6% were biological fathers; 5% were grandmothers; 5% were foster mothers; and 5% were adults who knew the youth well but did not fall into the other categories. Data Collection
Procedures
Respondents were interviewed by one of two interviewers. Ninety of the interviews took place in respondents’ homes; the remaining 21 took place in an agency office. Interviews were conducted within one week of a youth’s referral to the agency. Each respondent was told that information was being obtained to conduct a study and to help provide information needed to evaluate the youth’s application to the agency. Each respondent was told that the interviewer was not involved in making the decision regarding the youth’s placement. The Interview The interview included questions with prestructured response formats and one standardized measure, The Parent Version of the Child Behavior Checklist (Achenbach & Edelbrock, 1983). Interview questions focused on the youth’s demographic status, current problems, the crisis that led to his or her referral to the agency, and the youth’s use of mental health, welfare, and juvenile justice system services from birth to the present time. Mental health services included psychiatric hospitals, psychiatric wards of general hospitals, residential treatment centers, group homes, day treatment, and outpatient therapy. Welfare services included foster care, receiving centers, and emergency shelters. Juvenile justice system services included correctional facilities and detention homes. For each service that was used, the respondent stated the name of the facility and the month and year in which the youth was admitted and discharged. In addition, respondents were asked whether the court or county had ever declared the youth dependent, neglected, abused, delinquent, or unruly.
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The Child Behavior Checklist (Achenbach & Edelbrock, 1983) is a standardized measure of child behavior problems. It has been found to be reliable and valid for the groups studied (Achenbach & Edelbrock, 1983). It comes with normative data for children who have not been referred to a mental health facility over the last year. This measure was included to allow a description of the severity of the behavioral problems of the sample. Because of the prestructured response formats used for questions and items on the Child Behavior Checklist an assessment of interrater reliability was not necessary. The Case Record Review All data provided by respondents were checked against a second source of information. The data for youths in custody of a county department of human services (n = 56) were checked against county records. The data for all other youths (n = 55) were checked against case records sent to the agency as part Data that could not be reconciled of the agency’s routine intake process. were excluded from the study. Results Sample Characteristics The average age of the study youths was 14.5 years. Sixty percent were girls, 75% were white, and 50% had a family income from wages of less than $14,000 per year. One third of the youths’ families had received no income from wages over the last 12 months. Eighty-six percent of the youths came from families in which their biological parents did not live together. Only 17%, however, lived in their most recent family home with neither a biological nor an adoptive parent. Fifty-one percent of the study youths were in the custody of a county department of human services. Nearly 90% of the youths scored in the clinical range on the Child Behavior Checklist (Achenbach & Edelbrock, 1983). There were no statistically significant associations among age, sex, and race in the sample. Question I: What mental health, werfare, and juvenile justice system services have youths used across the life course? Ninety-six percent of referred youths had used at least one service. As Table 1 reveals, the most frequently used service was outpatient therapy (83%); the least frequently used was day treatment (~1%). Ninety-three percent of referred youths had used at least one out-of-home placement. Some out-of-home placements (i.e., psychiatric hospitals and wards, group homes, foster homes, and detention homes) were used two or
247
Youths Referred to Blental Health Facilities TABLE 1 Percentage of Youths Using Services, by Use Category Use Category 5% n
Type of Service Psychiatric Hospital Psychiatric Ward Residential Treatment Group Home Day Treatment Outpatient Foster Home Receiving Center Emergency Shelter Detention Home Note.
50 44 27 17 1 89 32 20 28 27
Ever Used 47 41 25 16
%
Multiple Usea 40 43 21 41 0 52 63 20 25 63
107 subjects used at least one service.
aPercentage
of youths using a service who used it two or more times.
TABLE 2 Percentage of Youths Using Any Out-of-Home Placements, by Times Used Categorp Times Used 0 1 2 3 4 5 6-9 10 - 1.5 16-23
% 7 22 14 18 9 6 14 7 2
Note. n = 111 aPlacements” refers to placements of any duration in psychiatric hospitals, psychiatric Bards, residential treatment centers, group homes, foster homes, receiving centers, emergency shelters, and detention homes.
248
Wells and Whittington
TABLE 3 Percentage of Youths Using Out-of-Home Placements Lasting Two Weeks or Longer, by Use Category
Type of Placement Psychiatric Hospital Psychiatric Ward Residential Treatment Group Home Foster Home Receiving Center Emergency Shelter Detention Home
n 49 31 24 15 29 13 6 11
Use Category 1 2-3 61 37 65 36 83 17 67 33 34 52 9 28 100 0 45
45
4-9 2 0 0 0 14 0 0 9
Note: n refers to number of subjects who had used a service two weeks or more.
more times by more than one-third of the referred youths who used them. Table 2 shows that nearly one-quarter of the sample had used six or more prior out-of-home placements. Yet, when out-of-home placements lasting less than two weeks were excluded from the analysis, it became clear that extensive multiple use (i.e., use of a service four or more times) of long-term placements occurred only for foster homes and detention homes. These data are displayed in Table 3. We also calculated the percentages of referred youths using each service who were boys and girls, whites and blacks, and younger than 11.5 years, between 11.5 and 13.9 years, between 14.0 and 16.5 years, and older than 16.5 years. A greater percentage of girls (56%) than of boys (29%) used psychiatric hospitals; a greater percentage of blacks (55%) than of whites (16%) used residential treatment; and a greater percentage of whites (88%) than of blacks (55%) used outpatient therapy. These associations were tested with a chi-square test for goodness of fit. The associations between sex and prior use of a psychiatric hospital (X2 (1, N = 111) = 7.88, p < .Ol), between race and prior use of residential treatment (X2 (1, N = 104) = 14.47, p < .Ol), and between race and prior use of outpatient therapy (X2 (1, N = 104) = 12.28, p < .Ol) were all statistically significant. Additional chi-square analyses revealed that these results were not due to the co-occurrence of demographic variables. Question 2: What is the extent of service use across the life course? The median age of first use of any service was 10 years. Once they had entered the system, referred youths spent a median of 25 months in care.
Youths Referred to Mental Health Facilities
239
When out-of-home placements were considered alone, referred youths spent a median of 6.7 months in out-of-home placement. As Table 4 reveals, referred youths spent the most time in foster homes (a median of 18 months) and the least in emergency shelters (a median of less than 1 month). Boys spent more total time than girls in residential treatment, detention homes, and foster homes. The greatest discrepancy occurred for residential treatment: boys spent a median of 22 months in treatment (with a range of 5 to 82.25 months) and girls spent a median of 5 months in treatment (with a range of .3 to 45 months).
TABLE 4 Statistics, Duration of Service Use
Type of Service
N
Psychiatric Hospital Psychiatric Ward Residential Treatment Group Home Outpatient Foster Home Receiving Center Emergency Shelter Detention Home All Types
50 44
Median Months 3 1
27 17 89 32 20 28 27 107
7 3 10 18 2
D, - Dga 1 - 16
aRefers to the first and ninth decile of the distribution of total months spent in a type of service.
Whites spent more time than blacks in psychiatric wards. Whites spent a median of 1.8 months in treatment (with a range of .l to 7.25 months); blacks Blacks spent a median of .9 months (with a range of .03 to 3.15 months). spent more total time in residential treatment than whites. Blacks spent a median of 25 months in treatment (with a range of .3 to 82.25 months); whites spent a median of 4 months (with a range of .3 to 68 months). By and large, there were too few subjects to allow us to assess differences in use of specific services as a function of a referred youth’s current age. Age at first use of any service, however, was found to correlate with total months used services to a statistically significant degree (r = -.54, p < .Ol). The younger a youth was at first service use, the more time he or she was likely to spend using services across the life course. Moreover, there was a group of referred youths who used services at an Seventeen percent first used services at early age and used them repeatedly. age 5.5 or younger. Nine was the median number of services used by this
Wells and Whittington group, compared to 4 for the rest of the sample, and 5.5 was the median number of out-of-home placements used by this group, compared to 3 for the rest of the sample. Question 3: To what extent do youths move from use of weLfare and juvenile justice system services to use of mental health system services? The majority of referred youths (58%) use services in more than one system: 34% used both welfare and mental health services; 10% used both juvenile justice and mental health services; and 14% used services in all three systems. No youths used only welfare and juvenile justice system services. Thirty-nine percent of referred youths used services in only one system: 36% used mental health system services only, 2% welfare system services only, and 1% juvenile justice system services only. Four percent used no services in any system. There was no clear pattern with respect to order of use. Question 4: Are less restrictive restrictive ones?
mental health services used before more
Sixty-six percent of referred youths used both a less restrictive mental health service (i.e., outpatient therapy and/or day treatment) and a more restrictive service (i.e., psychiatric hospitals, psychiatric wards, residential treatment centers, or group homes). Eighty-two percent of that group had used outpatient therapy, at least once, before either a psychiatric hospital or ward, a residential treatment center, or a group home. Question 5: What services are used first ? What is the relationship between the type of service usedjirst and the duration of subsequent service use? Forty-nine percent of referred youths used nonrestrictive mental health services as their first service, 24% used out-of-home mental health placement services first, 15% used out-of-home welfare placement services first, and 13% used out-of-home emergency services first. These data are displayed in Table 5. When we tested differences in total months spent in all services by youths first using each of the four types of services listed in Table 5, through a oneway analysis of variance, the means differed to a statistically significant degree (F (3, 100) = 8.29, p < .Ol). Youths who used an out-of-home welfare placement service first spent more time using services (M = 69.8) than youths first using nonrestrictive mental health services (A4 = 32.8). out-of-home emergency mental health placement services (A4 = 27.4), or out-of-home services (M = 22.5).
251
Youths Referred to Mental Health Facilities TABLE 5 Percentage of Youths Using Services, by Type of Service First Used Type of Service First Used Nonrestrictive Mental Health Services Outpatient Therapy Out-of-Home Emergency Services Receiving Center Emergency Shelter Detention Home Out-of-Home Mental Health Placement Services Group Home Residential Treatment Psychiatric Ward Psychiatric Hospital Out-of-Home Welfare Placement Foster Home
5%
% 49
49 13 6 4 3 24 2 4 10 8 1.5 15
Note: n = 107
We categorized the services youths used first by their age at first use. The results revealed that 1) of the 21 youths who began service use at age 5 or younger, the greatest percentage (78%) used foster homes first; 2) of the 82 youths who began service use between ages 6 and 16, the greatest percentage (51%) used outpatient treatment first; and 3) of the 4 youths who began service use at age 17 or 18, the greatest percentage (75%) used a psychiatric hospital first. Question 6: What are the characteristics of the current referral? We examined characteristics of the current referral in terms of the most recent service used, the number of months between the crisis that triggered the current referral and the referral, and the restrictivity of the current referral compared to the restrictivity of the most recent service used. As Table 6 reveals, the most frequently used recent service was the Sixty-four percent of respondents psychiatric hospital or ward (41%). reported that youths had been “in crisis” for seven months or more. Twentyone percent reported that the youths had been “in crisis” two years or more. For 50% of referred youths the current referral was less restrictive than the most recent service, for 45% it was more restrictive, and for 5% it was the same.
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252
TABLE 6 Percentage of Youths in Two Referral-Characteristic n
Characteristic Months in Current Crisis? <3 3-6 7 - 12 13 -24 > 25
months months months months months
Most Recent Type of Serviceb Psychiatric Hospital/Ward Residential Treatment/Group Home Day Treatment/Outpatient Foster Home
Receiving Center/Emergency Shelter Detention Home
Categories
90
23 17 32 15 23
21 15 29 14 21
44 7 20 7 12 7
41 7 20 7 11 7
atI = 110. bn _ - 107. If more than one service was used before the referral, the most restrictive was counted.
service
Discussion
This study assessed neither the quality nor the appropriateness of the services used by referred youths, nor did it take into account constraints on service use imposed by the systems of care in the communities in which referred youths received services. In addition, the study did not assess the impact on distribution and accessibility of services resulting from policy changes that have occurred over the period (1969-1986) covered by the study. Nonetheless, this descriptive study has some strengths. It focuses on all the mental health, welfare, and juvenile justice system services used across the life course by a relatively large number of adolescent referrals to mental health group care programs at one mental health facility. Although the data were retrospective, they were provided primarily by mothers who knew the youths well. The data were confirmed through a review of youths’ case records. Moreover, the major study findings, which are summarized below, carry some implications for understanding the increased use of mental health group care services by adolescents. The findings also suggest issues important to improving the care and treatment of children and youths in need of services.
Youths Referred to Mental Health Facilities Major study findings are summarized
253
below.
Summary of Findings First, referred youths used a variety of services across the life course. Ninety-six percent used at least one service, 93% used at least one prior outof-home placement, and almost 25% used six or more prior out-of-home placements. Second, referred youths spent a considerable amount of time using services; 25 months was the median. The time spent, however, varied tremendously by service type. For example, the middle 80% of youths who used foster care used this service from 1 to 61 months. Third, the majority of referred youths (58%) used services in more than one system. There was no clear pattern with respect to order of use but, within the mental health system, less restrictive services generally were used before more restrictive services. Fourth, differences in sex, race, and age emerged in both the type of services used and time spent in services. For example, a greater percentage of blacks (55%) than of whites (16%) had used residential treatment; blacks also spent more time (a median of 22 months) in treatment than whites (a median of 4 months). Fifth, the earlier a youth started using services, the more time he or she spent using services across the life course. In addition, a small but significant group of referred youths began using services at a young age and used them repeatedly. Implications Understanding the context for use of mental health group care. It is not easy to explain the increase in the proportion of youths in mental health group care facilities. Prior treatment of admitted youths, in light of the number of youths who use these services repeatedly, is only one consideration; the issue cannot be understood fully without attention to the type, severity and chronicity of their emotional problems, the criteria for admission to programs of all types, the available alternatives to public and private hospitalization, funding mechanisms that may favor one service over another, and how all these factors change over time. In understanding this issue, however, the data reported in this study also point to the importance of evaluating the changing adequacy of the community and family environments in which troubled youths have lived. This sample of disturbed and largely poor adolescents has used multiple services over the last 10 to 15 years. Their families have been unable on their own to provide the support these children needed. During this time, the proportion of children and youths living in poverty has increased, substantiated reports of child abuse have increased, the number of children
Wells and Whittington and youths living in single parent families have increased (Burt & Pittman, 1985). and some of the major federal social programs designed to support families have been dismantled (McGowan, 1985). These changes may have placed a greater number of children and youths at risk for removal from their homes; and they may have made it more difficult for the children and youths to return, once removed, than in the past. Considered within this broad context, it is not surprising that some economically (and culturally) impoverished seriously emotionally disturbed youths are using out-of-home placements and using them repeatedly. We need to examine existing policies, programs, and research agendas to assess how welfare and mental health concepts, programs, and systems can be integrated. The problems of seriously emotionally disturbed and poor youths cannot be addressed separately from their families’ needs for food, housing, education, medical care and employment. Adequacy ofServices. In view of the early use of services by this sample and the strong relationship between age at first use and subsequent use, it is clear that the community and placement services that were provided were either inadequate or insufficient. Youths in this sample have failed in the systems serving children and youth, or perhaps can best be described as system-induced fai1ures.l Various initiatives have been proposed to improve services for seriously emotionally disturbed youth (cf. Stroul & Friedman, 1986). Only those which relate directly to our study data will be elaborated here. First, it is clear that the range of services that were available were inadequate, as evidenced by the few referred youths in this study who used day treatment and by the failure of any respondents, in the pilot study for this study, to identify use of intensive in-home or after-care services. Admittedly some of these services may be used more frequently now than they were over the last decade by this sample. Furthermore it is not clear how many youths in this sample would have profited from such services if they had been available. Nevertheless it is clear that less restrictive, family-based, and after-care services must be expanded. Indeed, in light of the seeming intractability of some problems experienced by youths and their families, we may need to not only expand the type of services that are available but also to reconceptualize the services that are needed. It is also clear that the mechanisms for identifying children and families in need of services and then matching them to programs must be strengthened. It is telling that 21% of youth in this sample had been in crisis for two or more years before their referral, that more than one-quarter had been in the foster care system, and that some groups spent much more time using some ‘This study challenges some commonly-held assumptions regarding services used by youths It has become almost a truism in the mental referred to mental health group care facilities. health policy literature that youths referred to mental health group facilities whether they beresidential treatment centers or psychiatric hospitals have not had treatment. This is clearly not the case for this sample.
Youths Referred
to >lental
Health
Facilities
255
services than others. The failure to assess and diagnose children and families in need of services and to provide them with programs designed to meet their specific needs may well contribute to the cycles of out-of-home placement documented in our study. Well-trained staff members must also be employed to work with children The and families at every point where they have contact with a system. amount of time referred youths in this sample have spent using services within and across systems hints at the complexity of their problems and Yet it is estimated underscores their need for treatment by skilled clinicians. that only 10% of public child welfare workers have Master of Social Work degrees (Lieberman, Russell, & Homby, 1988) and there are only 4,000 board-certified child psychologists in this country (Landers, 1989). Finally, the responsibility felt by providers of services for youths in their care must be enhanced. Although to examine the reasons associated with each youth’s movement from one service to another was beyond the scope of this study, impressions derived from the case record review revealed how easily movement can be rationalized by the language of policy, how readily programmatic failure can be explained away through an appeal to the psychodynamics of an individual case, and how difficult a task is faced by staff members who try to follow through with an individual case. A system composed of autonomous, relatively short-term services works against continuity of care in the sense that may be the most meaningful to a child: maintaining a relationship with one and the same clinician who can support growth and development over the long haul. Both the case record review and the serial placements used by our sample suggest that individual facilities should evaluate the appropriateness and the quality of environments to which youths in their care are being discharged. Minimally, we need to heighten the responsibility felt by service providers for at least the next step taken by their young clients. Emergence of a population of chronically disabled young adults. Among the referred youths who have had multiple placements there is also a small group--close to 20% in this sample--who started using services before age 5. We believe that some of these youths have very severe emotional problems, have been abandoned by their parents, have not been able to live with substitute parents, and have spent their childhood and early adolescence cycling through out-of-home placements. Current mental health and welfare policies, with their emphasis on treatment in the least restrictive environment possible, on prevention of placement, and on planning for permanency have worked to deny the existence of such youths. Moreover, many existing mental health group care programs are not well equipped to help these youths. Generally such programs assume that youths have had largely normative socialization experiences, have parents who are available for involvement in their treatment, and have some capacity for object relationship. We need to prevent the accumulation of the emotional, educational, and health-related deficits associated with moving from place to
Wells and Whittington
256
place and to develop new approaches to provide such youths with the longterm support they need (Wells, in press). Such youths also foretell the emergence of a population of chronically disabled young adults in our society; that outcome also must be avoided.
References Achenbach, T. M., & Edelbrock, C. Checklist
and Revised
Child
Printers. Burt, M., & Pittman, K. (1985). Urban Institute.
(1983).
Behavior
Profile.
Manual
for
the Child
Burlington,
Testing the social safety net.
Behavior
VT: Queen
Washington,
City
DC: The
The Education for All Handicapped Children Act, Pub. L. No. 94-142 (1975). Egan, J. (1985). Emerging trends in mental health care for adolescents,
Paper presented before the Select Committee on Children, Youth, and Families, U.S. Congress, Washington, DC. Knitzer, J. (1982). Unclaimed children. Washington, DC: Children’s Defense Fund. Landers, S. (1989, June). Disturbed children slip through legal safety net. APA Monitor, p. 22. Lieberman, A., Russell, M., & Homby, H. (1988). National Survey of Child Welfare Workers. Portland, ME: University of Southern Maine, National Child Welfare Resource Center for Management and Administration. McGowan, B. (1988). Family-based services and public policy: Context and implications. In J. Whittaker, J. Kinney, E. Tracy, & C. Booth (Eds.), Improving practice technology for work with high risk families: Homebuilders’ Social Work Education Project (Monograph
Lessons from the No. 6, pp. 69-89).
Seattle: University of Washington, Center for Social Welfare Research. Stroul, B., & Friedman, R. (1986). A system of care for severely emotionally disturbed children and youth. Washington, D.C.: Georgetown University Child Development Center, CASSP Technical Assistance Center. Taube, C. A., & Barrett, S. A. (1985). Mental Health, United States, 1985. Rockville, MD: National Institute of Mental Health. Weithom, L. A. (1988). Mental hospitalization of troublesome youth: An analysis of skyrocketing admission rates. Stanford Law Review, 40,773-838. Wells, K. (1990). Placement of emotionally disturbed children in residential treatment:
A review of placement
criteria and implications for practice
and research..
Manuscript submitted for publication. Wells, K. (in press). Eagerly awaiting a home. Severely emotionally disturbed youth lost in our systems of care: A personal reflection. Child and Youth Care Quarterly.