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(Letter Report, 01/28/94, GAO/HEHS-94-56). A recent study has estimated that more than 10 percent of the nation's youth are engaging in behaviors that seriously jeopardize their futures, including poor academic performance, substance abuse, delinquency, and unprotected sex. One approach for dealing with at-risk youth--residential care--removes them from where they normally live and places them in settings ranging from tents in the woods to suburban homes, where they are taught skills and prepared to return to their communities and become contributing members of society. GAO found that although few rigorous evaluations of residential programs have been done, the studies issued so far suggest that residential care can successfully treat some high-risk youths. Thorough evaluations are needed to determine which treatments are most effective and what the long-term effects of the treatment are for youths so that policymakers can make sound decisions on the most effective mix of programs and the best role for residential care. Program officials and other experts agree that some key elements enhance the programs' ability to alter high-risk behavior, such as close ties with the youths' families and continuing support after the youths have left the residential setting and returned to their neighborhoods. --------------------------- Indexing Terms ----------------------------- REPORTNUM: HEHS-94-56 TITLE: Residential Care: Some High-Risk Youth Benefit, But More Study Needed DATE: 01/28/94 SUBJECT: State-administered programs Disadvantaged persons Public assistance programs Local governments Minors Program evaluation Juvenile offender rehabilitation Juvenile correctional facilities Juvenile delinquency Rehabilitation programs IDENTIFIER: Starr Commonwealth, Cedar Village Program (Albion, MI) Boys Town Home Campus Program (Boys Town, NE) Paint Creek Youth Center Program (Bainbridge, OH) Piney Woods Country Life School Program (Piney Woods, MS) Hyde School Program (Bath, ME) Oasis Center Program (Nashville, TN) Salesmanship Club Youth Camp Program (Hawkins, TX) Harbor Schools and Family Services, Haverhill Program (Haverhill, MA) Boysville Program (Clinton, MI) Children's Village Program (Dobbs Ferry, NY) Bridge Over Troubled Waters Transitional Living Program (Boston, MA) ************************************************************************** * This file contains an ASCII representation of the text of a GAO * * report. 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We are unable to accept electronic orders * * for printed documents at this time. * ************************************************************************** Cover ================================================================ COVER Report to the Chairman, Subcommittee on Oversight of Government Management, Committee on Governmental Affairs, U.S. Senate January 1994 RESIDENTIAL CARE - SOME HIGH-RISK YOUTH BENEFIT, BUT MORE STUDY NEEDED GAO/HEHS-94-56 Residential Care Abbreviations =============================================================== ABBREV AIDS - acquired immunodeficiency syndrome GED - general educational development Letter =============================================================== LETTER B-249960 January 28, 1994 The Honorable Carl M. Levin Chairman, Subcommittee on Oversight of Government Management Committee on Governmental Affairs United States Senate Dear Mr. Chairman: The nation faces daunting challenges in deciding how best to approach the problem of youth whose behavior places them at risk of not becoming self-sufficient members of society. One study has estimated that more than 10 percent of the nation's youth aged 10 to 17 engage in three or more of the four behaviors most commonly associated with this risk: poor performance in school, substance abuse, delinquency, and early unprotected sexual activity.\1 One approach for dealing with at-risk youth--residential care--removes youths from where they normally live and places them in settings ranging from tents in the wilderness to family-like residences in the suburbs. In these settings, youths are taught skills and provided treatment designed to prepare them to return to their communities and become contributing members of society. Because the Subcommittee is interested in the role of the federal government in providing education, health, and social services to children living in precarious environments, you asked us to study residential programs that provide comprehensive long-term help for youths who are exhibiting multiple high-risk behaviors. Our study objectives were to determine what is known about the effectiveness of such programs in preparing youths to lead self-sufficient, productive lives and what can be learned about key program characteristics important for mitigating risky behaviors of young people. -------------------- \1 Joy G. Dryfoos, Adolescents at Risk: Prevalence and Prevention (New York: Oxford University Press, 1990). BACKGROUND ------------------------------------------------------------ Letter :1 Studies indicate that the consequences associated with high-risk behaviors are costly not only in terms of individual suffering and diminished quality of life, but also in terms of long-term social costs and lost productivity. Some examples follow: On average, each male who drops out of high school will earn $260,000 less and pay $78,000 less in taxes during his lifetime than those who graduate from high school. Similar estimates for a female dropout were $200,000 and $60,000, respectively. Over 500,000 youths entered detention centers in 1988, and the average cost to hold one youth in custody for a year was nearly $30,000. Early unprotected sexual activity costs taxpayers an estimated $19 billion annually for income support, health care, and nutrition for families begun by adolescents. It also increases the incidence of sexually transmitted diseases, including acquired immunodeficiency syndrome (AIDS). Experts recognize that problems of youths who exhibit multiple high-risk behaviors are best addressed simultaneously and intensively over an extended period, in part because problem behaviors are often interrelated. For example, some high-risk youths experience problems in school, become abusers of drugs and alcohol, and become involved in delinquent activity. One way to serve high-risk youth is through comprehensive, long-term residential programs that remove young people from their homes, generally for 6 to 18 months. The programs provide education, health, and social services to address the youths' multiple problems in-house or through arrangements with local providers. Other ways of addressing youths' problems include nonresidential community-based programs that serve youths at home or at school or other community locations. The severity of problem behaviors exhibited by youths served in residential programs varies considerably. Some youths engage in high-risk activities, such as drug peddling or prostitution, or suffer from severe psychological and social problems. They may be referred to residential programs by juvenile justice, child welfare, or mental health organizations. Other youths are truant from school or run away from home. Some who live in crime-ridden neighborhoods or who come from hostile families need protection. Parents or social agencies may refer these youths to residential care programs, including boarding schools, which provide an opportunity for the youths to be educated and receive guidance in a safe and stable environment. Many youths in these programs come from low-income homes in troubled neighborhoods. Many have been victims of physical and sexual abuse and have had a number of prior placements such as foster care or correctional facilities. SCOPE AND METHODOLOGY ------------------------------------------------------------ Letter :2 To examine what is known about the effectiveness of residential care programs, we searched the literature and contacted experts on the needs of at-risk adolescents to identify recent studies of program effectiveness. We obtained and reviewed relevant studies. Because national associations and agencies we contacted could not provide comprehensive listings of long-term residential programs for youths aged 10 to 17, we relied on program officials and other experts in the field to suggest individual programs that, in their opinion, were notable or had some documented measures of effectiveness. In all, we judgmentally selected and contacted 29 residential programs which, based on information we had at the time, were likely to meet the following criteria: served youths aged 10 to 17; provided long-term, comprehensive services that addressed each of the four problem behaviors of poor performance in school, substance abuse, delinquency, and early unprotected sexual activity; and had recent outcome data on program effectiveness. After contacting the 29 programs, we found that 17 met our criteria and included them in our review. We also included another program, the Piney Woods Country Life School, a boarding school that serves youth who are not currently exhibiting the four problem behaviors, but who come primarily from dangerous urban neighborhoods where they may be at increased risk of adopting the behaviors. Appendix III lists the names and addresses of these 18 programs. We visited 9 of the 18 programs--selected to illustrate a variety of populations (ranging from youths with relatively minor problems to those convicted of felonies) and locations (urban, suburban, and rural). We conducted telephone interviews with officials of the nine programs we did not visit to obtain comparable information about program orientation and outcomes, participant profiles, and funding. We used the views of program officials and other experts we contacted and the literature to develop a list of program characteristics that appeared to be key to program success. We then asked officials from the 18 programs to assess the importance of these key characteristics to their programs' success. We conducted our work between August 1992 and November 1993 in accordance with generally accepted government auditing standards. Appendixes I and II contain descriptions of each program included in our study and results of evaluations and outcome measurements. RESULTS IN BRIEF ------------------------------------------------------------ Letter :3 Residential care appears to be a viable treatment option for some high-risk youths. Each of the 18 programs we contacted reported benefits for some youths in such areas as maintaining attendance in school and avoiding drug abuse and criminal behavior. However, programs seldom conduct controlled or comparison studies to determine how outcomes are linked to their treatment efforts, and few programs have conducted studies to show what happened to participants more than 12 months after they left the programs. Not enough is known about residential care programs to provide a clear picture of which kinds of treatment approaches work best or about the effectiveness of the treatment over the long term. Further, no consensus exists on which youths are best served by residential care rather than community-based care or how residential care should be combined with community-based care to best serve at-risk youths over time. Many program officials and other experts we spoke with said that further research is needed into the effectiveness of residential care and other treatment approaches. This could be an appropriate role for the federal government. The programs we reviewed differed greatly from one another in such respects as size, setting, and treatment approach. Despite these differences, program officials considered certain characteristics to be key for success. These 11 characteristics (see pp. 16-21) included involving a parent or other concerned adult in the client's care, placing a strong emphasis on building self-esteem, and planning for the youth's return to the community after completing the program. One of the characteristics that seemed to be particularly important was an effective link with community-based services that continue to support high-risk youths and their families after the youths leave residential care. RESIDENTIAL PROGRAMS PROVIDE BENEFITS, BUT MORE INFORMATION ON THEIR EFFECTIVENESS IS NEEDED ------------------------------------------------------------ Letter :4 All programs we contacted reported positive outcomes for some youths, such as achieving certain educational or employment goals or avoiding illegal activity after completing the program. However, few programs conducted rigorous evaluations to measure effectiveness or long-term outcomes. Program reports ranged from a one-time collection of data to a rigorous study using a control group. Programs we reviewed typically reported outcome data on participants for periods of 12 months or less after discharge. None of the studies we reviewed referred to any specific criteria that could be used to evaluate the results reported. The following examples depict the results reported at 12 months after discharge: Of 27 participants in the Eckerd Family Youth Alternatives, Inc., Wilderness Educational System, Camp E-How-Kee (Brooksville, Florida), who were discharged in the 1991-92 year and for whom data were available, 18 (67 percent) had neither dropped out of school nor been truant. Of 113 youths released from Boysville of Michigan, Clinton Campus, in 1991, 17 (15 percent) were employed full- or part-time, 64 (57 percent) were unemployed, and the employment status of 32 (28 percent) was unknown. Of the 52 participants who successfully completed the Starr Commonwealth, Cedar Village program (Albion, Michigan) in 1991, 40 (77 percent) had no record of subsequent arrests. Twelve (23 percent) were rearrested, and 8 (15 percent) of them were convicted. Of the 30 participants from the KidsPeace National Centers for Kids in Crisis, Presidential Treatment Center (Bethlehem, Pennsylvania) contacted 12 to 24 months after their discharge in 1990, 23 (77 percent) were in school or had earned a general educational development (GED) certificate. Studies of 14 of 18 programs we contacted did not use control or comparison groups. We could therefore not determine whether the outcomes reported were due to the programs' treatments or to other factors. However, one program we visited--Father Flanagan's Boys' Home, Boys Town Home Campus near Omaha, Nebraska--had conducted two longitudinal studies using a comparison group, and another--New Life Youth Services, Paint Creek Youth Center in Bainbridge, Ohio--had conducted a study using a control group. Boys Town Home Campus, in two separate studies, compared outcomes for its youths to outcomes for another group of youths who were referred to the program during the same period, and met eligibility or admission requirements, but did not attend. One study, which looked at educational attainment and occupational status, found Boys Town participants outperforming the comparison group on most measures. For example, 83 percent of participants had graduated from high school or obtained a GED, compared to 69 percent of the comparison group. The other study, which looked at relations with friends, family, and supervising adults, found significantly more improvement over time among Boys Town participants than among the comparison group. Paint Creek Youth Center randomly assigned youths to control and treatment groups to evaluate its effectiveness as an alternative to a state correctional facility. The incarceration rate for Paint Creek participants 1 year after discharge was 23 percent compared to the control group's 29 percent. This difference was not statistically significant. However, study investigators commented that, despite the lack of a statistically significant difference, the Paint Creek study should lend support to the argument that such programs can be run as cost effectively as training schools and without undue risk to the public. Information is also limited in two other important areas: treatment effects over the long term and the place of residential care in the continuum of treatment. Longer term data are needed to test the endurance of treatment effects. Our review of the literature identified a number of studies that found that some youth leaving residential facilities have a difficult time maintaining treatment gains. Five programs we contacted studied program effects longer than 12 months after discharge. One of them--Boysville--found that, for the 317 youths discharged in 1987 from its residential programs, the cumulative reimprisonment rate rose from 9 percent in the first year following discharge to 15 percent in the second year and to 20 percent (a total of 62 youths) in the third year. Information is also limited on the appropriate place of residential care in the service continuum--that is, which at-risk youth are best served by residential care rather than community-based care and how residential care should be combined with community-based care to best serve at-risk youth over time. Boysville has been examining the relative roles of its residential care and community-based programs in serving at-risk youth and their families and has concluded that changes should be made in its residential care approach. Program officials reported that while they had always believed their program to be superior, it did not fully meet their high expectations. Therefore, they concluded that a radically different approach to serving clients was needed. As a result, Boysville officials are planning to restructure their program by shortening the time youth spend in residential care and placing increased emphasis on community-based care. Program officials and other experts stated that rigorous studies of long-term program effectiveness using control or comparison groups are difficult to conduct. Specifically, program officials cited the following barriers to conducting such studies: difficulty tracking youth after they leave the program, high cost, and reservations about the ethics of withholding treatment from a control group. Without such evaluations, however, program officials have limited data to show the specific effects their treatment has had on the lives of the clients they have served, and policymakers lack information on whether programs have been a worthwhile social and economic investment. Officials from 14 of the 18 programs we reviewed said studies are needed that (1) are longitudinal and use control groups, (2) identify youth who would be best served by residential treatment, and (3) determine whether some youth could be successfully treated in less costly, less restrictive nonresidential settings. Further, some experts suggested that an appropriate federal role might include supporting effectiveness studies of residential care and other treatment approaches. Experts and program officials cited both advantages and disadvantages to residential care. On the positive side, experts with whom we spoke and the literature we reviewed indicated that residential care is suited for addressing the needs of some at-risk adolescents because providing comprehensive services, around-the-clock contact with clients, and services focused on individual needs can provide an effective treatment environment; removing clients from dangerous home and community influences can provide a safe setting for addressing their problem behaviors; and establishing a routine and discipline can bring order to what may have been fairly chaotic lives. On the other hand, our review of the literature suggests that residential care is a restrictive form of care; can disrupt youths' attachments because it removes them from family and community, which is the setting to which treatment gains will have to transfer if positive outcomes are to be sustained after discharge; and is costly. For example, 10 of the 18 residential programs we contacted cost over $40,000 per youth for a year of treatment. However, not enough is known about the long-term effectiveness of residential care, or where it best fits in the continuum of services, to determine under what circumstances it may be cost effective compared with other types of care such as community-based treatment. PROGRAMS VARY IN APPROACH BUT SHARE KEY CHARACTERISTICS ------------------------------------------------------------ Letter :5 The programs we contacted varied considerably in setting and size, the types of troubled youth they serve, their treatment approach, cost, and funding sources. Program types ranged from a small urban program that served 8 homeless adolescent girls who had been actively engaged in prostitution or at risk of doing so, to a large suburban program on a 1,400-acre campus serving 560 young men and women with a variety of problems. Average length of treatment ranged from 6 months to 2 years, with a median stay of 12 months. Table 1 summarizes selected aspects of the programs we visited, and table 2 shows these aspects for the programs we contacted by telephone. The programs served youth with a wide variety of problems, ranging from felony offenses, such as aggravated assault or burglary, to truancy and defiance of parental authority. One program we visited--Piney Woods Country Life School near Jackson, Mississippi--primarily served youth who were not exhibiting specific problem behaviors but, in many cases, came from dangerous urban neighborhoods. Two other programs, The Hyde School in Bath, Maine, and Oasis Center, Michael's Kids House in Nashville, Tennessee, did not keep records of problem behaviors exhibited by their students before they came to the program. With the exception of these three programs, officials at all others reported that some youth in their programs exhibited all four risky behaviors--poor performance in school, delinquency, substance abuse, and early unprotected sexual activity. Further, as indicated in figure 1, 10 of the programs estimated that 50 percent or more of program youths exhibited all four behaviors. Table 1 Residential Programs GAO Visited Vary in Setting, Size, and Cost Salesmanship Program Boysville Bridge Boys Town Hyde Paint Creek Piney Woods Camp Starr Threshold ----------------- ---------------- ---------------- ---------------- ---------------- ---------------- ---------------- ---------------- ---------------- ---------------- Setting Clinton, Boston, Boys Town, Bath, Maine Bainbridge, Piney Woods, Hawkins, Texas Albion, Seattle, Michigan Massachusetts Nebraska Ohio Mississippi Michigan Washington A 150-acre Tents on a A 60-acre Restored living A 1,400-acre campus--the A complex of A 2,000-acre 1,250-acre Cottages on a First, a youth treatment space on four campus former estate of barrack-like campus wilderness 350-acre campus shelter, then complex on a floors of a in suburban shipbuilder John dormitories and in a rural campsite in rural south- apartments in 400-acre campus rectory in a Omaha S. Hyde other facilities setting central residential residential area in a rural area Michigan areas Percent of youth 70 20 60 Not provided 77 Not provided 29 75 75 with all four risky behaviors\a Average 1992 121 16 558 195 28 345 65 58 6 population Average stay 12 months 8 months 18 months 2 years 17 months Not provided 6 months 10 months 19 months Treatment cost\b One year $46,508 $22,609 $49,279 $16,923 for 9- $35,188 $19,443 for 9- $25,738 $51,373 $28,927 Average stay $46,508 $15,073 $73,918 month school $51,023 month school $12,869 $42,811 $45,802 year year Funding source Percentage 93 72 23 - 96 - 12 96 93 public 7 28 77 100 4 100 88 4 7 Percentage private ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- \a Risky behaviors are (1) poor performance in school, (2) substance abuse, (3) delinquency, and (4) early, unprotected sexual activity. Percentages are based on program officials' estimates. \b Annual treatment costs are computed by dividing total program budget by average population. Costs vary across programs and are not strictly comparable. All programs provide services that target each of the four risky behaviors. However, some programs collaborate with existing community providers to provide such services as schooling at no cost to the program, while other programs employ their own teachers to educate clients. Other cost variations may reflect differences in the education level and intensity of staffing, type of facility, or other factors. Table 2 Residential Programs GAO Contacted by Telephone Vary in Setting, Size, and Cost Children's Program Village Eastern Nebraska Eastfield Eckerd Harbor Hillside KidsPeace Oasis Pressley ----------------- ---------------- ---------------- ---------------- ---------------- ---------------- ---------------- ---------------- ---------------- ---------------- Setting Dobbs Ferry, New Omaha, Nebraska Los Gatos, Brooksville, Haverhill, Rochester, New Bethlehem, Nashville, Ona, West York California Florida Massachusetts York Pennsylvania Tennessee Virginia A large group One of 21 home in a Three cottages A wilderness A restored home Cottages in an A complex of 7 First, a group Program in residential residential on a campus in a camp in central in a residential urban cottages on a home in a small, rural treatment setting residential area Florida neighborhood of neighborhood suburban campus residential community cottages on a a small town near Hillside's area; apartments campus school later Percent of youth 10 100 35 100 90 5 50 Not provided 50 with all four risky behaviors\a Average 1992 12 8 24 56 15 48 97 13 19 population Average stay 15 months 9 months 15 months 13 months 12 months 12 months 15 months 9 mos. (group 7 months home) Treatment cost\b One year $65,496 $24,740 $132,493 $41,071 $51,986 $51,746 $84,168 $24,321 $49,772 Average stay $79,141 $18,555 $165,616 $45,863 $51,986 $51,746 $105,210 Not provided $29,033 Funding source Percentage 87 100 94 52 99 100 97 89 100 public 13 - 6 48 1 - 3 11 - Percentage private ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- \a Risky behaviors are (1) poor performance in school, (2) substance abuse, (3) delinquency, and (4) early, unprotected sexual activity. Percentages are based on program officials' estimates. \b Annual treatment costs are computed by dividing total program budget by average population. Costs vary across programs and are not strictly comparable. All programs provide services that target each of the four risky behaviors. However, some programs collaborate with existing community providers to provide such services as schooling at no cost to the program, while other programs employ their own teachers to educate clients. Other variations may reflect differences in the education level and intensity of staffing, type of facility, or other factors. Figure 1: Youths Who Exhibit All Four Risky Behaviors Constitute Differing Percentages of Program Populations (See figure in printed edition.) Notes: Programs are listed by increasing percentage of youths (left to right) who exhibited the following four risky behaviors: (1) poor performance in school, (2) delinquency, (3) substance abuse, and (4) early, unprotected sexual activity. Two of the eighteen programs were unable to provide data on problem behavior. The annual cost of serving one youth ranged from about $20,000 to about $132,000, with a median cost of about $44,000. The most costly programs did not necessarily serve youth with the highest percentage of risky behaviors. (See fig. 2.) Figure 2: Annual Treatment Costs Do Not Appear to Be Linked to the Percentage of Youths With Four Risky Behaviors (See figure in printed edition.) Notes: Programs are listed by increasing percentage (left to right) of youth who exhibited all four risky behaviors. Annual treatment costs are computed by dividing total program budget by average population. Two programs could not provide data on the percentage of youth with all four risky behaviors. The annual cost per youth at these programs are (1) Hyde School, $20,073 and (2) Oasis Center, Michael's Kids House, $24,321. While most programs depended largely on public funding, funding sources varied considerably. Fourteen of the 18 programs in our study received over half of their funding from public sources, and 10 received 90 percent or more. While most public funds were from state governments, some of this money included federal funds for foster care and other purposes that were passed on to the programs by the states. Few program officials we interviewed could provide us with complete information about the portion of public funds for their programs that originated at the federal level. Although programs we studied varied with respect to the severity of the participants' problems, we found several similarities among participants' backgrounds. Twelve of the programs reported that most youth were from low-income families; seven said most of their participants came from dangerous or crime-ridden neighborhoods. Reported rates of sexual abuse among youths at 15 of the programs were high, ranging from 30 to 100 percent of the girls and 20 to 70 percent of the boys. Eleven programs said at least 80 percent of their youth had previous out-of-home placements, including foster care, psychiatric hospitals, group homes, and jails. Amid the considerable variety of program approaches, program officials and other experts said that certain key elements were important for success. Descriptions of these 11 key elements follow. DEVELOPING INDIVIDUAL TREATMENT PLANS ---------------------------------------------------------- Letter :5.1 According to program officials, nearly all programs in our study developed individual treatment plans for each youth. Plans, in some cases, are updated at specific intervals, such as monthly. Often the youth participate in the planning process by identifying issues they need to address and in setting goals. At Starr Commonwealth, Cedar Village, each youth's plan is discussed in monthly peer group meetings. One program official from Boysville noted that if youths can see their own treatment gains, they will begin to see themselves as successful. PARTICIPATION OF A CARING ADULT ---------------------------------------------------------- Letter :5.2 Important in many youths' successful experiences in such programs, officials said, was the presence of a caring adult, such as a counselor or other staff member. For example, a Boys Town official told us that his program asserts that all behavioral change can only take place in the context of a caring relationship--youth will listen and learn only from adults they believe care about them. A Starr Commonwealth official said his program's expectation is that the trust developed in an adult will extend to other adults after youths leave the program. At Boys Town Home Campus and the Salesmanship Club Youth Camp, staff live with the youths around the clock, 7 days a week, and are involved in virtually all of the youths' activities. SELF-ESTEEM BUILDING ---------------------------------------------------------- Letter :5.3 According to officials from most programs, it is important for the programs to provide opportunities to build self-esteem so that youths can develop a sense of success; two officials told us that the youths in the programs are accustomed to failure. Programs build self-esteem through such activities as sporting events, physical education, and academics and by teaching practical skills such as planning and budgeting for household expenditures. PLANNING FOR POST-PROGRAM LIFE ---------------------------------------------------------- Letter :5.4 Planning for transition from the program may begin as soon as youths enter the program. An official from Harbor Schools and Family Services, Haverhill Program (Haverhill, Massachusetts) said program officials begin to talk with youths about discharge and arranging placement even before admission. After leaving residential programs, youths are discharged to such settings as their biological families, foster care, or independent living. To prepare for the transition, some programs connect the youths to services in their community and work with the family to strengthen relationships and resolve problems such as substance abuse. During their stay, youths are provided assistance with career planning, vocational education, and finding a suitable place to live. TEACHING SOCIAL, COPING, AND LIVING SKILLS ---------------------------------------------------------- Letter :5.5 One of the most important purposes of residential care is to prepare youths to function in the everyday world. To this end, youths are taught skills such as establishing good work habits, handling confrontations, and planning and preparing nutritious meals. Some youths have never learned how to hold a meaningful conversation around the dinner table or have never been required to keep their rooms tidy. Programs use group activities as well as individual instruction to develop and enhance these skills. In some programs, special events are used to teach practical lessons and skills. Youths at the Salesmanship Club Youth Camp, for example, plan and work together as a group to organize and carry out week-long camping trips. Youths at Boys Town Home Campus share a daily family-style dinner, which they help to prepare, with their house mates and family teachers (surrogate parent figures who live with the youth on a 24-hour basis). COORDINATION OF SERVICES ---------------------------------------------------------- Letter :5.6 Program officials viewed coordination of services as important, whether the services were provided by a single caseworker or a team. At Boysville, Clinton Campus, teams of directors, specialists, educational coordinators, and others who work with the families track the academic, social, and family progress of each youth under their care and collaborate in carrying out treatment goals. At Boys Town Home Campus, the family teachers coordinate all services provided to the youths entrusted to their care. INVOLVING THE FAMILY ---------------------------------------------------------- Letter :5.7 Programs acknowledge that youths' problem behaviors are often related to family problems and dysfunction. Several programs we contacted involve families as part of the formal treatment approach, and three programs require such participation. The Hyde School requires parents to agree to attend certain activities before the school agrees to admit students. Parents are required to participate three times a year with their children at the school in several days of group discussions and physical challenges, including rigorous outdoor activities. The Salesmanship Club Youth Camp requires the parents to participate in therapy during their child's stay in camp and encourages the parents to continue therapy for 6 months after their child's release. Programs that involved the family typically had social workers and therapists work with parents individually, in parent support groups, and with parents and children together. Some programs provided counseling for parents as well as treatment for problems such as substance abuse. While nearly all programs we contacted considered family involvement to be desirable, some said it was not always feasible. The program may be too far from a parent's residence or a family may be unwilling to participate. POSITIVE PEER CULTURE ---------------------------------------------------------- Letter :5.8 Peer influence is used to effect healthy behavior changes in youths. For example, three programs that serve mostly youths who are convicted felons use participants' influence on each other to foster insight and growth. At all three programs, youths are assigned to peer groups and conduct nearly all their activities in these groups. Staff work with the peer groups to foster desirable values and behavior patterns. At Starr Commonwealth, Cedar Village, and Boysville, Clinton Campus, for example, daily group meetings focus on a particular experience or problem surfaced by one of the youths from personal experience. Youths also initiate impromptu meetings to call one another to task for negative behaviors. ENFORCING A STRICT CODE OF DISCIPLINE ---------------------------------------------------------- Letter :5.9 Officials from several programs believed a strict code of discipline for residents was of great importance. At The Hyde School, for example, accountability is the fundamental structure on which the school's discipline system is built. Students encourage each other to report violations of school rules. If a student knows, but does not report, that another student has disobeyed Hyde rules, both students are considered equal offenders and subject to discipline. POST-PROGRAM SUPPORT --------------------------------------------------------- Letter :5.10 Twelve of the programs we contacted continue services, such as counseling and school placement for the youths and family counseling, after the youths are discharged from residential care. Of those programs that do not directly provide aftercare, four told us that they link the youths and their families with such services in the community. A number of research efforts have suggested that a youth's environment after discharge is crucial to sustaining the effects of residential treatment. For example, a 1966 study of a group of 50 boys who were discharged from the Bellefaire Jewish Children's Bureau's residential program in Ohio found that successful outcomes were directly related to the quality of the family environment to which youths returned after discharge.\2 A 1991 study of youths discharged from the same residential setting in the mid-1980s confirmed the importance of post-program support.\3 One program we contacted--The Children's Village in Dobbs Ferry, New York--conducted a study of aftercare. This study, now in its ninth year, is demonstrating the effectiveness of intensive aftercare provided to a sample of youths (all males, mostly aged 13 when they entered the program) discharged from the residential program. The aftercare included counseling to help participants complete school, secure employment, and adjust in the community. The program also encouraged participants to save money by offering to match what they had saved. The comparison group consisted of youths from The Children's Village whose aftercare was limited to such contact as bimonthly mailings on job training and education and verbal encouragement. Among the findings from the first 6 years of this study was a 12-percent school dropout rate among the group receiving intensive aftercare versus a 29-percent rate for the comparison group. -------------------- \2 M.E. Allerhand, R. Weber, and M. Haug, Adaptation and Adaptability: The Belle Faire Follow-up Study (New York: Child Welfare League of America, 1966). \3 K. Wells, E. Wyatt, S. Hobfall, "Factors Associated With Youth Discharged From Residential Treatment," 1991, Children and Youth Services Review, 13, 199-216. PROVIDING A FAMILY-LIKE ATMOSPHERE --------------------------------------------------------- Letter :5.11 According to program officials, because many at-risk youths have not had the opportunity to grow up in constructive family environments, several of the programs help youths develop skills and relationships in a healthy family-like setting. Use of this approach was particularly important at Boys Town Home Campus, where the treatment approach centers around a teaching family headed by a married couple that acts as surrogate parents. Teaching parents participate in such activities as shopping with the youths, taking them to medical appointments, attending school functions, and helping them with their homework. The youths have household responsibilities such as cleaning their rooms and planning and cooking daily meals. Similar to Boys Town, the Bridge Over Troubled Waters Transitional Living Program in Boston, Massachusetts, operates its program much as a household would operate, with participants scheduled to shop, cook, and do other chores on a rotating basis. Figure 3 shows the number of program officials citing each key element as important to their programs' success. Although 12 programs provide post-program support and considered it to be of great or moderate importance to their success, four others considered it important but were unable to provide it. Figure 3: Program Elements That Officials Consider Important to Success (See figure in printed edition.) CONCLUSIONS ------------------------------------------------------------ Letter :6 While few rigorous evaluations of residential programs have been done, the outcome studies conducted to date suggest that residential care can be successful as a treatment approach for some high-risk youths. However, limited information is available to draw conclusions about how residential care can be best applied in the continuum of services for high-risk youths and their families. Additional study is needed to answer such questions as which youth are best treated in residential settings and which would be better treated in less restrictive and less costly community-based programs. In particular, rigorous evaluations are needed to determine which treatment approaches are most effective and what the long-term effects of the treatment are for youths--in residential and other programs--so policymakers can make sound decisions about the most effective mix of programs and the best role for residential care. Although conclusions cannot be drawn about the success of residential programs, there appears to be some consensus among program officials and other experts that certain key elements enhance the programs' ability to alter high-risk behavior. Program officials agree that any effective residential program for high-risk youths should include such elements as a close alliance with the youths' families whenever possible as well as continuing support after the youths have left the residential setting and returned to their community. The scarcity of rigorous outcome studies limits the ability of policymakers to determine whether support for residential programs constitutes the best use of limited public resources. Conducting rigorous program evaluation is expensive and complicated. However, without such research, questions will remain about what the most cost-effective approaches are for treating at-risk youths. MATTER FOR CONSIDERATION BY THE CONGRESS ------------------------------------------------------------ Letter :7 If the Congress decides that the federal government should reexamine its financial support for programs serving at-risk youth, it should consider earmarking funds for rigorous evaluations of residential care and other treatment approaches for this population to determine what kinds of programs work best for which youths and the appropriate place of residential treatment on the service continuum. ---------------------------------------------------------- Letter :7.1 We are sending copies of this report to the Secretary of Health and Human Services, the Attorney General, appropriate congressional committees, and other interested parties. Please call me on (202) 512-7119 if you or your staff have any questions. Other major contributors to this report are listed in appendix IV. Sincerely yours, Mark V. Nadel Associate Director, National and Public Health Issues PROGRAMS GAO VISITED =========================================================== Appendix I The following descriptions of nine programs we visited contain data obtained from interviews with program officials and written material they provided. We did not verify the data--including program costs and the effectiveness studies and reports. The methodologies used to measure program outcomes and the factors they measured varied, thereby preventing comparison among programs. Programs are listed in alphabetical order. BOYSVILLE OF MICHIGAN, CLINTON CAMPUS --------------------------------------------------------- Appendix I:1 The program seeks to meet the social, educational, economic, and spiritual needs of its clients and staff through such means as providing a community-oriented living and working environment and maintaining group programs that incorporate peer influence, individual attention, family involvement, and staff teamwork in an open setting. Boysville expects its youth to become more responsible and to learn to appreciate their own and others' personal worth. SETTING ----------------------------------------------------- Appendix I:1.0.1 The Clinton Campus in Clinton, Michigan, one of Boysville of Michigan's 13 residential programs, covers 400 acres of mostly crop land, of which 60 acres are reserved for the treatment program. The campus includes dormitories, school and recreational facilities, a central cafeteria, and administrative offices. Boysville of Michigan, Inc., headquartered on the Clinton campus, is a private, nonprofit child and family service agency serving about 900 clients a year in Michigan and Ohio through its residential, community, and home-based programs. NUMBER OF YOUTH SERVED IN 1992 ----------------------------------------------------- Appendix I:1.0.2 The maximum capacity of the program was 125; the average population at a given time was 121. The total population served was not provided. CHARACTERISTICS OF YOUTHS SERVED ----------------------------------------------------- Appendix I:1.0.3 The program serves boys aged 12 and older, 60 percent of whom come from the Detroit area. About half are adjudicated delinquents who would otherwise serve their sentences in the state's training school; the other half are wards of the state Department of Social Services and referred because of delinquent conduct. Clinton accepts the more severe delinquency cases--referred boys have committed crimes against property or persons, drug-related offenses, or sexual offenses. However, Clinton does not accept boys who are psychotic, who do not have the mental capacity to participate in the education program, or who have a history of unprovoked assaults. Of the 1992 participants, about two-thirds were African-American and one-fourth white. Nearly all of the 1992 participants had at least one previous placement and 73 percent had single parents. Based on disclosures during counseling sessions, staff estimate that 70 to 100 percent of the boys had been sexually abused. About 70 percent of the youths served have exhibited all four risky behaviors: poor performance in school, substance abuse, delinquency, and early, unprotected sexual activity. LENGTH OF STAY ----------------------------------------------------- Appendix I:1.0.4 The average length of stay was 1 year; stays ranged from 8 to 16 months. COST PER YOUTH ----------------------------------------------------- Appendix I:1.0.5 For 1 year of treatment, the cost was $46,508; for an average stay of 1 year, the cost was $46,508. FUNDING SOURCES ----------------------------------------------------- Appendix I:1.0.6 The following funding sources are for all of Boysville of Michigan, Inc., including the Clinton Campus. Percent ---------------------------------------------------------------------- -------- Ohio and Michigan state Departments of Social Services fees and county 64 fees, exclusive of any federal funds Title IV-E Foster Care passed through the state 25 Donations and other private support 6 U.S. Department of Health and Human Services grants 2 U.S. Departments of Agriculture and Justice grants 2 Investment income and other 1 -------------------------------------------------------------------------------- TREATMENT APPROACH ----------------------------------------------------- Appendix I:1.0.7 Boys are assigned to a peer group of about 12, who live, eat, attend classes, and undergo daily therapy sessions together. The sessions are facilitated by a treatment coordinator. The sessions begin with each member in turn stating an issue, such as anger management or victimization, that he's working on at the time. The group then decides to focus the meeting on one member, who receives help to talk through and think about his issue and is offered advice when possible. At the end of the meeting, the treatment coordinator summarizes the discussion and comments on the group dynamics. In addition, if at any time a group member feels that someone in the group is acting inappropriately, he can call a "circle," meaning the group members circle around and talk through the issue. The treatment coordinator is a member of an interdisciplinary treatment team responsible for formulating and implementing each boy's treatment goals and tracking progress. Family therapy is a key component of treatment--staff try to involve the family in counseling sessions, which may continue for up to 6 months after discharge. Throughout the program, Clinton staff emphasize four basic values--to help, respect, trust in, and take responsibility for self and others. As boys learn to control their behavior and demonstrate they are learning the basic values, they are moved along a three-step system leading to their release. Boys move from the first step, where they are expected to need much guidance from their peers and staff, to the last, where they are expected to do the right thing for the right reason without relying on rules, staff direction, or peer opinions. EFFECTIVENESS DATA ----------------------------------------------------- Appendix I:1.0.8 Routinely collected data. At 3 and 12 months after departure, Boysville staff conduct telephone surveys of youths and their families. A comparison of some 3- and 12-month outcomes for the 113 youths released from the Clinton Campus in 1991 follows: 59 percent were in a setting less restrictive than the Clinton Campus at 3 months after discharge; at 12 months, that figure was 52 percent. However, the drop mainly reflects an increase in the "unknown" category. The number of boys who were enrolled in school decreased from 53 percent 3 months after discharge to 46 percent at 12 months after discharge. The decline is due to those who had dropped out of school and had not obtained a high school diploma or a general educational development certificate. Special studies. No special studies have been conducted specifically of the Clinton campus. However, Boysville has done several studies of its programs' performance in general. In one study, Boysville analyzed the imprisonment rates of youth released from its group homes and campus-based residential facilities in 1985 and 1987. Twenty-five percent of those who were tracked for 5 years (1985 cohort) and 20 percent of those who were tracked for 3 years (1987 cohort) were imprisoned in Michigan. The type of treatment received (campus-based residential treatment or community-based group home) and the legal status (child welfare case or delinquency case) were found to be unrelated to imprisonment rates, but two other factors were found to be significant: boys released to their homes, relatives' homes, or independent living situations were less likely to be imprisoned, and nonwhite boys who had multiple convictions before coming to Boysville were more likely to be imprisoned. Boysville also analyzed 1982-89 outcome data for its Michigan residential programs. Analysts found declines in the percentage of boys successfully released who were still maintaining a less restrictive living situation 12 months after release. Successful completion means a boy has met all or nearly all of his treatment goals such as improving academic skills or developing appropriate and productive relationships. Of the successful releases in 1982, 68 percent were in a less restrictive setting 12 months after release. Of the successful releases in 1989, 54 percent were in a less restrictive setting 12 months after release. Using 1990 data, Boysville also evaluated the cost effectiveness of two residential programs, a foster care program, and a home-based program. Boysville found that the residential programs cost more than the other programs and resulted in fewer successful releases than the home-based program--but more than the foster care program. With regard to campus-based residential care, these special studies led Boysville to propose shortening the time boys spend in such care and provide longer term and more intensive community-based aftercare for youths and their families. Boysville plans to assign campus-based residential care a more limited role in the continuum of services the agency offers. Campus-based residential care would be reserved for those youths who cannot initially be safely treated in the community (because of potential harm to themselves or others) or who have already demonstrated an unwillingness or inability to respond to community-based treatment. Boysville officials said that, ideally, youths should be placed in the least restrictive setting available, such as a nonresidential program, in the continuum of care. THE BRIDGE OVER TROUBLED WATERS TRANSITIONAL LIVING PROGRAM --------------------------------------------------------- Appendix I:2 The Bridge Transitional Living Program aims to help youth make the transition from the streets to become fully sustaining members of society. SETTING ----------------------------------------------------- Appendix I:2.0.1 The Bridge Transitional Living Program occupies four floors of a remodeled rectory in a lower-income Boston residential neighborhood. The first floor contains a kitchen/eating area and a living area; bedrooms are on the upper floors. Rooms are simple but light and spacious, and decorations reflect occupants' preferences. The program is one of a variety of services provided by Bridge Over Troubled Waters, a nonprofit organization in Boston. Bridge's other services include an independent living program, medical outreach van, GED program, medical and dental care, a substance abuse counseling program, and runaway and family counseling. NUMBER OF YOUTHS SERVED IN 1992 ----------------------------------------------------- Appendix I:2.0.2 The maximum capacity for the program was 16; the average population at a given time was 16. The total served was 43. CHARACTERISTICS OF YOUTHS SERVED ----------------------------------------------------- Appendix I:2.0.3 The program serves both men and women ranging in age from 16 through 22; in 1992, 74 percent were under age 20. The primary reason for referral to the program is homelessness. However, about 80 percent of these youths have been physically abused or neglected and about 40 percent, sexually abused. Forty percent are white; 40 percent, African-American; and 20 percent, Hispanic. About 20 percent of the youths served have exhibited all four risky behaviors: poor performance in school, substance abuse, delinquency, and early unprotected sexual activity. LENGTH OF STAY ----------------------------------------------------- Appendix I:2.0.4 The average length of stay was 8 months; stays ranged from 6 to 18 months. COST PER YOUTH ----------------------------------------------------- Appendix I:2.0.5 For 1 year of treatment, the cost was $22,609; for an average stay of 8 months, the cost was $15,073. Costs do not include education. FUNDING SOURCES ----------------------------------------------------- Appendix I:2.0.6 Percent ---------------------------------------------------------------------- -------- HHS Transitional Living Program grant 62 HHS Runaway and Homeless Youth grant 10 Foundations and corporations 16 United Way 10 Local donations 2 -------------------------------------------------------------------------------- TREATMENT APPROACH ----------------------------------------------------- Appendix I:2.0.7 The program prepares homeless adolescents to live independently. The program coordinator works with each youth to design a specific plan at intake. Based on that plan, youths receive individual and group therapy, medical services, and education at other facilities both within and outside Bridge. However, youths return "home," i.e., to the Bridge Transitional Living Program, each evening to a full complement of housekeeping, cooking, and gardening jobs and time with the peers they come to regard as a family and a support group. The house setting, peer group, and program coordinator--who is in charge of the house and is seen as a parent figure--are much like a family. Program officials regard this environment as critical and see the family setting as enabling youths, who have been largely isolated, to open up and receive support on hurtful issues. In addition to functioning as a parent figure, the program coordinator also facilitates a Tuesday night meeting, with compulsory attendance, at which youths review events of the previous week, including the consequences of their actions on others and on the effective functioning of the household. The program generally does not release youths until they are involved in a job or vocational program. Some go on to the Bridge Independent Living program, perhaps to share an apartment based on a friendship formed at the Bridge Transitional Living Program. Bridge recently began a follow-up group aimed at maintaining youths' contacts with Bridge after discharge. EFFECTIVENESS DATA ----------------------------------------------------- Appendix I:2.0.8 Routinely collected data. For the 1993 annual report, the Bridge compiled data on outcomes such as education, living situation, and work status of 13 youths who were at the Bridge Transitional Living Program for at least 6 months beginning in September 1991 and had been out of the program between 1 and 15 months. The report shows that 9 (69 percent) were working full time, two (15 percent) were in college full time, and the other two were rearing children who were being supported by the children's fathers; and 11 (85 percent) had earned a high school diploma or GED certificate--10 since coming to the Bridge Transitional Living Program--and the other 2 (15 percent) were still enrolled in a GED program. Special studies. A 1986 report summarized the results of a 2-year study by a researcher at the University of Massachusetts who evaluated outcomes of 2 years' participants in Bridge House, the precursor to the Bridge Transitional Living Program. The report examined the program's effectiveness in achieving improved self-concept and more stable education, employment, and living status for a group of 16- and 17-year-old youths. The study reported that 11 youths who had been out of the program an average of 5.7 months fared significantly better than did a group of 18 youths with similar backgrounds who were involved in programs other than Bridge's transitional living program. For example, 10 (91 percent) of the program youths were employed, compared with eight (44 percent) of the non-Bridge group; and 7 (64 percent) of the program youths were in school or had graduated compared with six (33 percent) of the non-Bridge group. The Bridge Transitional Living Program is one of 10 study sites included in a federally funded multiyear transitional living program study. The study will gather information--such as living situation, change in drug and alcohol use, and progress in education--at intake, 6 months later, and 6 months after discharge. FATHER FLANAGAN'S BOYS' HOME, BOYS TOWN HOME CAMPUS --------------------------------------------------------- Appendix I:3 The program seeks to provide food, clothing, shelter, medical care, education, spiritual development, and treatment for the behavioral and emotional problems of homeless, abused, neglected, and delinquent youths who require out-of-home placement. In doing so, it hopes to give them the skills they need to live in a larger society and lead useful lives. SETTING ----------------------------------------------------- Appendix I:3.0.1 Boys Town's Home Campus consists of about 1,400 acres in suburban Omaha, Nebraska. It contains a high school and middle school, churches, a hospital, a farm, research and training facilities, administrative offices, and 76 homes--each of which houses two family teachers and four to eight youth. In addition to the Boys Town Home Campus residential care, Father Flanagan's Boys' Home provides a variety of services, including emergency shelters, therapeutic foster care, family preservation, and parent training. The organization has used programs developed at the home campus as models for Boys Town USA sites it has established in 13 cities across the country. It also provides training and consultation to other programs and operates a national hot line. NUMBER OF YOUTHS SERVED IN 1992 ----------------------------------------------------- Appendix I:3.0.2 The maximum capacity was 562; the average population at a given time was 558. The total served was 847. CHARACTERISTICS OF YOUTHS SERVED ----------------------------------------------------- Appendix I:3.0.3 Boys Town serves mainly boys and girls who are 13 to 19 years old. The average age at admission is about 15. Most are referred to the program by social service agencies. They typically come from low-income families who live in midwest urban neighborhoods that are marred by crime and drug problems. They have an average of two prior placements such as foster care or group homes, and about 30 percent have juvenile court arrest records. Fifty-eight percent are white, 24 percent are African-American, and 18 percent are other minorities. Nearly 73 percent of the youth admitted are considered out of control of parental authority. Other common problems include vandalism and theft, verbal aggression, and school learning problems. Program officials estimate that about 80 percent of the girls and 35 percent of the boys have been victims of sexual abuse. About 60 percent of the youths served have exhibited all four risky behaviors: poor performance in school, substance abuse, delinquency, and early, unprotected sexual activity. LENGTH OF STAY ----------------------------------------------------- Appendix I:3.0.4 The average length of stay was 18 months; stays ranged from 10 months to 6 years. COST PER YOUTH ----------------------------------------------------- Appendix I:3.0.5 For 1 year of treatment, the cost was $49,279. For an average stay of 18 months, the cost was $73,918. FUNDING SOURCES ----------------------------------------------------- Appendix I:3.0.6 Percent ---------------------------------------------------------------------- -------- Private contributions 33 Father Flanagan's Foundation 26 Fees from public and nonprofit agencies 23 Legacies and bequests 16 Miscellaneous 2 -------------------------------------------------------------------------------- TREATMENT APPROACH ----------------------------------------------------- Appendix I:3.0.7 Boys Town's Family Home Program uses family teachers--specially trained married couples who live in homes on campus with four to eight youths on a year-round basis. The family teachers function in a role analogous to parents--providing counsel, taking the youths shopping and to medical appointments, and teaching them how to live in the family and community. Family teachers also function as the primary treatment agents. They strive to motivate youths to learn appropriate behavior and reduce destructive behavior, offering both praise and corrections throughout the day. They also coordinate the youths' treatment with other agency service providers. As part of a program emphasizing skills needed to operate in family and societal settings, the program teaches skills to resolve disputes and solve problems. Boys and girls are taught to organize their thoughts and daily activities, participate in family life activities, negotiate satisfactory relationships with others, and solve problems rationally. Youths are initially placed on a point system on which they earn or lose points depending on their daily conduct. Positive points earn the youths special privileges for the next day and can be accumulated for larger privileges in the future. Boys Town boys and girls attend the campus high school or middle school whose curricula and teaching methods are designed to address both academic and social skills that will be relevant in school, in their home communities, and in employment settings. Because many youths are reading several years below their grade levels, Boys Town has established a Reading Center where youths receive remedial reading classes and staff conduct research to diagnose and develop new ways to address reading deficiencies. EFFECTIVENESS DATA ----------------------------------------------------- Appendix I:3.0.8 Routinely collected data. In June 1993, Boys Town began to collect outcome data on all youths discharged from its programs--including residential care and family preservation--90 and 180 days after discharge. Boys Town social workers are conducting interviews with the youths and, when appropriate, the families. Information gathered includes where the youths are living, their employment history, and their education status. Boys Town plans to collate the data in quarterly reports that will be used to evaluate treatment effectiveness and modify and improve their programs. Boys Town also hopes to compare the cost effectiveness of its residential care and family preservation programs. The data collection will be expanded to include a random sample of youths 1 year after discharge. Special studies. Boys Town has conducted recent studies of its residential program using comparison groups. Boys Town conducted a longitudinal follow-up study of 497 former residents--who entered Boys Town between May 1981 and June 1985--and compared their progress with that of a group of 84 youths who had been accepted to Boys Town during the same time period but who did not attend. Participants were interviewed by telephone before, during, and every 3 to 6 months after their stay at Boys Town. Final interviews took place in 1989. Results indicated that the Boys Town group did significantly better in such things as rate of graduation from high school, grade point average, and attitudes about the importance and chances of attending college. For example, 83 percent of the Boys Town youth graduated from high school or completed a GED certificate, while 69 percent of the comparison group did so. Another study conducted by Boys Town compared its 1987-1989 graduates--surveyed in 1990--to a sample of "typical" high school graduates. Boys Town graduates were asked about their lives after program completion, in areas such as employment, post-secondary education, and church attendance. Interviewers were able to contact 121 of 193 Boys Town graduates. Study results showed that Boys Town youths--who typically have had more behavior and academic problems--did as well or better than the comparison group in several areas. For example, 93 percent of the Boys Town youths were in school and/or had a job compared to 88 percent of the comparison group and 84 percent of the Boys Town youths reported that they did not use drugs other than alcohol, compared to 62 percent of the comparison group. THE HYDE SCHOOL --------------------------------------------------------- Appendix I:4 The Hyde School seeks to provide a learning environment in which individuals develop character and discover a purpose for their lives. Originally founded as a more general boarding school, the Hyde School has an education approach that emphasizes effort over achievement, which has moved it in the direction of working more closely with youth with behavior problems. SETTING ----------------------------------------------------- Appendix I:4.0.1 The Hyde School in Bath, Maine, is located on a 150-acre campus--the former estate of shipbuilder John S. Hyde. The original mansion has been restored and now houses classrooms and faculty offices. Classes are also held in a converted carriage house. The campus includes 6 dormitories for 12 to 24 students each; a sports complex and several outdoor playing fields; a family learning center for parent weekends and retreats; and a student union, which contains a performing arts center, the student/faculty dining room, and a study hall. NUMBER OF YOUTHS SERVED IN 1992 ----------------------------------------------------- Appendix I:4.0.2 The maximum capacity was 200; the average population at a given time was 195. The total served was 195. CHARACTERISTICS OF YOUTHS SERVED ----------------------------------------------------- Appendix I:4.0.3 Hyde students are boys and girls aged 13 to 19. About 60 percent are male and 40 percent are female. Most students are white; about 10 percent are minorities, including Asian, African-American, and Hispanic. Most students come from upper-income families and neighborhoods. Students come from many states with about 15 percent of them coming from Maine. Most of Hyde's students have a history of family problems. Primary reasons for referral are rebelliousness, lack of respect for authority, and poor performance in school. About 10 percent of the students have been in drug rehabilitation programs. Hyde has an ongoing program to accept a total of five students selected by the Boys Clubs of New York City and the Boys and Girls Clubs of Washington, D.C., based on their potential as students. LENGTH OF STAY ----------------------------------------------------- Appendix I:4.0.4 The average length of stay was 2 school years; stays ranged from 1 to 5 school years. COST PER YOUTH ----------------------------------------------------- Appendix I:4.0.5 For 1 year of treatment (including the Summer Challenge Program), the cost was $20,073. For an average stay of two 9-month school years, the cost was $33,846. FUNDING SOURCES ----------------------------------------------------- Appendix I:4.0.6 Percent ---------------------------------------------------------------------- -------- Tuition payments 92 Contributions 8 -------------------------------------------------------------------------------- TREATMENT APPROACH ----------------------------------------------------- Appendix I:4.0.7 Hyde School is a nonsectarian college preparatory boarding school for grades 8 through 12. Most students live in dormitories on campus. Each dormitory has a school staff member serving as resident house mother or father. Student roommates are matched so that one is an older student and one is a younger or new student. Students are responsible for keeping their rooms clean and for dormitory maintenance, such as cleaning the bathrooms or vacuuming the living room. Students, faculty, and staff eat meals together in the dining hall. Students are required to participate in sports and encouraged to participate in performing arts activities and community service. Hyde students are graded on both their academic achievement and their level of effort in school. Their effort grade must be at least as high as their achievement grade to be acceptable. Hyde maintains that the first step toward appropriate behavior may be just going through the motions but that, eventually, the student will begin to make an effort and finally take responsibility for his or her success. Students are expected to report all inappropriate behavior to staff and are taught that reporting is an act of caring. Students encourage each other to self-report. However, if a student knows, but does not report, that another student has broken school rules, such as by drinking or using drugs, both are treated as equal offenders. Students are not expelled for their inappropriate behavior, but must work on eliminating it. Hyde believes that parental participation in the program is imperative--if the youth is to make permanent life changes, the parent and family must participate and change as well. Parents of Hyde students must attend monthly meetings and a yearly retreat held in their home regions of the country, a 3-day campus seminar, and on-campus family weekends in the fall and spring. EFFECTIVENESS DATA ----------------------------------------------------- Appendix I:4.0.8 Routinely collected data. Hyde keeps records of the number of students who go on to 4-year colleges. School officials report that about 90 percent do so. Special studies. None NEW LIFE YOUTH SERVICES, PAINT CREEK YOUTH CENTER --------------------------------------------------------- Appendix I:5 The program seeks to provide comprehensive, high-quality services tailored to the individual requirements of youths convicted of felonies such as aggravated burglary or manslaughter. The goal is to change the youths' values so that they can stand up to negative influences when they return to the community. SETTING ----------------------------------------------------- Appendix I:5.0.1 Located east of Cincinnati on 32 rural acres in Bainbridge, Ohio, Paint Creek consists of very spartan, barracks-like dormitories and classrooms, an office building containing a kitchen and dining room, and a recreational area. The facility also includes a woodworking shop, basketball court, playing field, and two tennis courts. New Life Youth Services, Inc., a private, nonprofit organization in Cincinnati, provides a variety of residential and community-based programs. NUMBER OF YOUTHS SERVED IN 1992 ----------------------------------------------------- Appendix I:5.0.2 The maximum capacity was 33; the average population at a given time was 28. The total served was 51. CHARACTERISTICS OF YOUTHS SERVED ----------------------------------------------------- Appendix I:5.0.3 Paint Creek serves boys aged 15 to 18 at the time of admission. These boys, who come from southwest Ohio--principally Columbus, Cincinnati, and Dayton--have been convicted of a class 1 or 2 felony, such as aggravated burglary. Between 50 and 75 percent come from low-income families, and between 60 and 70 percent are from crime-ridden neighborhoods. About 60 percent are white; the rest are mainly African-American. Seventy-one percent come from single-parent families and another 11 percent are reported as having no parent. Youths may be referred by the sentencing judge but must pass screening by the Ohio Department of Youth Services. Youths accepted into the program must be able to function in a group and be housed in a facility that is not physically secured. The program does not serve youths who have been convicted of murder nor high-profile youths such as gang leaders. About 77 percent of the youths served have exhibited all four risky behaviors: poor performance in school, substance abuse, delinquency, and early, unprotected sexual activity. LENGTH OF STAY ----------------------------------------------------- Appendix I:5.0.4 The average length of stay was 17 months; information on the ranges of the stays was not available. COST PER YOUTH ----------------------------------------------------- Appendix I:5.0.5 For 1 year of treatment, the cost was $35,188. For an average 17-month stay, the cost was $51,023. Costs exclude medical costs, which are billed directly to Medicaid, and education services, which are provided on site by the local school district. FUNDING SOURCES ----------------------------------------------------- Appendix I:5.0.6 Percent ---------------------------------------------------------------------- -------- Ohio Department of Human Service 93 U.S. Department of Agriculture lunch program 3 Subsidy from New Life Youth Services 3 Wood shop sales and miscellaneous 1 -------------------------------------------------------------------------------- TREATMENT APPROACH ----------------------------------------------------- Appendix I:5.0.7 Paint Creek uses a combination of therapeutic approaches in a strong peer culture. First, boys are required to acknowledge that they have criminal personalities, which they have to overcome by adopting a new way of thinking. Second, they are required to accept responsibility for their own behavior and--individually and collectively--for their rehabilitation. For example, peers (as they refer to one another) call each other to task for behaviors that reflect "thinking errors," such as physical or verbal abuse of others or projecting blame. Paint Creek is second only to state correctional institutions in terms of restrictiveness. Youths move around the campus single file with one hand on the shoulder of the youth in front. During meetings, one youth is assigned to sit in front of the door to discourage others from leaving. Youths are required to earn their way out of the facility, progressing through three levels of increasing privilege. Initially youths must earn such basic amenities as permission to hang a poster behind their beds. Later, youths earn permission to participate in community service activities and to have personal radios. Ultimately, youths earn permission to move around the campus unsupervised after notifying staff and checking in with staff upon their return. While at Paint Creek, boys attend school. The curriculum is intended to parallel the one used in public schools. The program provides a special education section and a high school section into which boys can progress when ready. During a period of intensive aftercare, a community services worker is assigned to the youths as a support person. Initially, a boy can leave the house only with the community service worker's permission and accompanied by a parent, except to go to school, work, or an appointment arranged by Paint Creek staff. Gradually, the youth progresses to increasing freedom of action and less supervision. EFFECTIVENESS DATA ----------------------------------------------------- Appendix I:5.0.8 Routinely collected data. None Special studies. A Rand Corporation study of Paint Creek examined rates of recidivism within 1 year of discharge. The study compared 75 youths assigned to Paint Creek between February 1986 and April 1988 with a randomly assigned control group serving time at two state correctional institutions. The study found Paint Creek youths had a 51-percent rearrest rate compared to 61 percent for the control group. The reincarceration rate was 23 percent for Paint Creek youths compared to 29 percent for the control group. Neither difference was statistically significant. The 1993 Rand report suggested that, despite the lack of statistically significant differences, the Paint Creek study should lend support to the argument that such programs can be run as cost effectively as training schools and without undue risk to the public. PINEY WOODS COUNTRY LIFE SCHOOL --------------------------------------------------------- Appendix I:6 Piney Woods' objectives are to strengthen students' reading, writing, and critical thinking skills; to develop good study habits and a strong work ethic in each student; and to eliminate the sense of academic futility and build a sense of academic achievement. The school believes that, throughout the United States, there are students, especially black students, who have the capability to succeed, but do not have the opportunity to do so for financial or other reasons. SETTING ----------------------------------------------------- Appendix I:6.0.1 The school is 21 miles southeast of Jackson, Mississippi, on 2,000 rural acres that include woods, lakes, farmland, and 50 acres of campus. On the campus are several dormitories, classroom buildings, a cafeteria, a recreation center, administrative offices, a general store, faculty and staff homes, and the log cabin that served as the original school building. NUMBER OF YOUTHS SERVED IN 1992 ----------------------------------------------------- Appendix I:6.0.2 The maximum capacity was 345; the average population at a given time was 345. The total served was 345. CHARACTERISTICS OF YOUTHS SERVED ----------------------------------------------------- Appendix I:6.0.3 Piney Woods is a private school serving male and female boarding students in grades 7 through 12. Most students come from low-income families--many from dangerous urban neighborhoods. While most students are not currently exhibiting problem behavior, many students are at increased risk of academic failure or delinquency and other personal troubles. All students are black--about half are from Mississippi, and the rest are from 22 other states and 3 African countries. To be admitted to Piney Woods, students must have a minimum C-minus grade average and be in good standing with their current schools. They can have no prevailing substance abuse or delinquency problems. LENGTH OF STAY ----------------------------------------------------- Appendix I:6.0.4 There is no representative average stay. Some students stay from grade 7 through high school graduation. Others begin in grade 11 and remain 2 years. The school rarely accepts grade 12 students because it prefers to have students for more than 1 year. COST PER YOUTH ----------------------------------------------------- Appendix I:6.0.5 The cost for a 9-month school year was $19,443. FUNDING SOURCES ----------------------------------------------------- Appendix I:6.0.6 Percent ---------------------------------------------------------------------- -------- Gifts and grants 34 Endowment fund and other investments 52 Student tuition 7 Miscellaneous income 7 -------------------------------------------------------------------------------- TREATMENT APPROACH ----------------------------------------------------- Appendix I:6.0.7 Students live in dormitories on campus and are housed two to a room. The daily schedule of a dormitory for girls in grades 9 through 12 provides an example of their routine. Wake-up time is 5:30 a.m.; room check is at 6:30 a.m. (beds must be made with hospital corners); breakfast is at 7:00 a.m. (all students must be present). Students attend classes until about 2:00 p.m. After school they are responsible for housecleaning and other chores at the dormitory. On weekday evenings, students must do homework from 7:00 to 9:00 p.m. Students must sign out when they leave the dormitory, saying where they are going. They must have a pass signed by the dorm parent if they are out after 5:00 p.m. Lights out is at 10:00 p.m. for grades 9 through 10 and 10:30 p.m. for grades 11 through 12. In addition to their studies and dormitory cleaning responsibilities, students in grade 7 and above are required to participate in the student work program 10 hours per week to receive meaningful work experience and to earn work credit toward tuition charges. Assignments include grounds maintenance, working at the souvenir shop and book store, and working in the administrative offices. On Sunday, students are required to attend Sunday school and church services. On Thursday, Friday, and Saturday evenings, there are recreational activities at the campus recreation center. These include playing computer games, swimming, and watching TV and movies. Parties are held around holidays. The school has strict grooming, dress, and behavior codes. Students can be suspended or expelled for such things as failure to attend class; use of tobacco, alcohol, or drugs; and failure to follow the dress code. EFFECTIVENESS DATA ----------------------------------------------------- Appendix I:6.0.8 Routinely collected data. The percentage of students who go on to college is calculated each year. Officials report that it ranges from 90 to 95 percent for each graduating class. Special studies. None SALESMANSHIP CLUB YOUTH AND FAMILY CENTERS, INC., YOUTH CAMP --------------------------------------------------------- Appendix I:7 The program seeks to provide a wilderness environment in which young people can experience success and learn problem-solving skills under the supervision of trained counselors. SETTING ----------------------------------------------------- Appendix I:7.0.1 The Youth Camp is located on a 1,250-acre wilderness site east of Dallas in Hawkins, Texas. It is organized into three boys' and three girls' campsites grouped by age and developmental level. Each group consists of about 12 youth and has 4 counselors. Youths build their own tents with wood floors to serve as living quarters, weekend kitchen and dining facilities, and bathroom facilities. The site includes a school, central dining hall used on weekdays, and recreational facilities. The camp is one of three programs for at-risk youth and their families that the Salesmanship Club of Dallas operates. The other two are a comprehensive day treatment center and school program for at-risk youth and an intensive outpatient family therapy program, both in Dallas. NUMBER OF YOUTHS SERVED IN 1992 ----------------------------------------------------- Appendix I:7.0.2 The maximum capacity was 72; the average population at a given time was 65. The total served was 158. CHARACTERISTICS OF YOUTHS SERVED ----------------------------------------------------- Appendix I:7.0.3 The camp serves boys aged 12 to 14 and girls aged 13 to 16 from the Dallas metropolitan area who are experiencing emotional or behavioral problems at school or home. Most boys and girls are white and are from lower-middle or lower income families. Typical participants have problems in school, are substance abusers, and have behavior problems such as defiance of authority. Many have been physically and emotionally abused, and many are suffering from depression. To be accepted into the program, youths must have an intellectual capacity of slow normal to bright, be physically capable of participating in normal camp routine, and cannot be pregnant or dependent on drugs. Boys and girls are generally not accepted if they have sexually abused other children, are actively psychotic or suicidal or have parents who disagree on the need for placement or refuse to participate in therapy. Most youths are referred to the program by their parents and are not in the custody of a public agency. About 29 percent of the youths served have exhibited all four risky behaviors: poor performance in school, substance abuse, delinquency, and early, unprotected sexual activity. LENGTH OF STAY ----------------------------------------------------- Appendix I:7.0.4 The average length of stay was 6 months; stays ranged from 4 to 12 months. COST PER YOUTH ----------------------------------------------------- Appendix I:7.0.5 For 1 year of treatment, the cost was $25,738. For the average stay of 6 months, the cost was $12,869. FUNDING SOURCES ----------------------------------------------------- Appendix I:7.0.6 Percent ---------------------------------------------------------------------- -------- Salesmanship Club 86 Program service fees 10 United Way 2 Miscellaneous 2 -------------------------------------------------------------------------------- TREATMENT APPROACH ----------------------------------------------------- Appendix I:7.0.7 Each group of about 12 boys or girls is viewed as an independent therapeutic community that must work together to meet its needs in such areas as shelter, food, and emotional support. Counselors live with the youth around the clock in the camp setting, with two on duty at any one time. The groups design and build their tents and plan their daily activities, including trips away from the wilderness site. They attend school on site for 3 hours a day and return home at least one weekend a month. Difficulties in group interactions, including problem behavior, are dealt with immediately through "huddle-ups." In these huddle-ups, group members help one another address and resolve problems with the objective of building the social skills and self-esteem needed to be successful. Family participation is also an important element of the program--the youths' families are required to participate in family therapy in Dallas and are encouraged to continue therapy for up to 6 months after the youths complete the program. EFFECTIVENESS DATA ----------------------------------------------------- Appendix I:7.0.8 Routinely collected data. Cumulative data on campers and their families are collected routinely and reported in special studies such as that described below. Special studies. The Salesmanship Club programs have an evaluation system that--since 1983--has gathered data and reported on the characteristics of the families and youths served as well as the impact of services provided. The current study group consists of 314 youth and families served by the Salesmanship Club's programs--including 157 discharged from the youth camp--between July 1989 and April 1991. Youths and families are interviewed at intake, at discharge, and for several years after leaving program services. For a September 1991 report, the program was able to contact and obtain information from 76 of 133 families at 6 months after discharge. While program officials caution that data are not necessarily representative of all families in the program, they believe the families who participated in the study are making clear progress. For example, 72 percent of the youths had been receiving special education services before they entered the program compared to 29 percent receiving them 6 months after discharge and family satisfaction ratings were high, with 81 percent of the families rating themselves a 5 or 6 on a scale ranging from "very unsatisfied" with the program (1) to "very satisfied" with the program (6). STARR COMMONWEALTH SCHOOLS, CEDAR VILLAGE RESIDENTIAL PROGRAM --------------------------------------------------------- Appendix I:8 The program seeks to provide for the care, education, treatment, counseling, and nonsectarian spiritual guidance of troubled children and youths. Its goals are for participants to develop positive attitudes and values, recognize and reach for their potential, improve their self-image, increase their self-confidence, and return to their home communities. SETTING ----------------------------------------------------- Appendix I:8.0.1 Cedar Village is located on Starr Commonwealth Schools' Albion, Michigan, campus, a 350-acre wooded area in rural south central Michigan. The campus includes cottages, school and recreation facilities, and administrative offices. Cedar Village is one of three residential programs on the campus. The Albion Campus residential programs served 361 youths in 1992 and are located on one of three residential campuses operated by Starr Commonwealth Schools. In addition to residential care, Starr Commonwealth also provides community-based services such as an alternative education program and in-home care. In 1992, Starr Commonwealth Schools served 4,950 children, youths, families, and adults in Michigan and Ohio. NUMBER OF YOUTHS SERVED IN 1992 ----------------------------------------------------- Appendix I:8.0.2 The maximum capacity was 57; the average population at a given time was 58. The total served was 121. CHARACTERISTICS OF YOUTHS SERVED ----------------------------------------------------- Appendix I:8.0.3 The program serves boys, aged 14 to 18, largely from low-income, single-parent families living in poor communities in eastern Michigan, from the upper peninsula down through the Detroit area. All youths entering the program are delinquents, typically with multiple felony convictions such as breaking and entering, assault, motor vehicle theft, and drug sales. Of the 83 youths released in 1992, 53 percent were African-American, and 34 percent were white. Most boys in the program have had previous placements, usually in youth homes. Of the youths released in 1992, 64 percent have a substance abuse problem, about 36 percent have experienced physical abuse or neglect, and 50 to 60 percent have been sexually abused. To be accepted by the program, boys must be able to socialize in a group and, among other things, not be highly violent or chronically truant. About 70 percent of the youths served have exhibited all four risky behaviors: poor performance in school, substance abuse, delinquency, and early, unprotected sexual activity. LENGTH OF STAY ----------------------------------------------------- Appendix I:8.0.4 The average length of stay was 10 months; stays ranged from 7 to 14 months. COST PER YOUTH ----------------------------------------------------- Appendix I:8.0.5 For 1 year of treatment, the cost was $51,373. For the average stay of 10 months, the cost was $42,811. Costs include special education costs not covered by the school district. FUNDING SOURCES ----------------------------------------------------- Appendix I:8.0.6 Percent ---------------------------------------------------------------------- -------- Michigan State Department of Social Services per diem (about 33 94 percent federal Title IV-E Foster Care) Federal food reimbursement 2 Investment income 2 Contributions 2 -------------------------------------------------------------------------------- TREATMENT APPROACH ----------------------------------------------------- Appendix I:8.0.7 Typically a boy begins his stay by taking educational and psychological tests. Staff use the test results with other input such as staff observations to develop the boy's individual growth plan. Based on vacancies in cottages and on the boy's compatibility, he is then assigned to a peer group of 10 to 12 boys within a cottage. Seven staff are assigned to each cottage. Except for individual counseling or medical treatment, the boys live, eat, attend classes, and undergo therapy with their peer group. Through the group process and under the guidance of staff counselors, the boys develop a sense of self-worth and learn to take care of themselves and others. Once the peer group is satisfied that a boy has dealt with the group's feedback on his problems and is resolving them, the group makes the initial recommendation that he is ready for release. Staff consider the group's recommendation in deciding whether a boy has achieved the goals in his growth plan and is ready to return to the community. Staff maintain contact with the boy's family throughout the program. When the boy arrives at Cedar Village, staff counselors and a family service worker immediately begin working with the family to develop a post-placement plan. The goal is to create a supportive environment for the boy once he is discharged. Counselors and the service worker may hold family conferences to strengthen family relationships or address problems such as substance abuse in the family. Families are encouraged to visit the campus, where apartments are available for their stay. EFFECTIVENESS DATA ----------------------------------------------------- Appendix I:8.0.8 Routinely collected data. Starr Commonwealth Schools collects data on outcomes at 3 and 12 months after discharge. A comparison of some outcomes for the 52 youths who successfully completed Cedar Village's program in 1991 follows. While only 47 boys could be contacted for the 3-month survey, all 52 boys were contacted for the 12-month survey. Of those contacted, 47 were in a less or equally restrictive setting relative to Cedar Village at 3 months after discharge; at 12 months, 41 were; 43 were in school and/or working at 3 months after discharge; at 12 months, 40 were; and 4 had been rearrested at 3 months after discharge; at 12 months, the cumulative number of boys who had been rearrested was 12. Special studies. None available YOUTHCARE, THRESHOLD PROGRAM --------------------------------------------------------- Appendix I:9 The program is designed to help young women leave street life by providing a safe, stable place to live, a stable source of income, effective role models, and some resolution of family issues. Threshold's goals include helping the women to work and live effectively in their current situation and to be prepared for their future role as adults. SETTING ----------------------------------------------------- Appendix I:9.0.1 Threshold uses a number of residential settings in and around Seattle, Washington, for its three-phased program. Phase I is located in a shelter for runaway youth. The shelter, a brick house in an urban neighborhood, has six bedrooms and is close to bus lines. A licensed group care home in Seattle serves as the phase II residence. During phase III, girls aged 18 and older live independently, such as in their own apartments, while younger girls live with foster families. YouthCare, a Seattle-based private, nonprofit agency, provides residential programs and counseling, education, and medical care and other services to meet the needs of youth in crisis in the local community. NUMBER OF YOUTHS SERVED IN 1992 ----------------------------------------------------- Appendix I:9.0.2 The maximum capacity was eight (four in phase I and four in phase II); the average population at a given time was six for phases I and II. The total served was 10. CHARACTERISTICS OF YOUTHS SERVED ----------------------------------------------------- Appendix I:9.0.3 Threshold serves girls aged 14 to 18 who have been physically, sexually, or emotionally abused or neglected and who have histories of prostitution or are at high risk of becoming involved in prostitution. Girls come from low-income families in the county and usually have had prior placements or interventions such as foster care and family counseling. All girls are referred by state child protective services. Of the 1992 participants, six were white, three were African-American, and one was Native American. Girls accepted into the program must be motivated to stop such behaviors as abusing drugs or alcohol, engaging in prostitution, or assaulting others. About 75 percent of the youth served have exhibited all four risky behaviors: poor performance in school, substance abuse, delinquency, and early, unprotected sexual activity. LENGTH OF STAY ----------------------------------------------------- Appendix I:9.0.4 The average length of stay was 7 months for phase I plus 12 months for phase II; stays ranged from 3 to 8 months for phase I and from 12 to 16 months for phase II. COST PER YOUTH ----------------------------------------------------- Appendix I:9.0.5 For 1 year of treatment, the cost was $28,927; for the average stay of 19 months, the cost was $45,802. Costs cover phase I and II only. Local school districts pay for the education of girls who attend district schools. Phase III services are funded by YouthCare unrestricted funds and not by the Washington state grant. FUNDING SOURCES ----------------------------------------------------- Appendix I:9.0.6 Percent ---------------------------------------------------------------------- -------- Washington State Department of Social and Health Services grant 93 United Way 7 -------------------------------------------------------------------------------- TREATMENT APPROACH ----------------------------------------------------- Appendix I:9.0.7 Phase I, which is very structured, is designed to stabilize the girls' behavior and allow staff to assess individual needs and develop a trusting relationship with the girls. Initially, the girls must stay in the house except to attend school and go on occasional outings with other residents and staff. The girls must sever all ties with their former associates. They are also expected to attend individual counseling sessions with their Threshold caseworker, pursue at least a GED certificate through local schools or programs, learn job-finding skills, find jobs if they are old enough, and perform household chores. Many residents for the first time learn how to clean their rooms, wash laundry, prepare meals, budget, and shop. The girls must demonstrate cooperation, motivation, and responsibility to earn privileges such as 1-hour walks or overnight stays with friends or relatives. Girls attend a weekly meeting where they may discuss problems arising from communal living or any topic of interest to the group. After demonstrating they have the skills to live in a semi-independent manner, girls graduate to phase II. The phase II group home operates as a family home, allowing the girls to earn the right to be alone in the house, carry keys, and have friends over. In addition to pursuing education and employment goals, girls continue to care for themselves, taking on more responsibility for cleaning and meals. Because many of the girls missed the opportunity to participate in, and learn from, recreational activities while they were growing up, the program provides many activities such as camping and visits to local parks. In phase III, girls move to independent living situations or supportive foster care homes where they continue to receive support and care from Threshold staff for 6 months to a year or more. EFFECTIVENESS DATA ----------------------------------------------------- Appendix I:9.0.8 Routinely collected data. None Special studies. Six months after they left Threshold's phase II, 24 girls who had entered phase II between January 1987 and July 1989 were assessed by YouthCare. YouthCare found 10 girls (42 percent) were living in a stable situation, employed or attending a school or vocational training program, and were free of substance abuse and involvement in crime. Eight girls (33 percent) had returned to street life or were abusing drugs, and no information was available on 6 girls (25 percent) who could not be contacted. PROGRAMS GAO CONTACTED BY TELEPHONE ========================================================== Appendix II The following descriptions of nine programs we contacted by telephone contain data obtained from interviews with program officials and written material they provided. We did not verify the data--including program costs and the effectiveness studies and reports. The methodologies used to measure program outcomes and the factors they measured varied, thereby preventing comparison among programs. Programs are listed in alphabetical order. THE CHILDREN'S VILLAGE, TOMPKINS TRANSITIONAL CARE PROGRAM -------------------------------------------------------- Appendix II:1 The program provides comprehensive services to the most at-risk segment of the Children's Village population to move youth successfully to a less restrictive Children's Village or other program. SETTING ---------------------------------------------------- Appendix II:1.0.1 The Tompkins program is located on the Children's Village campus in Dobbs Ferry, New York. It is housed in a single cottage at the center of an ellipse of 21 residential treatment cottages, which are divided into seven "neighborhood" units. The Children's Village has provided residential care for children since 1851. Currently, in addition to its campus-based residential treatment, it provides community-based group homes for boys, and foster family care homes for boys and girls. NUMBER OF YOUTHS SERVED IN 1992 ---------------------------------------------------- Appendix II:1.0.2 The maximum capacity was 12; the average population at a given time was 12. The total served was 15. CHARACTERISTICS OF YOUTHS SERVED ---------------------------------------------------- Appendix II:1.0.3 Tompkins serves boys aged 8 to 15. All have had previous placements: approximately half are in the next stage of their recovery after release from a mental hospital; and the other half are referred from other Children's Village programs where their behavior has suddenly deteriorated due to some trauma. Their specific problems include conduct disorder, lack of impulse control, depression, episodes of violence, attention deficit disorder, hyperactivity, or being a danger to themselves or others. All are from New York state, principally New York City and nearby counties, and are referred by the New York Department of Social Services. Tompkins excludes boys for whom a less restrictive approach would be appropriate. All come from families whose income is below poverty level. About 20 percent are reported as having no parents; the remaining 80 percent are from single-parent families. Between 60 and 70 percent have been sexually abused and 90 percent have been physically abused or neglected. About 10 percent of the youths served have exhibited all four risky behaviors: poor performance in school, substance abuse, delinquency, and early, unprotected sexual activity. LENGTH OF STAY ---------------------------------------------------- Appendix II:1.0.4 The average length of stay was 15 months; stays ranged from 6 to 24 months. COST PER YOUTH ---------------------------------------------------- Appendix II:1.0.5 For 1 year of treatment, the cost was $65,496; for an average stay of 15 months, the cost was $79,141. This included all costs except fundraising and investment counseling fees and education, which is provided by an on-campus public school. FUNDING SOURCES ---------------------------------------------------- Appendix II:1.0.6 Percent ---------------------------------------------------------------------- -------- New York Department of Social Services 71 Medicaid 14 Investment income 6 Contributions 3 Reimbursement for services 3 Local districts 2 Food programs 1 -------------------------------------------------------------------------------- TREATMENT APPROACH ---------------------------------------------------- Appendix II:1.0.7 Tompkins is the most intensively staffed of the Children's Village residential treatment cottages, providing around-the-clock coverage by therapists trained to use the living environment as a treatment tool. Tompkins' higher staff-to-youth ratios and more intensive clinical services allow treatment of youth who would otherwise require psychiatric hospitalization. As with other Children's Village programs, cottage life is important to the Tompkins program. To provide a firm structure that establishes boundaries of behavior, cottages have clear rules as well as clear consequences for breaking them. Each boy has a primary case manager and must sign a contract that commits to specified behaviors. A daily checklist reports and rewards acceptable behavior. Group therapy uses life events to teach appropriate behavior. The program uses special events such as carnivals, circuses, and art fairs to develop youths' skills and thereby enhance their self-esteem. EFFECTIVENESS DATA ---------------------------------------------------- Appendix II:1.0.8 Routinely collected data. None Special studies. No special studies have been conducted specifically of the Tompkins program. One study, which has aftercare as a principal component, is under way for selected participants of Children's Village. This study, now in its ninth year, examines a program called Work Appreciation for Youth, which involves intensive counseling, work ethics education, and financial incentives for saving money. Work Appreciation for Youth participants--who are about 80 percent minorities and are all academically deficient--receive these services both while at Children's Village and after discharge. The study tracks the performance of 65 of these participants and compares it to another group of youths who did not participate in the Work Appreciation for Youth program while at Children's Village--and who received less intensive aftercare services. Based on data from the first 6 years of the study, youths who have remained in the Work Appreciation for Youth program have significantly outperformed the comparison group with respect to not dropping out of school, completing high school, and earning some money. For example, 40 percent of the Work Appreciation for Youth participants have graduated or received a GED certificate, compared to 18 percent of the comparison group; and 12 percent of the Work Appreciation for Youth participants have dropped out of school, compared to 29 percent of the comparison group. EASTERN NEBRASKA COMMUNITY OFFICE OF MENTAL HEALTH ADOLESCENT TREATMENT FACILITY -------------------------------------------------------- Appendix II:2 The program aims to make boys more self-aware and more controlled in behavior and emotions. The intent is that they be reunited with their biological families, if available, or with surrogate families or placed in other long-term or permanent situations. SETTING ---------------------------------------------------- Appendix II:2.0.1 The Adolescent Treatment Facility is in a large group home in a residential neighborhood in Omaha, Nebraska. It has its own fenced black-topped tennis/basketball court. The facility is one of three long-term residential treatment facilities that the Eastern Nebraska Community Office of Mental Health operates within a service spectrum that also includes emergency short-term care, therapeutic foster care, and home-based mental health services to children and adolescents. In addition, the agency provides residential and day rehabilitative services for adults. NUMBER OF YOUTHS SERVED IN 1992 ---------------------------------------------------- Appendix II:2.0.2 The maximum capacity was 8; the average population at a given time was 8. The total served was 14. CHARACTERISTICS OF YOUTHS SERVED ---------------------------------------------------- Appendix II:2.0.3 This program provides around-the-clock treatment and care for boys aged 12 to 19 with diagnosable psychiatric disorders--such as major depression or conduct disorder--for whom a less controlled treatment setting is not considered appropriate. Boys must have sufficient intellectual potential to respond to active psychological treatment. They are referred by the Nebraska Department of Social Services, but most have been charged as delinquents and have plea bargained to a less serious charge with the understanding that noncooperation could result in their being placed in the corrections system. All have been through a psychiatric hospital and received a recommendation against their return home. Ninety-nine percent of the boys' families are below the poverty level, and 80 percent are single-parent families. About 90 percent of the boys come from the Omaha metropolitan area. Almost all of the youths served have exhibited all four risky behaviors: poor performance in school, substance abuse, delinquency, and early, unprotected sexual activity. LENGTH OF STAY ---------------------------------------------------- Appendix II:2.0.4 The average length of stay was 9 months; stays ranged from 5 to 12 months. COST PER YOUTH ---------------------------------------------------- Appendix II:2.0.5 For 1 year of treatment, the cost was $24,740; for an average stay of 9 months, the cost was $18,555. These figures include all costs except administrative and school costs. FUNDING SOURCES ---------------------------------------------------- Appendix II:2.0.6 Percent ---------------------------------------------------------------------- -------- Nebraska Department of Social Services 83 Nebraska Department of Public Institutions 1 7 -------------------------------------------------------------------------------- TREATMENT APPROACH ---------------------------------------------------- Appendix II:2.0.7 The first day a boy is in the program, staff develop an interim treatment plan; 2 weeks later, staff develop a comprehensive plan with the participation of the boy, his family, and his Department of Social Services caseworker. Others whom the family and youth identify as important are also invited to participate. The program identifies the boy's and family's strengths and weaknesses, and uses an individualized approach to provide encouragement for the boy to build on identified strengths. Efforts include working to empower the boy by teaching social, coping, and living skills--thereby boosting self-esteem. To produce changes in behavior, the program uses a system of tokens and positive reinforcement for good behavior. By accumulating tokens, boys can progress to a higher level in the program in which they are permitted to engage in more independent actions as they demonstrate increased skills and self-control. Criteria for returning youths to their families include improvement of family dynamics, communication, and understanding so that the family can function as an effective unit. The treatment plan identifies strengths and weaknesses of the boy's family and sets goals and objectives with time frames--for example, to improve family communications or to teach parents to use incentives for good behavior instead of punishment for inappropriate behavior. The program conducts weekly meetings with parents and helps the family identify and link with community supports that will provide family survival skills. EFFECTIVENESS DATA ---------------------------------------------------- Appendix II:2.0.8 Routinely collected data. Other than monitoring changes in youths' scores on a standardized test of child behavior over the course of the program, Eastern Nebraska collects data on a single outcome--the setting to which boys are discharged. The program was able to contact 10 boys who were discharged in 1991: Of the five who were contacted 12 to 18 months after discharge, none was in a correctional institution, one was in another residential placement, and four were living with a biological parent. Of the five who were contacted 18 to 24 months after discharge, three were in a correctional institution and the other two, in foster care. Special studies. None EASTFIELD MING QUONG, LOS GATOS INTENSIVE RESIDENTIAL TREATMENT UNITS -------------------------------------------------------- Appendix II:3 This program's intent is to help youth improve their social, emotional, and behavioral functioning and move successfully to a less restrictive setting. SETTING ---------------------------------------------------- Appendix II:3.0.1 The Subacute Residential Services program is housed in three cottages on a campus in Los Gatos, California. The cottages are family style, with central living rooms and kitchens. The campus also includes a gym, an activity room, a swimming pool, a playing field, climbing equipment, and a jogging trail. In addition to residential care, Eastfield Ming Quong operates a variety of child and family mental health programs in Santa Clara County, California, including child and adolescent in-home treatment, a family clinic, and school-based day treatment. NUMBER OF YOUTHS SERVED IN 1992 ---------------------------------------------------- Appendix II:3.0.2 The maximum capacity was 30; the average population at a given time was 24. The total served was 36. CHARACTERISTICS OF YOUTHS SERVED ---------------------------------------------------- Appendix II:3.0.3 The program serves boys aged 10 to 15 with serious psychiatric disorders, ranging from depression to medically controlled psychosis, or major learning handicaps such as attention deficit disorder. Approximately 70 percent are referred by the California Division of Family and Child Services, 20 percent by the county mental health emergency center, 6 percent by the schools, and 2 percent each by health care facilities and family members. About 73 percent of these boys are white; 15 percent, Hispanic; 8 percent, African-American; and 4 percent, Asian. Their family incomes average $9,500, with 92 percent below the poverty level. About 62 percent are from single-parent families. Family problems include domestic violence and drug and alcohol problems. Youths come from Santa Clara County, California--generally from low-income sections with high crime rates, some gang activity, and poor housing. About 35 percent of the youths served have exhibited all four risky behaviors: poor performance in school, substance abuse, delinquency, and early, unprotected sexual activity. LENGTH OF STAY ---------------------------------------------------- Appendix II:3.0.4 The average length of stay was 15 months; stays ranged from 12 to 18 months. COST PER YOUTH IN 1992 ---------------------------------------------------- Appendix II:3.0.5 For 1 year of treatment, the cost was $132,493; for an average stay of 15 months, the cost was $165,616. These figures include all direct and indirect costs except education. According to program officials, costs also reflect high staff-to-youth ratios required by the state licensing agency and by the rate classification system for group homes. FUNDING SOURCES ---------------------------------------------------- Appendix II:3.0.6 Percent ---------------------------------------------------------------------- -------- California Department of Social Services 65 State mental health program 15 Medicaid 13 Charitable contributions 6 School lunch program 1 -------------------------------------------------------------------------------- TREATMENT APPROACH ---------------------------------------------------- Appendix II:3.0.7 Treatment is based largely on using activities and relationships of daily living as opportunities for addressing individual problems. Each cottage houses 8 youths and has a primary therapist who is responsible exclusively for youths in that cottage. Boys spend after-school hours and weekends largely with the residents of their cottage. The therapist is responsible for developing and coordinating the treatment plan for each youth. The plan is woven into all aspects of the program: individual therapy, group therapy, recreational activities, family therapy, and--in coordination with the community schools the youth attends--educational program. Throughout its activities, the program uses a system that holds boys responsible for achieving their behavioral goals and rewards positive behavior with points that accumulate to earn promotion through four levels to discharge. Eastfield Ming Quong also attaches importance to family counseling, though family participation is not a requirement. Family therapy sessions occur once each week with the youths included at the discretion of the primary therapist. EFFECTIVENESS DATA ---------------------------------------------------- Appendix II:3.0.8 Routinely collected data. The program collects data on a single outcome: the setting to which boys are discharged. For the 139 youth discharged during 1991 and 1992, 78 percent were discharged to a lower level of care--such as a parent, relative, community group home, or a foster home; 16 percent were discharged to the same level of care; and 6 percent were discharged to a higher level of care (a psychiatric hospital). Special studies. None ECKERD FAMILY YOUTH ALTERNATIVES, INC., WILDERNESS EDUCATIONAL SYSTEM, CAMP E-HOW-KEE -------------------------------------------------------- Appendix II:4 The program focuses on direct, daily care that promotes children's self-esteem, interpersonal competence, success in school, and positive involvement with family and community. The aim is to assist children in developing appropriate social competencies, personal values, and self-management skills that can be successfully transferred to their home, school, and community setting. SETTING ---------------------------------------------------- Appendix II:4.0.1 Camp E-How-Kee in Brooksville, Florida, is in a wilderness area in the central part of the state. It is 1 of 19 programs operated by Eckerd Family Youth Alternatives, Inc., of Clearwater, Florida. These programs, which serve youth from seven states, include 13 wilderness camps, a juvenile correctional facility, a short-term residential program for less serious offenders, and the Florida Conservation Corps. NUMBER OF YOUTHS SERVED IN 1992 ---------------------------------------------------- Appendix II:4.0.2 The maximum capacity was 60; the average population at a given time was 56. The total served was 110. CHARACTERISTICS OF YOUTHS SERVED ---------------------------------------------------- Appendix II:4.0.3 Camp E-How-Kee serves boys aged 10 to 16 from the central Florida area. They are primarily status offenders or truants. The boys typically come from lower-middle-income urban families with a history of child abuse, substance abuse, and marital problems. Most boys are referred by the Florida Department of Health and Rehabilitation Services. About 60 percent have been victims of sexual abuse. All youths have had multiple failures in other treatment programs or out-of-home placements such as foster care, short-term residential psychiatric hospitals, and counseling. Of the 1991-92 participants, about 52 percent have received court judgments, with an average of three convictions; 19 percent of the judgments were for crimes against persons. Eighty-five percent are white, 12 percent are African-American, and 3 percent are Hispanic. Almost all of the youths served have exhibited all four risky behaviors: poor performance in school, substance abuse, delinquency, and early, unprotected sexual activity. LENGTH OF STAY ---------------------------------------------------- Appendix II:4.0.4 The average length of stay was 13 months; stays ranged from 9 to 15 months. COST PER YOUTH ---------------------------------------------------- Appendix II:4.0.5 For 1 year of treatment, the cost was $41,071; for an average stay of 13 months, the cost was $45,863. FUNDING SOURCES ---------------------------------------------------- Appendix II:4.0.6 Percent ---------------------------------------------------------------------- -------- Fees from social service and juvenile welfare agencies 52 Private insurance 5 Eckerd Family Endowment 43 -------------------------------------------------------------------------------- TREATMENT APPROACH ---------------------------------------------------- Appendix II:4.0.7 Boys in the program live in a wilderness setting in small groups of peers and counselors. The groups construct their own shelters, cut their own wood for cooking and heating, make needed repairs, and provide their own recreation. The program is designed to increase the boys' feelings of self-worth by developing the skills they acquire in providing for their own basic needs and by seeing how many "luxuries" they can do without and still be content and comfortable. Within these groups--through daily routines and special activities--boys are taught to identify and resolve problems. Each boy pursues an individual education plan that places priority on listening, speaking, writing, and reading. While the boys are in camp, parents are required to participate in parent therapy groups, attend three family conferences yearly at the camp, and maintain contact with Eckerd family workers. Youth make home visits for 4 days every 6 weeks to give them and their families a chance to practice new skills. The parent organization, Eckerd Family Youth Alternatives, Inc., provides aftercare services for up to 6 months to maintain and build on the gains made at the camp. Aftercare includes identifying individual needs, such as counseling or care for chronic health problems, and helping families contact appropriate community service agencies. A program family worker continues to work with the youth and families through frequent face-to-face contact supplemented by phone calls. EFFECTIVENESS DATA ---------------------------------------------------- Appendix II:4.0.8 Routinely collected data. At 6 and 12 months after discharge, the program collects outcome information. At the time of our study, the program had 12-month data on 33 of the 42 boys discharged in fiscal year 1992. The data showed the following: Delinquency: 18 (55 percent) had no further encounter with the law while 15 (45 percent) had--resulting in such actions as commitment to a secure residential program or being put on probation. Education: 9 (27 percent) were truant or had dropped out of school. Living status: 59 percent (17 of the 29 for whom the program had this data) were living with their natural or adoptive families; the remainder were in placements such as foster care and group homes. Special studies. No special studies had been conducted for Camp E-How-Kee. However, the Eckerd Wilderness Education System is conducting a 3-year longitudinal study of 250 campers--50 from each of 5 camps other than E-How-Kee--beginning with campers entering in May 1990. Data will be collected for the period before the youths entered the program, during the program, and 3 years after. The preliminary report issued in June 1992 reported gains made by youth at the time of discharge in academics, family functioning, behavior, and self-esteem. HARBOR SCHOOLS AND FAMILY SERVICES, HAVERHILL PROGRAM -------------------------------------------------------- Appendix II:5 The immediate tasks are to break the cycle of failure, stop the victimization of self and others, and bring order to chaotic lives. The goal is to stabilize the participants' behavior and move them back with their families or to less restrictive programs. SETTING ---------------------------------------------------- Appendix II:5.0.1 Haverhill Residential Facility is in a restored 19th-century house in a residential neighborhood of Haverhill--a small city 35 miles north of Boston. Harbor Schools and Family Services operates a variety of youth and family service programs in several locations in Massachusetts. In addition to residential care, they include short-term (30-day maximum) crisis resolution residential programs, day programs such as special education and group therapy, and community services such as family preservation and support services for teen parents. NUMBER OF YOUTHS SERVED IN 1992 ---------------------------------------------------- Appendix II:5.0.2 The maximum capacity was 16; the average population at a given time was 15. The total served was 22. CHARACTERISTICS OF YOUTHS SERVED ---------------------------------------------------- Appendix II:5.0.3 Harbor Schools' Haverhill facility serves girls aged 13 to 16 at admission. About 80 percent are from families with incomes below the poverty level. These families live mainly in poor urban or suburban areas in New England--primarily in Massachusetts. Forty-eight percent of the girls are white, 19 percent are African-American, and 20 percent are Hispanic. The girls display an array of unmanageable behaviors, including disruptiveness, sexual promiscuity, habitual truancy, and drug abuse. Most are in Haverhill because of a status offense. Nearly all have been victims of physical and sexual abuse, and 90 percent show signs of chronic malnutrition and lack of regular medical care. Most suffer from depression and feelings of isolation. About 5 percent are psychotic and have been sent to Haverhill instead of mental institutions. All have had previous placements and average about five--mostly in foster care. About 90 percent of the youths served have exhibited all four risky behaviors: poor performance in school, substance abuse, delinquency, and early, unprotected sexual activity. LENGTH OF STAY ---------------------------------------------------- Appendix II:5.0.4 The average length of stay was 1 year; stays ranged from 3 to 24 months. COST PER YOUTH ---------------------------------------------------- Appendix II:5.0.5 For 1 year of treatment, the cost was $51,986; for an average stay of 1 year, the cost was $51,986. FUNDING SOURCES ---------------------------------------------------- Appendix II:5.0.6 Percent ---------------------------------------------------------------------- -------- Massachusetts Department of Social Services 61 Massachusetts Department of Education and local school systems 29 Fees from out-of-state governments 7 Miscellaneous 3 -------------------------------------------------------------------------------- TREATMENT APPROACH ---------------------------------------------------- Appendix II:5.0.7 Harbor's Haverhill program treatment is designed to provide a highly structured environment in which girls receive reinforcement for positive behavior. The program uses an 86-point behavior checklist as part of its comprehensive behavior management system. Girls are taught new skills for dealing with anger, anxiety, and frustration. Each girl progresses at her own pace from one level of the program to the next less restrictive level. Girls receive individual therapy each week from private clinicians and also attend group counseling sessions supervised by staff and clinicians. These group sessions serve in part to allow the girls to make decisions about the daily operations of the program. Every girl has an individual education plan and attends small classes of four to eight students on the program premises. They also receive training in practical life skills. They can join a work-study program, and some hold down after-school and weekend jobs. All girls are involved in the recreation program, which includes sports, crafts, camping, scouting, and local movies. Family involvement takes place through parental support groups and individual contacts with a staff caseworker who provides information about the girls' progress and about techniques for better parenting. EFFECTIVENESS DATA ---------------------------------------------------- Appendix II:5.0.8 Routinely collected data. None Special studies. No studies have been conducted exclusively of the Haverhill program. However, in 1989 the Harbor Schools' executive director conducted a one-time survey of 20 youths who had been discharged from Harbor programs--including Haverhill--over a period of 2 years. The survey found that, 3 months after discharge, 14 (70 percent) of the youths had returned to school, family life, and part-time work. HILLSIDE CHILDREN'S CENTER, RESIDENTIAL TREATMENT CENTER -------------------------------------------------------- Appendix II:6 The program's goal is to provide comprehensive, high-quality child welfare, education, juvenile justice, and mental health services based on the needs of children and their families. The program aims to achieve each youth's individual treatment goals and a smooth transition from residential care back to their families, communities, and schools. SETTING ---------------------------------------------------- Appendix II:6.0.1 The Residential Treatment Center cottages are in an urban neighborhood of Rochester, New York, on a campus with several programs, including Hillside Children's Center school and emergency shelter. The residential center is one of 20 programs operated by Hillside Children's Center. Others include two psychiatric residential treatment centers, day treatment programs, intensive family support programs, and therapeutic foster homes. NUMBER OF YOUTHS SERVED IN 1992 ---------------------------------------------------- Appendix II:6.0.2 The maximum capacity was 48; the average population at a given time was 48. The total served was 100. CHARACTERISTICS OF YOUTHS SERVED ---------------------------------------------------- Appendix II:6.0.3 The Residential Treatment Center serves boys and girls mainly aged 6 to 17 from lower-income urban neighborhoods in New York state, largely in Rochester. Sixty-five percent are white, and 25 percent, African-American. Nearly half of the youths come from families with a history of physical violence, and 27 percent come from families with an adult alcohol abuser. Youths admitted are unmanageable or unable to function safely in the home or school setting. The program avoids admitting youth with severe violent behavior and active substance abuse problems. Less than 5 percent of the youths served have exhibited all four risky behaviors: poor performance in school, substance abuse, delinquency, and early, unprotected sexual activity. LENGTH OF STAY ---------------------------------------------------- Appendix II:6.0.4 The average length of stay was 12 months; stays ranged from 6 to 20 months. COST PER YOUTH ---------------------------------------------------- Appendix II:6.0.5 For 1 year of treatment, the cost was $51,746; for an average stay of 1 year, the cost was $51,746. FUNDING SOURCES ---------------------------------------------------- Appendix II:6.0.6 Percent ---------------------------------------------------------------------- -------- New York Department of Social Services 100 -------------------------------------------------------------------------------- TREATMENT APPROACH ---------------------------------------------------- Appendix II:6.0.7 Upon admission to the Residential Treatment Center, boys and girls are assigned to one of three residential cottages. They live with about 15 other youth of the same sex and similar age. In the cottage setting, staff teach youth independent living skills and monitor their behavior. The staff give points to the youths as part of a reward system for appropriate behavior. Youth attend Hillside's campus school and, in addition to psychiatric and psychological services, receive specialized services such as recreation, art, and dance therapy. The program is designed to work with family members in planning treatment for their child and for themselves. The family meets with their child's social worker and program treatment team and is offered assistance with and referral to other services as needed. After discharge, the residential center offers continuing counseling services for 6 months to help the youths make the transition to community life. EFFECTIVENESS DATA ---------------------------------------------------- Appendix II:6.0.8 Routinely collected data. The program gathers data on discharge status such as whether youths leave Hillside for a more or a less restrictive setting and the degree to which each youth's individual treatment goals have been met. It reported that in 1992 there was a slight improvement over 1991 in the rate of achievement of these goals at the time of discharge. Special studies. None KIDSPEACE NATIONAL CENTERS FOR KIDS IN CRISIS, PRESIDENTIAL TREATMENT CENTER -------------------------------------------------------- Appendix II:7 The program tries to teach life skills, develop self-discipline, and foster respect for authority as well as individual rights. The goal is to enable the youths to function independently with behavior appropriate for their age and to facilitate their return to a less restrictive environment. SETTING ---------------------------------------------------- Appendix II:7.0.1 The Presidential Center consists of a complex of seven cottages in Bethlehem, Pennsylvania. The program is one of several KidsPeace programs that share a campus in a residential section of a suburban community. The campus includes a large gymnasium, swimming pool, and other recreational facilities. KidsPeace National Centers for Kids in Crisis, a 111-year-old organization, operates additional long-term residential treatment facilities, a psychiatric hospital, and various other treatment facilities at sites in Pennsylvania, Indiana, and New England. NUMBER OF YOUTHS SERVED IN 1992 ---------------------------------------------------- Appendix II:7.0.2 The maximum capacity was 103; the average population at a given time was 97. The total served was 150. CHARACTERISTICS OF YOUTHS SERVED ---------------------------------------------------- Appendix II:7.0.3 The program serves boys aged 8 to 18 and girls aged 10 to 13 and 16 to 18 (girls aged 14 to 15 are served in another KidsPeace program). In 1992, 75 percent were male and 25 percent, female; 79 percent were white and 18 percent, African-American. About half of the youths' families receive some form of public assistance, and half are single-parent families. Approximately 70 percent of the boys and girls are documented sexual abuse victims. Seventy percent of the youths are from suburban or rural communities. The program draws participants from the 26 states east of the Mississippi River, with 40 percent coming from Pennsylvania. Ninety-two percent of the youths are referred by a state department of social services, which may include court referrals. Eight percent are private referrals with third-party insurance. Between 80 and 90 percent have been in a previous placement. The program does not accept youths with an intelligence quotient of less than 70 or with histories of homicide or aggravated assault. Nor does the program accept youths who are heavily involved in street gangs or severely psychotic or schizophrenic. About 50 percent of the youths served have exhibited all four risky behaviors: poor performance in school, substance abuse, delinquency, and early, unprotected sexual activity. LENGTH OF STAY ---------------------------------------------------- Appendix II:7.0.4 The average length of stay was 15 months; stays ranged from 10 to 18 months. COST PER YOUTH ---------------------------------------------------- Appendix II:7.0.5 For 1 year of treatment, the cost was $84,168; for an average stay of 15 months, the cost was $105,210. FUNDING SOURCES ---------------------------------------------------- Appendix II:7.0.6 Percent ---------------------------------------------------------------------- -------- Fees paid by public agencies 58 School 23 Medicaid 15 Third party insurance 3 State food 1 -------------------------------------------------------------------------------- TREATMENT APPROACH ---------------------------------------------------- Appendix II:7.0.7 After giving extensive psychological and psychiatric tests to an entering youth, interdisciplinary program staff work together to develop a highly individualized treatment plan, which is updated monthly, and a discharge plan for the youth within 15 days of arrival. An individual counselor and a therapist manage implementation of the plan. In a highly structured environment, the program sets out basic expectations, rules, and consequences of breaking the rules. These consequences are enforced by a counselor assigned to the youth. Youths live in cottages where the environment is designed to nurture and provide support. They receive weekly individual and group counseling and regular reviews of their progress under the supervision of a staff psychiatrist. Treatment staff monitor and grade behavior throughout all activities, including recreational activities. Youths receive daily grades on behaviors, and these form the basis for privileges such as allowances, extended bedtimes, and outing participation. Youths in the program go to one of three private schools that the program shares with other KidsPeace programs. Families receive counseling either from program staff--if the families live nearby--or from clinical affiliates in their communities. Youths participate with their families in that counseling either while on home visits or by monthly conference call. In developing a plan for discharge, a program social worker coordinates with service resources in the community to which the youth is returning. After discharge, program staff provide in-home counseling to sustain program gains. EFFECTIVENESS DATA ---------------------------------------------------- Appendix II:7.0.8 Routinely collected data. None Special studies. The program is currently in the fourth year of an evaluative research project looking at selected outcomes between 1 and 2 years after discharge. The project was able to contact 30 of the 78 youths who were discharged in 1990 after completing at least 6 months in the program. Some did not answer all questions; however, of those that responded, outcomes reported included 23 of the 30 (77 percent) were living in a less restrictive setting; 15 of 27 (56 percent) reported they had not had any police involvement, while 12 reported they had; 8 of 25 (32 percent) were employed; and 23 (77 percent) were satisfied with the care they had received. OASIS CENTER, MICHAEL'S KIDS HOUSE -------------------------------------------------------- Appendix II:8 The program provides counseling services and training in the living skills that will enable youths to live independently and to persevere in an educational setting or a job. SETTING ---------------------------------------------------- Appendix II:8.0.1 The Michael's Kids House group home in Nashville, Tennessee, is in a residential community close to city bus lines. It contains three bedrooms, two baths, a living room, dining room, kitchen, and office. As part of the program, some youths move on to apartments in which they live more independently. In addition to Michael's Kids House, Oasis Center programs in Nashville include a runaway shelter, crisis counseling, a teen crisis line, and a youth employment program. NUMBER OF YOUTHS SERVED IN 1992 ---------------------------------------------------- Appendix II:8.0.2 The maximum capacity was 13 (6 in the group home and 7 in apartments); the average population at a given time was 13. The total served was 32. CHARACTERISTICS OF YOUTHS SERVED ---------------------------------------------------- Appendix II:8.0.3 Michael's Kids House serves boys and girls aged 17 to 21 who do not have any other safe living alternatives and who typically have had numerous previous placements. All youths are in the custody of the Tennessee Department of Human Services. They are referred by that department or by the Tennessee Department of Youth Development because of a lack of a suitable family environment or behavior problems. Youths exhibit various problems, such as school failure, emotional difficulties, and drug abuse, and many are victims of parental abuse, neglect, or abandonment. About two-thirds are white and about one-quarter are African-American. To be eligible for the program, youths must be willing to pursue an education plan and maintain at least part-time employment. They must not be currently involved in destructive behavior such as drug and alcohol use or stealing. Finally, they must have a level of intelligence that will permit them to function within the program. LENGTH OF STAY ---------------------------------------------------- Appendix II:8.0.4 The average length of stay was 9 months in the group home, although data were not available for the apartment stay. Stays ranged from 9 months to 3 years for group home and apartment combined stay. COST PER YOUTH ---------------------------------------------------- Appendix II:8.0.5 For 1 year of treatment, the cost was $24,321. This figure includes costs of both group home and apartment phases. For an average stay of 9 months, the program could not provide cost data. FUNDING SOURCES ---------------------------------------------------- Appendix II:8.0.6 Percent ---------------------------------------------------------------------- -------- Tennessee Department of Human Services 75 Tennessee Department of Finance and Administration 13 Oasis Center 11 Food (U.S. Department of Agriculture) 1 -------------------------------------------------------------------------------- TREATMENT APPROACH ---------------------------------------------------- Appendix II:8.0.7 Michael's Kids House tries to provide a balance between freedom and structure within the context of a group home. While youths are encouraged to learn to make decisions on their own, they are required to sign an agreement to live within house rules. With the help of a primary counselor, youths develop a contract defining individual goals and the training in skills that will be needed after discharge. Youths who violate their contracts or house rules receive counseling, may be put on probation, and may be expelled from the program. Skills such as money management, comparative shopping, and eating nutritiously are taught in course form, and staff ensure that youths are given opportunities for supervised practice. The program also provides education assessment and counseling to help youths set appropriate educational goals. Additionally, it provides employment services such as a week-long course to help youth identify their strengths and weaknesses, instruction on how to get and keep employment, and job placement. All youth are required to participate in individual counseling and a group counseling session once a week. While staff are responsible for enforcing rules against illegal or destructive activity, their principal role is to guide youths in making personal decisions and to provide support as youths experience the consequences of those decisions. Staff work in shifts, with a counselor always on call. EFFECTIVENESS DATA ---------------------------------------------------- Appendix II:8.0.8 Routinely collected data. Oasis gathers information on Michael's Kids House Program youths after discharge--through phone calls and from what youths report at an annual homecoming event. Information includes boys' and girls' living status and education. They report that five of the nine youths (56 percent) who had completed the program in 1992 had achieved all aspects of what the program considers successful completion, meaning they (1) had been discharged to a placement outside the state human services system or to an independent living situation; (2) had a home to go to; and (3) had demonstrated the skills of employability, money management, and using support systems. All nine who completed the program were employed. Special studies. None PRESSLEY RIDGE SCHOOLS, GRANT GARDENS RESIDENTIAL PROGRAM -------------------------------------------------------- Appendix II:9 The program seeks to break the cycle of repeated out-of-home placements for status offenders, that is, youth with delinquent behavior such as chronic truancy or running away. It is operated by an organization that has the goal of being a national leader in developing and providing services to children and families with difficult problems. Pressley Ridge School at Grant Gardens was established to serve status offenders. SETTING ---------------------------------------------------- Appendix II:9.0.1 The residential program of Pressley Ridge School at Grant Gardens is in Ona, West Virginia--a small, rural community east of Huntington. Grant Gardens also provides community-based services such as family preservation and therapeutic foster care. It is 1 of 12 programs in Pennsylvania, West Virginia, Maryland, and Ohio operated by Pressley Ridge Schools of Pittsburgh. Pressley Ridge's services include in-home and family preservation services, a day-school, shelter care, foster care, and three residential facilities. NUMBER OF YOUTHS SERVED IN 1992 ---------------------------------------------------- Appendix II:9.0.2 The maximum capacity was 20; the average population at a given time was 19. The total served was 35. CHARACTERISTICS OF YOUTHS SERVED ---------------------------------------------------- Appendix II:9.0.3 The residential program of Pressley Ridge School at Grant Gardens serves boys and girls aged 13 to 17 from southern West Virginia. All of its youths, who are about equally divided between boys and girls, are in state custody for such offenses as truancy or being out of parental control, though some may have delinquency adjudications as well. About 90 percent of the youths have had previous placements. Eighty percent come from families with incomes below $15,000, and 95 percent come from single-parent families. About half have a history of physical abuse or neglect, and 30 percent have been sexually abused. Eighty percent of the boys and girls are referred by the West Virginia Department of Health and Human Services; 15 percent are referred by probation officers; and 5 percent are referred by mental health sources. About 50 percent of the youths served have exhibited all four risky behaviors: poor performance in school, substance abuse, delinquency, and early, unprotected sexual activity. LENGTH OF STAY ---------------------------------------------------- Appendix II:9.0.4 The average length of stay was 7 months; stays ranged from 3 to 24 months. COST PER YOUTH ---------------------------------------------------- Appendix II:9.0.5 For 1 year of treatment, the cost was $49,772; for an average stay of 7 months, the cost was $29,033. These figures include all costs except school, which is provided by the county school district without charge to the program. FUNDING SOURCES ---------------------------------------------------- Appendix II:9.0.6 Percent ---------------------------------------------------------------------- -------- Department of Social Services 22 Medicaid 75 Department of Education Chapter 1 3 -------------------------------------------------------------------------------- TREATMENT APPROACH ---------------------------------------------------- Appendix II:9.0.7 For each youth, staff develop (1) an individual treatment plan that addresses all identified issues, building on the youth's strengths, and (2) a behavior management plan that teaches skills for independent living. Each boy's or girl's progress toward achieving behavior goals is assessed at the end of each day, with the youth, staff, and peer group awarding points, as positive reinforcers, based on their combined assessment of the youth's behavior. Members of the peer group, which is central to the program, hold one another accountable for inappropriate behavior. As conflict arises or youth display inappropriate behavior, staff work within the group process, discussing the consequences of behaviors. Staff use role modeling to help youths learn appropriate behaviors in observed problem situations and relate them to situations that might arise at home or in the community. For example, when a youth loses his or her temper, staff may discuss and demonstrate behaviors that could later help the youth cope effectively with a family member's losing his or her temper. Staff also work on identified problems with the youth. Youths attend school on campus for as long as necessary until they can function in a community school setting. Most youths attend school on campus for about 25 percent of their stay at the residential programs at Grant Gardens. Thereafter, they attend community schools. The program emphasizes family participation, recognizing that even though the youth is in the custody of the state, he or she may return to the family. Staff ask families what the families need to help their youngsters achieve a successful outcome and try to help them meet those needs. By scheduling meetings at the family's convenience, the program is able to involve about 80 percent of families. Ninety percent of participants receive follow-up services in the first 6 months after discharge, paid for either by Medicaid or by the Department of Social Services on a fee-for-service basis. Based on needs identified in formulating discharge plans, Grant Gardens has also begun providing home services and child placement services for those boys and girls who cannot return to their families. EFFECTIVENESS DATA ---------------------------------------------------- Appendix II:9.0.8 Routinely collected data. According to Pressley Ridge officials, because Grant Gardens was established in 1990, they do not yet have outcome data for that program. However, they provided us with outcome data from Laurel Park, a program established several years earlier for status offenders in northern West Virginia. According to Pressley Ridge officials, the two programs are comparable and would be expected to have similar outcomes. Outcome data have been collected 1 to 2 years after discharge for all youths discharged from 1983 to 1990. Data include such measures as going to school or working, restrictiveness of living situation, educational placement, drug use, stealing, and negative police contacts. Of 15 youths discharged from Laurel Park during the year ending June 1990, for example, 10 (67 percent) were in school or working 1 year later, 11 (73 percent) had earned a high school diploma or GED certificate or were needing less support in school, 12 (80 percent) were in a less restrictive living situation, 3 (20 percent) were using drugs, and 3 (20 percent) had at least one police contact. Special studies. No special studies have been conducted at the residential program at Grant Gardens, but one has been conducted at Laurel Park. Pressley Ridge Schools collected outcome data for 3 years on youths discharged between July 1987 and June 1988. Pressley Ridge staffs were able to locate 14 of 17 youths 1 to 2 years after discharge and 12 of 17 youths 3 to 4 years after discharge from Laurel Park to participate in this study. Staff interviewed the youths' probation officers, caseworkers, other Pressley Ridge staff, teachers, youths' families, and the youths themselves. Three to 4 years after discharge, some outcomes showed improvement compared to 1 to 2 years after discharge, and others did not. For example, 3 to 4 years after discharge, all 12 (100 percent) were living in a less restrictive setting compared to 12 of 14 (86 percent) 1 to 2 years after discharge, 6 of 12 (50 percent) were either going to school or working compared to 5 of 14 (36 percent) 1 to 2 years after discharge, 2 of 12 (17 percent) were using drugs compared to 4 of 14 (29 percent) 1 to 2 years after discharge, 6 of 12 (50 percent) had been involved in a physically aggressive act compared to 5 of 14 (36 percent) 1 to 2 years after discharge, and 4 of 12 (33 percent) had negative police contacts compared to 3 of 14 (21 percent) 1 to 2 years after discharge. While other Pressley Ridge programs that provide therapeutic foster care, day school, or treatment in a wilderness setting showed better results than Laurel Park on several dimensions--such as school or work status--a larger percentage of Laurel Park youths were living with their own family, with a foster family, or independently on their own. NAMES AND ADDRESSES OF 18 PROGRAMS VISITED OR CONTACTED IN GAO STUDY ========================================================= Appendix III Boysville of Michigan Clinton Campus 8744 Clinton-Macon Road Clinton, MI 48236 The Bridge Over Troubled Waters Transitional Living Program 47 West Street Boston, MA 02111 The Children's Village Tompkins Transitional Care Program Dobb's Ferry, NY 10522 Eastern Nebraska Community Office of Mental Health Adolescent Treatment Facility 885 South 72nd Street Omaha, NE 68114 Eastfield Ming Quong Los Gatos Intensive Residential Treatment Units 499 Loma Alta Avenue Los Gatos, CA 95032 Eckerd Family Youth Alternatives, Inc. Wilderness Educational System Camp E-How-Kee 100 North Starcrest Drive Clearwater, FL 34618 Father Flanagan's Boys' Home Boys Town Home Campus Boys Town, NE 68010 Harbor Schools and Family Services Haverhill Program 26 Rolfes Lane Newbury, MA 01951 Hillside Children's Center Residential Treatment Center 1183 Monroe Avenue Rochester, NY 14620 The Hyde School 616 High Street Bath, ME 04530 KidsPeace National Centers for Kids in Crisis Presidential Treatment Center 5300 KidsPeace Drive Orefield, PA 18069 New Life Youth Services, Inc. Paint Creek Youth Center 1527 Madison Road Cincinnati, OH 45206 Oasis Center, Inc. Michael's Kids House 1219 16th Avenue South Nashville, TN 37212 Piney Woods Country Life School Highway 49 South Piney Woods, MS 39148 Pressley Ridge Schools Grant Gardens Residential Program 2580 Grant Gardens Road Ona, WV 25545 Salesmanship Club Youth and Family Centers, Inc. Youth Camp 106 East 10th Street Dallas, TX 75203 Starr Commonwealth Schools Cedar Village Residential Program Starr Commonwealth Road Albion, MI 49224 YouthCare Threshold Program 333 First Avenue West Seattle, WA 98119 MAJOR CONTRIBUTORS TO THIS REPORT ========================================================== Appendix IV HEALTH, EDUCATION, AND HUMAN SERVICES DIVISION, WASHINGTON, D.C. Gregory J. McDonald, Director, (202) 512-6805 Carl R. Fenstermaker, Assistant Director William A. Schmidt, Advisor SEATTLE REGIONAL OFFICE Barbara A. Billinghurst, Issue Area Manager Susan J. Lawless, Evaluator-in-Charge Susie Anschell, Evaluator Stanley H. Stenersen, Reports Analyst _