The harm of residential treatment:

● A review of the scholarly literature by the office of the U.S. Surgeon General found only “weak evidence” for the success of residential treatment.[1] 

● A second review found “when community-based services are available, they provide outcomes that are equivalent, at least [to residential treatment centers (RTCs)].”[2] 

● Still another review, published in 2020, found that “the dearth of research supporting the effectiveness of interventions delivered in [residential treatment] should be alarming to families, advocates, practitioners, and policymakers.”[3]

● Yet another study, of children institutionalized for mental health problems, found that seven years after discharge from residential treatment, 75 percent of the children were back in the only settings they could understand: institutions.  They were in psychiatric centers or jails.[4] 

● Even Shay Bilchik, former President of the Child Welfare League of America, the trade association for residential treatment centers and other agencies holding children in substitute care, has made a startling admission:  Bilchik admitted that they lack “good research” showing residential treatment’s effectiveness and “we find it hard to demonstrate success…”[5]  

So it’s no wonder even the thoroughly mainstream child welfare litigation group Children’s Rights (which we have criticized for failure to emphasize keeping families together) says institutionalization is so awful it needs to be drastically curbed.[6]

And see also this fact sheet on the failure of RTCs, from the Bazelon Center for Mental Health Law.

Better alternatives:

● In Milwaukee County, Wisconsin, Wraparound Milwaukee serves the same children formerly served in residential treatment – but the children are helped in their own homes or in foster homes.  The children do better, and it costs less.  Here’s what the Westchester County, New York, Journal News found, when it looked at alternatives to residential treatment. Excerpts from the story are in italics:

[Wraparound] cut the number of Milwaukee children in RTCs by 90 percent, dramatically shortened their stays, reunited hundreds of families, reduced the incidence of crime and saved millions of dollars in treatment costs. It became a national model for treating emotionally disturbed children, offering a more effective and economical means of helping youngsters without the traditional reliance on costly and controversial institutions.

“Wraparound Milwaukee demonstrates that the seemingly impossible can be made possible: Children’s care can be seamlessly integrated. The services given to children not only work, in terms of better clinical results, reduced delinquency, and fewer hospitalizations, but the services are also cost-effective,” the President’s New Freedom Commission on Mental Health said in October. “Imagine the nationwide impact on our juvenile justice system if this program were implemented in every community.”

Institutions have long argued that their role is crucial because most of the children have no stable homes. But Wraparound advocates say institutions have been too quick to write off families; Wraparound seeks out families and finds ways to make them work.

Of course, Milwaukee’s institutions didn’t simply accept all this.  On the contrary, they fought it every step of the way.

“I remember meeting with groups of people and folks saying, ‘Let’s get some reports out that show they (Wraparound) are going to start hurting kids now,’ ” said Cathy Connolly, president of St. Charles Youth & Family Services, which operates Milwaukee’s largest institution. “Well, nobody could ever bring the reports to the meetings, ’cause there were none that existed that said we were doing anything all that great. We didn’t really have any solid anything that demonstrated we were able to fix kids.”

Connolly and her colleagues lobbied fiercely for the status quo.  She was remarkably candid about the reason: 

“There were a couple big fears. . The first was, ‘How are we going to financially sustain ourselves?’ “

Eventually, however, Connolly’s agency embraced the new approach.  She told The Journal News:

“I think, looking back on it now, what we’re doing for kids today is far more helpful.”[7]

● Occasionally, residential treatment centers study their own programs, and, when they find only failure, have a crisis of conscience and face up to the results. 

“The state would ask us at the end of each year what we did with their money,” says Patrick Lawler, CEO of Youth Villages in Tennessee, “and we would tell them the truth. We spent it.”[8]

EMQ Child and Family Services in Northern California had a similar crisis of conscience.[9]  Both institutions radically reformed; rebuilding their programs to empty most of their residential beds and provide more and better help to more children in their own homes or foster homes. Said Lawler:

“In the 28 years I have been entrusted with caring for other people’s children, some of whom come from dire circumstances, I have learned firsthand there is no substitute for a child’s birth family. I used to think we could do a better job of raising these children. We know better now. The best way to help a child is to help his or her family. Extensive research bears this out. We studied the research, redesigned our existing programs and developed new ones to ensure that the emphasis is on strengthening the child’s family…There are sad circumstances when children cannot be placed with their birth parents or relatives. In these cases, foster and adoptive parents play vital roles in ensuring long-term success for these children.”[10]

But both institutions found their biggest problem wasn’t finding better alternatives.  Their biggest problem was fighting what EMQ calls “the group home industry” which tried to stop the state from paying for alternatives.                                                                                

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All-purpose foster care-industrial complex excuse checklist

While we can’t reproduce the unctuous tone, we can guarantee the content of the excuses that residential treatment centers and other institutions will offer to justify their existence – because we’ve heard them all so many times before.

So we’ve supplied a handy checklist of excuses you will hear from the foster care-industrial complex – and why they don’t wash.

___ Excuse #1: “We’ve already tried foster homes with these children.  They blow out of foster homes.”

RESPONSE: Aside from how revealing the offensive language is in terms of how the foster care-industrial complex really views children, the reason children sometimes don’t stay in family homes is that the homes themselves don’t get the support they need.  When children are served by Wraparound and similar programs they don’t “blow out” of foster homes, or their own homes.  But Wraparound programs rarely are available because the institutions are scarfing up all the money.

 ___ Excuse #2: Of course we believe in prevention, and we’d much rather children stay in their own homes.  But there always will be some children who need to be institutionalized.  We just want to make sure there is a full continuum of care.  The people who disagree with us believe in “one size fits all.”

RESPONSE: Whatever number of foster children might need to be institutionalized, we know that the number is so tiny that the overwhelming majority of institutional beds can be closed – just the way Youth Villages, EMQ Child and Family Services and Wraparound Milwaukee did it.  It is, in fact, the foster care-industrial complex that believes in one size fits all – substitute care, instead of a variety of safe, proven alternatives.  And the reason there is no “continuum of care” is that, again, the institutions are using up all the money.

___ Excuse #3: We’re not an institution.  We’ve got house parents and cottages.  We’re home-like.

 RESPONSE: You know that stuff people sometimes put on bread to lose weight? Stuff called “buttery spread” or “buttery light” but it always tastes like liquid plastic?  People know the difference between “buttery spread” and butter.  And children know the difference between “home-like” and home.  It’s not the buildings in a child’s life that bring stability, it’s the people. House parents typically quit every year or so, making institutions just as “unstable” as a succession of foster homes.  And many institutions still rely on shift staff which is, of course, even worse.  Children don’t need Potemkin Village families, they need real families.

 ___ Excuse #4: When the state uses alternatives to institutions it’s because the state doesn’t care about the kids.  When they send children elsewhere, they’re just doing it to save money.

RESPONSE: This is the most offensive claim of all.  The people who say others care only about money stay alive by charging states and localities huge amounts on a per diem basis.  So the longer they hold a child in their institutions the more money they make.  Talk about glass houses …

At NCCPR, we tend to be tax-and-spend liberals and proud of it.  But it is obscene to criticize a program just because, in addition to helping children, it also happens to save money.  In fact, when it comes to child welfare, in general, the better the option, the less it costs.

Updated April 18, 2011

[1]Department of Health and Human Services, Public Health Service, Mental Health: A Report of the Surgeon General 1999.

[2] Richard Barth, Institutions vs. Foster Care: The Empirical Base for a Century of Action, University of North Carolina, Jordan Institute for Families, June 17, 2002.

[3] Paul Lanier, et. al., “A systematic review of the effectiveness of children’s behavioral health interventions in psychiatric residential treatment facilities” Children and Youth Services Review, Vol. 113, June, 2020.

[4] Paul E. Greenbaum, et. al., ”National Adolescent and Child Treatment Study (NACTS): Outcomes for Children with Serious Emotional and Behavioral Disturbance,”  Journal of Emotional and Behavioral Disorders, Vol. 4, No. 3, July, 1996, pp. 130-146.

[5] Shay Bilchik, “Residential Treatment: Finding the Appropriate Level of Care,” CWLA Residential Group Care Quarterly Summer, 2005.

[6] Ira Lustbader, et. al., Families Over Facilities: Ending The Use Of Harmful And Unnecessary Institutions And Other Group Facilities In Child Welfare Systems (Children’s Rights: March 2, 2021).

[7] Shawn Cohen and Leah Rae, “Wraparound plan delivers success at less cost,” The Journal News, December 15, 2003. 

[8]Jamie Satterfield, “Youth Villages lauded as one of nation’s best in curbing youth crime,” Knoxville News-Sentinel, June 6, 2001.

[9] Martha Shirk, “The Gift of Wrapping,” Youth Today, June, 2003.

[10] Patrick Lawler, “Birth Family Is Best For Children,” Memphis Commercial Appeal March 20, 2001; see also, Bill Alexander, “Radical Idea Serves Youth, Saves Money,” Youth Today, June, 2001.