Selection Criteria – A START

After taking some time to reflect on the role this blog has in supporting parents of troubled teens, I continue to be concerned that there is too much still unsaid and, as such, I have decided that for now I would continue creating new posts.  With this said, and as before, please note that the information provided in these blogs has an element of personal opinion and should be read in this light.  Please seek appropriate independent professional advice to validate the opinions given.

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As noted in prior blogs, various groups are working to ensure that parents have as much information as possible before placing a teen in a therapeutic program.  One such organization is the Alliance for the Safe, Therapeutic and Appropriate use of Residential Treatment (A START – http://astart.fmhi.usf.edu/).

Per their website:

“A START, the Alliance for the Safe, Therapeutic, and Appropriate Use of Residential Treatment, is an organization of mental health professionals, parents, advocates, and young adults who came together in 2005 amidst growing concern about mistreatment of youth in residential programs.

These concerns were reinforced in hearings held in 2007 and 2008 by the Committee on Education and Labor of the U.S. House of Representatives. During these hearings, Committee Chairman George Miller described the practices in some of these programs in simple and powerful terms as “inhumane.”  The concerns were further documented in reports prepared by the Government Accountability Office, in which the GAO reported that allegations of abuse were widespread, and that “the current federal-state oversight situation is inadequate to protect youth from maltreatment” (more on this in a future blog)…

A START seeks to increase awareness of this problem, promote protections for children and families, and provide information about residential programs and community-based alternatives so that parents and youth can make the best choices. ….”

One of the ways, ASTART is achieving their objectives is by providing a simple fact sheet (see http://astart.fmhi.usf.edu/AStartDocs/factsheet.pdf) which parents can use to help guide them in their decision making process.  Some of the recommendations on the fact sheet are listed below.  Please note that, where applicable, I have added comments after each number based on our experiences.  As before, my goal is to create a single selection criteria questionnaire for parents to use but I feel it is more important to share the individual information and sources first.

Also as you read this, please remember there are good legitimate programs out there, the key is to weed out the other ones.

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We recommend that you beware of programs that

1. Are not state-licensed and accredited with regard to all 3 aspects of the program: the (1) educational, (2) mental/behavioral health and (3) residential components.

Comments for consideration: Ideally, all programs should be state-licensed and accredited with regard to all aspects of their program.  However, depending on the length of the program and the type of program, my thought is that there may be different considerations. As an example, if your son or daughter will be attending a residential treatment center for a short time period, say 3-5 months, whether the school is accredited for educational components may not be as important as whether the residential and mental health components have been accredited.  It may be more important that the credits earned during this time be transferable to the school district that your son or daughter will be attending next and that, if applicable, these units will count towards college credit (see Item 8 below).

As to the type of program, given the short- term nature of a wilderness program, my thought is that these programs should have special accreditation/training for wilderness/field work (e.g. Wilderness First Responder, EMT – Emergency Medical Technician, etc.) and mental/behavioral health.  However, it may not be as important that the wilderness program be accredited for educational and residential components. In all circumstances, programs should have adequate safety training but in the case of a wilderness program, this safety training is even more critical.  Ideally, all residential programs should have some form of residential and mental/behavioral health review/licensing/or accreditation.

Lastly, please keep in mind that not all states require licensing nor do all states have robust review procedures of the facilities that they have accredited/licensed.  For this reason, I must again reiterate the importance of a professional team supporting you in making a placement decision.  In addition, if while your son/daughter is attending a program you feel that there is something that just doesn’t seem right, follow your instinct and notify the appropriate person of your concern (i.e. educational consultant, therapist, etc.) and follow up.  Looking back, I feel that we could have avoided some hardships for our daughter and ourselves had we been more persistent.

2. Claim to be able to assess your child and make program recommendations by internet or by phone and then urge you to “act now” to prevent serious harm to your child and family.

Comments for consideration: Unfortunately, many families begin to take action when there is a crisis with their son or daughter.   Families will then quickly research by using search terms online such as troubled teens, teen addiction, etc..  In some cases, parents will call the programs that showed up on their search.

I am far from an expert but I know that it’s possible to attract traffic to your website by the use of key words.  Please note that driving traffic to a website may not be a bad thing as there are legitimate businesses attracting web traffic to their website, the risk comes with those websites/businesses that are not so ethical and/or knowledgeable.  Some of these programs/businesses may want you to act faster than you are comfortable with and/or than what is warranted.  In fact, you may have time to do adequate research through your local doctor, therapist, educational consultant, etc. and/or to contain the current situation.

However, to be clear, there are legitimate emergencies that must be dealt with immediately.  If you have a local support team already in place, contact the appropriate person.  Ideally, you had been working with a local team and had developed an emergency plan (local hospital, mental health crisis clinic, etc.).  If not, and it is a medical emergency/crisis, call 911.  As an example, if you are dealing with a suicide attempt or an overdose, you need an intervention and/or medical attention immediately – everything else can be dealt with later.

3. Recommend or support the use of private “escort” or “transport” services to take your child to the program.

Comments for consideration: The reality is that most of the teens that I met at the programs that my daughter attended went to the program with an escort service.  In our case, in both instances, our educational consultants recommended this option for our daughter.  In the first instance, we opted against using an escort service, and in the second instance, we did use these services but told our daughter that the escort service would be taking her to the new program and at what time the escort service would be arriving.  In fact, we met the escort team with our daughter the evening before they all left for the program.

I know that the choice to use an escort service is not that simple and depends on each individual family’s circumstance.  If all agree that this is necessary, in my opinion an escort service should be screened like any other program you are dealing with (e.g. who is recommending it, why, is there another option, do they have a record, what is their approach, etc.).

4. Do not respect the wisdom and expertise of parents and youth

• Do not allow your family and child to visit the program, see all the facilities and meet all the staff before deciding to admit your child.
• Tell you to expect that your child will lie to you while in the program, and encourage you not to believe reports of abuse because these will be “attempts at manipulation”
• Do not encourage you as parents to be active participants throughout all stages of the program
• Do not welcome feedback (praise or criticism) from your child regarding the program

Comments for consideration: On the first item, if your child is attending a wilderness program, it may be difficult to get him/her, or possibly yourself, to visit the program prior to admission.  However, if you are using a reliable educational consultant, the educational consultant (or someone from their team) should know the facilities, have a clear understanding of the programs therapist/staff/practices, etc..  Also, speak to parents whose son or daughter have attended the program, find out if your local therapist is familiar with the program, check with the appropriate agencies to determine if any charges (and what type of charges) have been brought up against the program, etc..  Simply stated, you need to feel comfortable.

As to having your son/daughter visit the residential program prior to placement, in our case we visited the programs that had been preselected based on our daughter’s needs, and prescreened through a review of their literature, phone calls to the program, and phone calls to former parents.  Our daughter did not visit the programs based on recommendations received from a couple of members of our team.  However, we did ask our daughter about her preferences and, when possible and appropriate, we tried to meet these.

5. Restrict youth & family rights in terms of:

• Contact with family by phone, mail and in person (for example, no phone contact or visits for first month; censored mail; monitored visits with no opportunities for parent/child discussion in private)
• Dress code (for example: require youth to wear jumpsuits or flip-flops)
• Typical age-appropriate behavior (for example: forbid eye contact with youth of the opposite sex; forbid speaking, smiling, or moving without permission)
• Parental rights (for example: do not contact parents immediately in the case of illness, injury, emergency or treatment/medication changes)
• Do not provide hotlines for youth and families to call at any time if they feel that their rights are being violated or they are being mistreated

Comments for consideration: We found that reduced phone communication was typical during the first few weeks of stay at each of the program our daughter attended. In one program, our daughter was also monitored while on the phone.  This made us feel very uncomfortable and had it not been for the level of comfort that we had with the program from various other sources this would have been unacceptable.  Our level of comfort came from the history our educational consultant had with the program, from our pre-enrollment visit to the program, from our pre-enrollment phone calls, from the parents we had spoken with prior to placement, from the conversation our local therapist had with the program therapist, etc..

We also learned that different states have different rules regarding letter writing privacy.  One state we dealt with allowed letters between teen and parent to be read by staff prior to being sent to the parent while another state considered this inappropriate.  As above, our level of comfort with these practices was directly impacted by all our other information on the program.

As to dress codes, we did run into some form of dress code at each program.  I think that there is more to this category as in some instances certain types of dress codes may not be appropriate (e.g. gang related attire, low cut outfits in a coed program, etc.).  The key may be appropriateness to the circumstances.  It may sound silly but I also feel that the standard should be applied uniformly whenever possible.  Otherwise, it may give the appearance of favoritism.

6. Use harsh and excessive discipline practices that include: seclusion, restraint, corporal punishment, punitive “behavioral modification,” fear tactics, humiliation, peer-on-peer discipline /peer pressure, forced labor, heightened physiological stress* or sedation by medication

* for example, excessive exercise, sleep deprivation, exposure to the elements, forced retention of bodily waste or nutritional deprivation

Comments for consideration: In addition to what is listed above, I think discipline has to fit the circumstances of your teen.  As an example, a teen entering a program struggling with depression/low self esteem, may react strongly to group therapy sessions where the struggling teen is singled out.

7. Provide sub-standard therapeutic intervention

• Do not provide an individualized program with a detailed explanation of the therapies, interventions & supports that will address your child’s specific needs
• Do not provide the kinds of therapies and supports that are recognized as most effective for the problem(s) or symptom(s) your child is experiencing
• The majority of participating youth are experiencing problems very different from the types of difficulties your child is experiencing-this suggests that the program emphasis will not be optimally focused on the needs of your child
• Claim to serve youth with specific psychiatric diagnoses* but do not have full-time licensed mental health professionals** on staff
• Provide individual, family or group psychotherapy that is delivered by staff who are not trained and licensed mental health professionals
• Force youth to self-disclose personal information and/or admit to having problems as proof of “therapeutic progress” or “recovery” or as a prerequisite for “graduating” from the program

Comments for consideration: Unless you’re a therapist, this is one of the areas where you need a team (which includes a therapist) to support your decision making and to help you assess if your son or daughter is getting the right treatment based on their needs.

8. Provide sub-standard education that is:

• Limited to some variety of monitored study halls, videotaped lessons or independent study
• Delivered by staff who are not licensed/certified teachers with degrees from accredited colleges
• Provided in an environment with a high student: teacher ratio (i.e. very few teachers for the number of students)
• Not providing credits that will be recognized by your child’s home school district, the State Department of Education where the program is located or by future college admissions departments
• Unwilling or incapable of recognizing your child’s IEP (Individualized Education Plan)

Comments for consideration: We found that the difference in the educational portion of programs was broad.  As examples, some programs had a heavy emphasis on arts while other programs tended to be more academically focused, some required a laptop for each teen while others had limited computer access.  I think looking at the bigger picture of who your son or daughter is, what are his /her support needs, what are his/her interest, what grade are they in, etc. will help you make the best choice for your family.

9. Admit youth with psychiatric diagnoses but then do not provide appropriate medical treatment:

• Do not complete an initial physical exam and psychiatric evaluation or review a physical exam/psychiatric evaluation conducted immediately prior to admission
• Do not request (prior to or upon admission to the program) your consent to contact psychiatrists, therapists and teachers who are currently working with your child or have worked with your child in the past
• Do not ensure that child/adolescent psychiatrists are regularly available to prescribe, monitor and adjust medications as needed
• Do not ensure that youth who are prescribed medications are administered medications by trained/qualified staff
• Over-medicate youth in order to sedate them
• Explicitly state that the program follows an anti-medication philosophy, particularly if your child is currently taking medication(s) for a diagnosed disorder

Comments for consideration: All of these are valid points.  In addition, there is subtlety in some of these points.  As an example, any program that does not require a physical immediately prior to admission is putting all other attendees and their staff potentially at risk of a communicable disease.

10. Require parents to sign contracts with unreasonable terms:

• Parents must agree to relinquish their custody rights
• Parents must agree to pay for services not rendered if youth leaves program
• Parents must agree not to hold program responsible for providing services as described in promotional materials or specified in original contract
• Parents must agree to pay rates and fees that are not clarified up front
• Parents must agree not to file suspected child abuse reports against program staff or participants
• Parents must agree not to sue program if their child or family is mistreated

Comments for consideration: We saw some of these requests in contracts (i.e. will not sue program).  As with any other contract, please read the contract carefully and ask questions before you sign.

11. Have been reported, investigated or cited by at least one source* for:

• Unsanitary or unsafe living conditions
• Nutritionally compromised diets
• Exposing youth to extreme environmental conditions or physical over-exertion
• Lack of supervision by staff (low staff: youth ratio)
• Medical neglect
• Physical or sexual abuse of youth by program staff or by other program youth
• Violation of youth/family rights

* for example: Dept. of Health, Dept. of Child Welfare, Dept. of Child Protection, Dept. of Education, Police Department, Family Advocacy Group, newspapers

Comments for consideration: In addition, to the agencies listed above, I recommend you also consider contacting some of the government agencies noted in the Resources page.

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I recognize that this is a lot of information to digest but hope that this blog helps you step back and look at the bigger picture.