Vol 1 • Issue 3 • Mar 2010

There has been much recent debate on the appropriate utilization of residential treatment for children with intensive behavioral health needs. Many have voiced concerns related to the cost and efficacy of this treatment modality. The fact is that residential contributes vital components to any robust integrated continuum of care system. Outcomes research has demonstrated this to be especially true when case formulation indicates a risk of harm to self or others, meets medically necessary treatment criterion, involves multiple co-occurring disabilities, and/or presents a history of elopement risk. Additionally, academic residential is a vital and necessary placement option for Local Education Authorities to meet Federal requirements pertaining to IDEA (Individuals with Disabilities Education Act), as well as the No Child Left Behind federal law.

Few would argue that, whenever possible, children should be placed in the most appropriate and least restrictive environment. All too often, least restrictive translates to least costly. The most appropriate intervention is not always accessed immediately; a cheaper “less restrictive” level of care is attempted in the hopes it will be effective. Sadly, this leads to a care management system that results in a child “failing up” through multiple ensuing levels of care deemed more restrictive (and expensive) but “most appropriate,” This process fails the care management best practice goal to “deliver the right care at the right time at the right cost.”

The most important criterion for determining a child’s plan of care is that it meets their current needs, increases functional autonomy, and leads to a long term and meaningful connection within their most natural circle of support. Failed lower level placements add additional costs not to mention additional problems for the child, family and community at large. Succeeding downward is a much better system of care for all stakeholders.

Safety, comprehensive assessments, stakeholder engagement as key partners in the treatment process, trauma informed best practices, 24 hour medical and multi-disciplinary professional access, and consistent compassionate care that is strength based and outcome focused are the core elements of a residential intervention that delivers cost effective solutions. That’s what has created such a good outcome for Bobby, this issue’s success story.

At Grafton, we focus on the two primary goals that any quality system of care should hope to accomplish: increasing functional autonomy and independence by utilizing naturalistic community based supports.

Each plan of care is as unique as those it serves. The only constant is the need to make the best, most informed, and evidence based “interventions that work.” While most times that means ensuring a child returns to their family, there must be other available outcome options when it is in the best interests of a child or adolescent. There are many measurements of residential treatment’s efficacy that deserve attention and validation; when appropriately utilized, its value can be seen every day in the lives it saves and in the families it restores.

Jim Gaynor

Success Story

ASSESSMENT:

Bobby*, a sixteen year old male, has been at Grafton since March 2009. He came to the psychiatric residential treatment facility (PRTF) with a history of self-destructive behaviors, violent aggressions, severe depression and anxiety, non-compliance and explosive anger. Bobby had numerous failed out-of-home placements and six psychiatric hospitalizations over the past four years. In addition, he had prolonged separation from his family and, despite receiving special education services, poor academic performance. He had been admitted to his last placement under Temporary Detaining Order status as a significant danger to himself.

DIAGNOSIS:

Bobby’s referral diagnoses included major depressive disorder, social phobia, mild mental retardation and mild spastic cerebral palsy. Aggressive and self-injurious behaviors resulted in him stabbing himself with a pen, biting chunks of flesh from his shoulders and banging his head against a wall. When he first came to Grafton, Bobby expressed excessive and persistent feelings of fear or panic when he encountered a social situation. Seemingly ordinary activities like initiating a conversation, participating in an activity, or eating lunch in the cafeteria caused significant anxiety and were avoided at all costs. On the first day of his enrollment, Bobby’s levels of unease were so elevated that he hit the medical director during his psychiatric evaluation interview.

THERAPEUTIC INTERVENTIONS:

During his first few weeks at Grafton, Bobby had a difficult transition to his treatment regimen. The continuation of his significant self-injurious behaviors and aggressive outbursts, aggravated by auditory hallucinations, necessitated 1:1 staffing to ensure his safety and that of those around him. He was extremely reclusive, isolating himself from others and refusing to participate in any group activities, even eating meals in the cafeteria.

Bobby’s multidisciplinary team worked collaboratively to find out his motivational preferences. Through a functional behavior assessment and observation, it became clear very quickly that he enjoyed one-on-one attention from staff and that he wanted to improve. He responded positively when directed to focus on positive aspects of his progress in treatment.

Intensive individual therapy provided ongoing emphasis on repetition of skills including anger management, impulse control and social skills. Music therapy targeted increasing positive interactions, social skills, self-expression and self-esteem. In addition, with mentoring, medication management and specialized education services, Bobby learned more effective ways of coping with his anger and impulsive high-risk behaviors.

A structured behavior management plan was implemented to provide limits and positive behavior supports. The plan, led by an experienced analyst, provided in vivo exposure (direct confrontation to feared situations and environments. The purpose of exposure treatment is to decrease an individual’s fearful reactions (emotions, thoughts or physical sensations) through repeated exposures to anxiety-producing material. In addition, a therapist acted as a “shadow” for Bobby, accompanying him in anxiety producing situations and teaching expected replacement behavior. Through a technique of graduated exposure, Bobby was exposed to feared social situations in a very sensitive manner. For example, Bobby’s fears of eating in the cafeteria started with a simple expectation—that he just get out of bed. Once he was able to overcome his anxiety around this step, the expectation moved to getting dressed, leaving the residential treatment unit, walking to the cafeteria, going inside the cafeteria and, finally, eating with others. Clinical research supports that systematic desensitization is a universally accepted and successful evidence based treatment intervention for phobias.

A closely monitored psychiatric regimen indicated that Bobby had a chronic thought disorder. As a result, an antipsychotic medication, Seroquel was prescribed. The combination of Seroquel with Celexa, an antidepressant useful in treating social anxiety and depression, were critical factors in Bobby’s treatment plan. His behaviors improved and he slowly began to attend school and experience success in the classroom. His grades began to improve and the reinforcement of doing well became a powerful motivator in his treatment program.

PROGRESS:

Bobby’s incidents of aggressive and self-injurious behaviors decreased by 50% in his tenure at Grafton. Recently, he has had no incidents of property destruction or self-injurious behaviors. In fact, Bobby’s Global Assessment of Functioning (GAF) increased from 40 to 52 in one year. In addition, his grades have improved, his attendance is excellent and he no longer requires 1:1 support. He has also made considerable strides in social interaction and is comfortable initiating social contact with employees and easily engages in conversations in the cafeteria.

Bobby’s stability and progress have allowed him to become a member of the vocational group on campus. He enjoys tending to herbs in Grafton’s on-campus greenhouse, a project that allows clients to learn skills while respecting and caring for other living things. It also provides clients like Bobby with an opportunity to interact with — and give back to — the local community.

Bobby shared recently, “I am going to a group home soon and want to become a chef. During my free time, I take care of herbs at our greenhouse and I enjoy fishing, hiking and camping. I have made a lot of progress here.”

*Client’s name has been changed to protect his privacy

• Infant and Toddler Connection of the Shenandoah Valley–Grafton was selected as the lead agency for Early Intervention “Part C” for the Shenandoah Valley and will partner with the City of Winchester’s Department of Social Services to provide early intervention services for local infants and toddlers – birth through age three – with disabilities. http://www.infantva.org/
• “Grafton’s Process for Applying for Medicaid EPSDT Funding for Clients”–a webinar was presented on March 15th to referral agencies.
• “Using a Comprehensive Diagnostic and Assessment Process for Creating Individualized Treatment Plans for Children with Autism Spectrum Disorders” presented at the Northern Virginia Comprehensive Services Act (CSA) Symposium on March 10th by Allyson Bateman, educational administrator and Shamsi Sadeghzadeh, clinical administrator.
• “Increasing Treatment Plan Mastery through Data Based Decision Making” presented at the 7th International Association for Positive Behavior Support conference (APBS) on March 26th by Lynette Johnson, director of education and Lisa Marshall, clinical administrator.

• “Positive Outcomes Obtained for Individuals with Intellectual Disabilities and the Organization Providing Services to them After Minimizing the Use of Physical Restraints” will be presented at the 10th annual International Research and Practice conference hosted by the British Institute of Learning Disability (BILD) in Dublin, Ireland on May 6th by CEO, Jim Gaynor and executive director of the Winchester facility, Kim Sanders. http://www.bildservices.org.uk
• “Promising Evidence Based Practices in Autism”, a webinar will be presented on April 21st at 1:00 PM. This webinar is geared towards parents and referral sources for clients placed at Grafton. For more information on autism, please visit
  http://www.autism-society.org

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