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Ideas and Issues

In this section we include discussions of various issues in residential care that we consider worthy of critical discussion. We are very interested in your reactions to these essays.  Please address your thoughts to

Issues currently discussed are:

Maintaining A Safe Environment [February, 2002]
Follow-up Study; RTF admission and adult criminal convictions  [October, 2001]
New Federal regulations on restraint in RTF's; Will they protect patients?  [September, 2001]

These discussions are summarized below.

Maintaining a Safe Environment In Our RTF

Groups of adolescents in congregate care facilities can become seriously dangerous.  Recent press reports of the near murder of a child care worker who was apparently alone in a "cottage" with a group of girls have re-emphasized this point.  Although our RTF routinely accepts youngsters who have demonstrated much more serious potential for socially dangerous behavior than any of the agencies where serious disruption has occurred (and, in fact, has accepted  transfers from those agencies of adolescents they considered unmangeable), we have been able to maintain a very superior safety record without resort to repressive measures like mechanical restraint and "seclusion" or "special care" areas.  We attribute the difference to administrative philosophy, physical planning, and staff training and deployment.  Click here for a more complete discussion.

RTF admission appears to reduce subsequent criminal convictions -- the first data from our follow-up study

With support from the Child Welfare Fund, we have been cooperating with Dr. Bernard Horowitz of Child Welfare Research  to collect and evaluate follow-up information comparing the first 52 adolescents discharged from our RTF with 52 comparable teenagers who were referred to the  RTF by the State Pre-Admission Certication Committee over the same period but were not admitted due to lack of space.  Our primary question is whether the high cost of RTF treatment for very disturbed children is justified by savings in other public costs that they would generate--both during their childhoods and as adults-- if they do not receive RTF care.  We are attempting to catalogue and compare the alternative medical, mental health, social service, substance abuse and juvenile justice resources utilized by the non-admitted group, as well as the services used by both groups as young adults.  We are also interested in indices of positive achievement--graduation, employment, etc.--of both groups.

The Office of Mental Health was able to collect much of this information through Medicaid records; unfortunately, however, after reviewing it, the OMH Bureau of Children and Families, which is firmly opposed to further RTF development, chose not to release the data.

However, we were able to obtain a comprehensive listing of adult criminal convictions in 13 downstate counties (including the five boroughs of New York City and all of the surrounding  counties in New York State) from the State Office of Court Administration.  These data indicated that while 39% of the RTF "alumni" were convicted of offenses in the period from their 18th birthdays to the time of the study, a full 60% of the group who were referred for treatment but not admitted subsequently were found guilty of criminal conduct during this period.  This result is highly statistically significant, and appears to suggest that individuals referred to us for RTF admission are extremely likely to engage in criminal conduct as adults, and that those who are not admitted are about 50% more likely than those who are to eventually face a criminal conviction

This finding was reported in the October, 2001  issue the American Psychiatric Association's journal, Psychiatric Services (Vol.52, No. 10, pp. 1391-92 ).  To view the full text, click here.

Comment on new Federal Regulations on Restraint and Seclusion

The Center for Medicare and Medicaid Services (formerly Health Care Finance Administration) of the Federal government has published extensive new rules on the use of seclusion and restraint in residential treatment facilities.  We applaud the intent of these regulations.  We are opposed to the use of seclusion or "time out" rooms under any circumstances.  Our residential treatment facility was designed more than a decade ago without any such rooms, and we have never used this approach which we consider inherently anti-therapeutic.  Similarly, we have never utilized mechanical "restraints" (cuffs, strait-jackets, etc.).

However, the regulations also apply to any physical intervention that might be considered coercive--such as breaking up a fight or attempting to take a dangerous object away from an agitated patient.  They also require specific clinically important actions which, while generally reasonable, may be inappropriate and even dangerous in certain situations.  Among other things, they mandate parental notification whenever a minor patient is held, with no provision for the patient's agreement or consent to such notification, and regardless  of the patient's relationship with the parent or guardian who is notified.   This sets an extremely dangerous precedent of Federally mandated parental notification in medical treatment of a minor.  In a comment submitted in response to this proposal, we discuss several of the risks and costs generated by the regulations as written, and propose modifications that would meet the same objectives more effectively at less risk and lower cost.

As far as we are currently aware, the agency has not responded to these concerns in any way at this time.


[this page last revised 2/22/02]