The Anatomy of Residential Care Placement-Decision Making

Background: Placement into residential care is generally viewed as an adverse outcome by child-serving systems, policy makers and consumers that is only defensible as a ‘last-resort-placement' for youth for whom all other placements options have been exhausted. Given the growing availability of community-based treatment/services alternatives, reduction of residential care utilization has become an explicit goal of many service systems. As part of the proposed symposium, this paper will present findings from an ethnographic case study, which over the course of a year examined decision-making processes about residential care.

Method: The study was conducted in one child welfare and mental health system and involved ethnographic observation, key informant interviews and document review. Over the period of a year, the PI attended weekly interdisciplinary placement screening committees, conducted interviews with child welfare and mental health supervisors as well as line staff, attended other relevant meetings about policies and procedures related to residential care, and reviewed internal documents related to residential care. Findings were transcribed and analyzed using a methodology of “Coding Consensus, Co-occurrence, and Comparison” outlined by Willms et al. (1990) and rooted in grounded theory. To increase trustworthiness of findings, data were coded independently by two investigators; we also utilized member checking and audit trails. NVivo 7.0 was used for the analysis.

Results: Findings related to the decision processes indicated that the decision to place a child into residential care is based on many different factors that are both clinical and nonclinical. They include (a) referral factors (caseworkers' subjective assessment of a case; court order, attorney/judges' wishes/decisions); (b) clinical factors (duration, type, and severity of behavioral problems; substance use history; maltreatment history; behavior in prior residential care settings); (c) service history (prior psychiatric hospitalization; placement history); (d) developmental factors (older age; developmental delays; time until ‘aging out' of system; educational needs/resources; (e) family situation (location of family; family's involvement; parental psychopathology; permanency plan; (f) residential care-related factors (bed availability; availability of specialized services; level of restrictiveness; social workers' individual knowledge of particular residential care settings); and (g) other factors (availability/appropriateness of alternative resources; residential care as “punishment;” incomplete information). Findings further underscored the difficulty of placing children with severe psychiatric problems. While a number of community-based interventions served as treatment alternatives, including the evidence-based intervention Multidimensional Treatment Foster Care, wraparound services and therapeutic behavioral services were most commonly utilized.

Implications: Findings underscore the complexity of the decision-making process, and the lack of clear criteria that would guide these decisions. While the screening process is overall clinically thoughtful, nonclinical factors, such as the workers' individual knowledge about a specific residential care setting frequently lowered the threshold for residential care placement and adequate consideration of alternative community-based resources. The utilization of wraparound services and therapeutic behavioral services as primary alternatives to residential care placement raise interesting questions about the perception and implementation of evidence-based practices that deserve further investigation beyond the context of a case study.