The Influence of Age, Gender, and Complex Trauma on the Relation between Treatment Conditions and the Use of Crisis Response Interventions in Therapeutic Residential Care

Background: Youth in therapeutic residential care (TRC) report higher rates of complex trauma (CT; 92%) than in community-based care (77%; Brigg et al., 2012). Many TRCs employ specific trauma-informed treatment models (Weiner et al., 2009) yet continue to use crisis response (CR) interventions that may impede youth progress. The use of CR interventions, such as restraint and seclusion, pose a risk to positive treatment outcomes (Sunseri, 2001, 2004) due to the potential for re-traumatizing youth with CT (Zelechoski et al. 2013). Yet, there is continued reliance on such techniques within TRCs (Muskett, 2014). Youth characteristics, such as gender, age, race, and impairment are associated with the use of restraints and seclusion during their treatment in TRCs (Roy et al., 2019). This study examined the moderating effects of client characteristics, including CT, on the relation between treatment factors and the use of CR among youth in TRC.

Methods: Data from a program evaluation of a Midwest youth psychiatric residential facility that transitioned from a traditional care model to a trauma-informed care model (Boel-Studt, 2017). Measures of client characteristics were age, gender, race, functional impairment, and CT. Treatment factors included treatment model and youth’s length of stay (LOS) in TRC. Three measures of CR were modeled: the total number of restraints, the total number of seclusions, and a variable of combined restraints and seclusions. A negative binomial regression was used to analyze the main effects and interaction effects of the models.

Results: The sample included 206 youth in either the traditional (n=104) or trauma-informed (n=102) care model. Youth averaged 7.68 (SD=19.76) seclusions, 7.79 (SD=14.41) restraints, and 15.47 (SD=27.3) total CR interventions during treatment with an average LOS of 39.2 (SD=18.68) weeks. Fifty females (58.82%) and 67 males (55.40%) experienced CT. All models were significant. There were significant main effects and interaction effects for gender, age, and CT across models. Compared to males, the percent change in the incident rate for seclusions and total CR interventions for females was a 1% increase for every additional week in treatment. Compared to youth in the traditional care model, the percent change in the incident rate for seclusions (0.6%), restraints (.75%), and total CR (.65%) decreased for each additional year of age of the youth in the trauma-informed care model. Compared to youth in the traditional care model, the percent change in the incident rate of restraints for youth in the trauma-informed care model was a 1.5% increase for every unit change in CT.

Conclusions and Implications: The findings support youth age, gender, and CT are important characteristics to consider with TRC treatment planning. The potential of alternative trauma-informed CR methods, specifically for younger children and youth with CT, may contribute to a reduction of restraint and seclusions (Roy et al., 2019) and reduce the risk of re-traumatization (Zelechoski et al. 2013), leading to shorter lengths of stay (Stanley & Boel-Studt, 2019) and improved treatment outcomes (Larzelere et al., 2001). Trauma-informed methods of CR should be considered to promote the safety of youth in treatment.