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Opinion & Essays - May, 2000 Issue #69 

How Much Help Do We Need?
When Growing Up Doesn't Happen Naturally:

By Cliff Johannsen, Ph.D.
E-mail: johannse@transport.com

[Dr. Johannsen has worked in the mental health, substance abuse, and juvenile corrections fields for 31 years, and has been a psychologist for the past 19 years. He currently has a practice in Oregon’s north Willamette Valley, where he provides assessment, therapy, and consulting services. His clients include individuals, families, placement specialists, and programs. He and his wife Linda have raised two daughters, some of it “struggling.”]

An expert recommended to Tony and Jennifer that their son, Nate, required a “secure residential” level of care. They understood that was not their home, but they didn't know where to begin looking. Nate was turned down by the only local program because he had a history of some fire play. That program was more convenient for visits and family sessions but did not have locked doors or continuous staff supervision.

The success of arranging for treatment and education of a struggling teen will depend upon the amount of time, effort, and money a parent can devote. First a parent must decide: shall they accept a placement arranged by their local agency (clinic, school, court, etc.), hire a placement expert, or find the placement themselves? In this column I will provide information that will be helpful to parents in any case. 

Case workers, social workers, probation officers and public schools can be involved in finding an alternative placement. Their decisions are often limited by funding and captive or in- house placement options. The amount and nature of the help a family receives can be affected by factors other than finding a good “fit.”

When families can afford the time and the several hundred up to a few thousand dollars required to hire an educational consultant, a range of additional placement options may become available. A few specialize in lower cost placements for middle and lower-middle class families. Consultants spend a great deal of their professional time visiting programs in order to make more informed placement recommendations regarding the best fit for each family’s circumstance. 

Parents using a do-it-yourself approach find themselves sorting through volumes of glossy brochures and videos, the standard marketing tools, in which all programs look wonderful and universally appropriate for all youth. Often, however, the critical information parents need to determine the most suitable program is not evident. While helpful for parents to visit a handful of programs in order to see beyond the brochure, after such visits parents are sometimes still unable to determine which program will best meet their child’s needs. They are vulnerable to making decisions based upon geography or cost rather than the types and amounts of care that will be delivered. Parents become saturated with information, confused, and angry about the amount of time the job requires, and sometimes shocked by the expenses involved. 

There are three dimensions that need to be considered when placing a child:

1) Acuity - (the amount of planning time available, ranging from one day to possibly months) Sometimes an emergency (the acuity), a bureaucracy, or a legal authority will take all or most options out of a parent’s hands. But when there are opportunities and days or weeks in which to work, then parents can make a difference in finding the best “fit” between a youth and their placement. 

2) Intensity - (how much activity, supervision, and treatment is provided in a given time period) a) The overall level-of-care required by a child and the programs that can provide it, must first be identified. b) Distinctions are then made within types of programs at that level. c) Specialty care based upon a child’s type of problem or a family’s preference is also considered. 

3) Duration - how many days, weeks, months, or years of care is required before services can safely be stepped-down.

“Stairs” is an apt metaphor for understanding intensity or level- of-care. As illustrated below, each step upward is a higher level of care. As one goes up the stairs the frequency of treatment interventions, the number of required activities, and the amount of supervision is progressively greater. 

“Outpatient” is the lowest and “acute hospital” is the highest level-of-care. A few decades ago those were the only choices. Today, the many steps in-between allow for making a better “fit” with a teen?s needs. A level of care should be selected in which there is at least an outside chance for the youth’s success. In our example, the expert advising Nate’s parents may have focused on the simple question “What level of care would prevent him from burning the place down?”

Other factors need to be considered as well. Programs that provide higher levels of care impose restrictions on a teen’s privileges and freedom. Such care is usually based upon “parental authority” or an order of the juvenile court, rather than the teen’s choice. Therefore it should be the kindest and “least restrictive” placement that has some chance of being successful. 

Choosing the “least restrictive” care tends to drive the level of care downward; treatment becomes more expensive as the level-of- care increases. When cost is not a factor, it is important to realize that too high a level-of-care can be harmful to youth. When cost is an issue, three strategies can be used. First, determine if a teen has attempted and been unable to benefit from a lower level-of-care. This presumes minimal risks at the lower level of care. Next, establish “medical necessity;” the list of symptoms that can reasonably justify the higher level of care. The third strategy, “utilization management,” consists of closely monitoring the duration of care. 

This approach differs from physical medicine, where the emergency room doctor tends to use the most advanced and powerful medicine available, prescribed in the highest dose a patient can tolerate. Any other strategy would likely make the problem worse in the long run. But in recent decades when that approach was applied to teens with mental, emotional, behavioral, or substance abuse problems, it resulted in long periods of hospitalization, enormous expense, often minimal improvement, and sometimes harm. 

Once the needed level of care has been determined, there are many potential distinctions between the type of care given at a particular level, or “step.” For example, there is a big difference between weekly and monthly outpatient sessions. There are also several types of boarding schools, for example, “therapeutic,” “emotional growth,” and “academic.” Although the “steps” in the illustration above mention only the “therapeutic,” there are some meaningful distinctions to be made among these types of boarding schools. 

The third aspect of a decision about the “intensity” of treatment deals with a program’s specialty. Here, ?levels? have little meaning. Instead, program elements may be desirable because they match what is believed to be a youth?s particular needs. Idiosyncratic to particular programs, they can include gender- specific care, specialties in a narrow range of disorders (learning, behavior, mood, eating, etc.), or the virtues of simple outdoor living. These program elements might exist due to the founder’s interest, or some expertise of the program’s staff. Basing a placement upon a program’s ‘specialty,’ before identifying the needed level-of-care, is a common planning mistake. 

It is helpful when making placement decisions, to decide what is the “most facilitative environment.” This concept, originating in the rehabilitation field, implies that teens will do better when their program elicits their strengths and minimizes their weaknesses. The availability of opportunities and supports within a program tends to broaden the care available rather than intensify it. 

Once care has been initiated, then, appropriate program length becomes the question. It is not unusual for several months to pass before some positive response to treatment is noted. However, it may be as little as a handful of sessions, or as long as three years. Judging a positive response depends upon the treatment goals, which can range from “crisis intervention,” to “growing up.” Modern health insurance policies focus upon “crisis intervention,” helping someone to get “out of danger.” Under those circumstances, some minimal improvement maintained over two or three sessions is enough to indicate readiness to “step-down” or cease treatment for the time being. 

When families are paying out-of-pocket for a more thorough type of treatment, then a signal for a teen’s readiness for a lower level- of-care might be three or four months of good performance. Most programs specify their average “length-of-stay,” stating for example, that they are a one-year or two-year program. 

When substantial time passes without some improvement it may indicate a higher level-of-care is needed. In that instance treatment is “stepped-up,” usually to the next higher level. If there was worsening in the original behavior it would indicate a need to jump more levels to provide a more appropriate level-of- care. 

Eventually the question becomes “How do we know when we’re finished?” One need not be the perfect human being in order to leave treatment. A teen’s care can be periodically stepped-down until they are using self-help exclusively; after all, that is the usual human condition. 

In summary, these points should be emphasized: 

1) Professionals in the business of matching a child and their family’s needs to the available programs tend to be social workers, educational consultants, case managers, and probation officers, more than some other disciplines.

2) Parents who take an active role in their child’s placement pay in the form of money, time, and emotional turmoil. 

3) Parents who choose a passive role, or have no opportunity play an active role, may pay the price of dissatisfaction with the placement. 

4) Family financial resources (including insurance coverage) are always part of the “fit.”

5) The placement’s proximity to home might be either “near” or “far,” depending upon individual circumstances, geography being only one factor. 

6) Placement is based on a combination of needs, including acuity, intensity, and duration. 

7) Planning the “fit” involves considering the level-of-care needed, program options within that level, and the child’s individual needs. 

8) Subsequent placements at higher or lower levels of care depends on the presence or absence of progress toward treatment goals.

Parents reading this column may find themselves thinking, “Okay, I understand. But what can I do and where do I start?” Those are topics for future columns in this series.

Copyright © 2000, Woodbury Reports, Inc. (This article may be reproduced without prior approval if the copyright notice and proper publication and author attribution accompanies the copy.)

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