In July, Katrina Ringrose and I traveled to Fordyce, Arkansas, to visit a residential mental health treatment program where three Maine youth were living. In my three years at DRM, I have visited youth with disabilities in out-of-home placements across the state of Maine, from Fort Fairfield to Saco, and many places in between. I have also visited Maine children in residential facilities in New Hampshire and Vermont. We conduct these visits using our federal access authority to connect with children placed away from their families and communities. We work to ensure that their rights are protected, that they have access to advocacy services, and that they are not subjected to abuse or neglect.
In the years before I started in this job, Maine DHHS had worked to decrease out-of-state placements for youth with disabilities. Unfortunately, those numbers have steadily risen over time. In 2016, 46 Maine youth received residential and hospital treatment out of state; in 2018, 87 Maine youth received residential and hospital treatment out of state.[1] DRM does not have comparable data for 2019, but as of October, 70 Maine children were in out-of-state residential placements. For context, there are approximately 300 residential treatment beds licensed in Maine, although providers report that they do not have enough staff to utilize that entire capacity. As the number of youth out of state has grown, so has the geographic scope of the problem. No longer are Maine children (whose families do not receive financial or logistical support from the state to visit them) kept within New England; we now send our youth to states including Missouri, Utah, Indiana, Illinois, Oklahoma, and Michigan.
This brings me back to our visit to Arkansas, the home of two programs that have served Maine youth in recent months (Millcreek, which we visited, and Piney Ridge, which has been the subject of recent shocking news reports [2]). One of the lessons DRM is learning as we try to stay abreast of where Maine youth are receiving treatment, and what issues they are facing in these unfamiliar places, is that rules and rights vary widely across the country. Although MaineCare requires out-of-state providers to follow Maine rules about our children’s rights, Maine rules are more protective than many other states’. This is important because our rules reflect our values and the best interests of our children, so that they can be safe and treated well when they are living away from home. These distant providers are not familiar with Maine’s rules, and our youth report many violations of their rights.
When we visited the Millcreek program in July, we saw that most of the 15 units were on “unit restriction,” so children were confined to their unit’s cinderblock corridor, in most cases milling about the dayroom and participating in no structured programming. Youth shared with us that this was a common state of affairs. Although the need for treatment is the sole justification for these children’s placements in an out-of-home setting, youth reported receiving only one hour per week of individualized therapy with their clinicians. Conditions on the residential units, in the recreational spaces, and at the school were poor; we saw exposed electrical outlets, crowded bedrooms, broken swings, and bleak classrooms. We came home shaken and sad.
Research shows that large institutions, out-of-home placements, lack of opportunity for meaningful family involvement in treatment, and congregate care generally are not the best practices for treating children with disabilities. And we know that emergency interventions such as restraint and seclusion – which can be re-traumatizing and have no therapeutic value – are all too common in out-of-home placements.[3]
Within our Maine-based residential treatment programs, we are more successful on some of those metrics. Maine programs are much smaller than Millcreek, which had over 200 children on its campus when we visited, ranging in age from 6-18, and hailing from 39 states. Our in-state facilities serve anywhere from 6 to 16 children, though some programs are on campuses with multiple units (like Millcreek), meaning that up to 40 or so children may be served at the same address. In recent years, Maine’s residential providers have consolidated their operations, so that programs that used to be smaller (up to 4 beds), more “home-like,” and scattered around the state are now congregated in the campus-based style. Providers report that these changes have been made for financial reasons, not to optimize treatment. This is also related to the widely acknowledged workforce crisis within children’s behavioral health in Maine – a campus-based approach allows for sharing scarce staff between programs in a way that would not be possible with smaller, scattered sites. Even these larger operations still struggle to recruit and retain adequate staff, with many providers unable to maintain the required ratios that would allow them to fill all their beds. So although Maine programs are smaller than the out-of-state programs we are utilizing for our children, they are not as small as research suggests they should be.
Although DHHS states that residential treatment is intended to be short-term – the MaineCare name for it is “intensive temporary residential treatment,” and DHHS indicates that the target time frame is 1-4 months – the average length of stay in 2018 (among youth who were discharged from the service in that year) was 11.3 months.[4] Presumably, this duration is “medically necessary,” the standard that must be met for MaineCare to continue paying for residential treatment. Why can’t residential treatment be accomplished more quickly, allowing children to return to their families and communities?
- One reason might be that families often find it difficult to have meaningful involvement in treatment. Explanations for this range from lack of capacity on behalf of families, to the geographic barriers that often exist (even within the state, children are frequently placed hours away from their homes), to the poor quality or complete lack of family therapy.
- Another factor could be that residential providers often struggle to provide safe and appropriate treatment to our children. DRM has read countless incident reports of children subjected to physical restraints by several adults after seemingly unnecessary power struggles with staff over food, toys, or leisure activities. Children are also regularly restrained after becoming escalated when their peers are struggling, a common and inherent drawback of congregate care settings for children with disabilities. Further, as we reported in 2017, providers at times call law enforcement when youth are dysregulated, a trend that unfortunately continues.
- Also, DRM has seen many instances, across providers, of treatment plans that remain the same month after month, despite lack of progress. And many, perhaps most, of the children in residential programs are receiving treatment that at best loosely conforms to evidence-based practices and rigorous standards.
- Some children are ready to discharge to a lower level of care, but due to long wait lists and scarcity of home and community-based services, the state has no discharge plan to offer them.[5]
We need better standards for quality of care and duration of treatment in our residential programs, and more availability of home-based services. Fortunately, Maine is in the process of undertaking those goals, in order to qualify for federal funds through the Family First Prevention Services Act. As summarized in the OCFS PowerPoint presentation available at the embedded link:
To meet the Qualified Residential Treatment Programs (QRTP) standard required for Family First funds, residential treatment programs (per the PowerPoint):
- “Must have a trauma-informed treatment model and capacity to meet clinical needs of children;
- Must have licensed clinical and nursing staff on site during business hours and available 24/7.
- Must facilitate family participation in treatment and document how they are integrated into treatment process;
- Must facilitate outreach to family members, including siblings and maintain family contact information;
- Must provide discharge planning and family-based aftercare for at least 6 months; and
- Must be accredited”
Few, if any, existing residential programs in Maine currently meet all of these standards. DRM plans to participate in the process of moving our state to one in which our youth can receive the supports they need in their homes and communities. Individuals who want to become involved can follow OCFS’s recommendations:
OCFS invites anyone who is interested in helping formally shape the process to volunteer for a committee by providing their contact information here.
[1] Children’s Behavioral Health Services Assessment Final Report, Public Consulting Group, December 15, 2018 (“PCG report”), page 36, available at https://www.maine.gov/dhhs/ocfs/cbhs/documents/ME-OCFS-CBHS-Assessment-Final-Report.pdf. Some information about the financial burden of sending Maine youth out of state is available on page 37 of the PCG report.
[2] This article also describes other information of great concern with regard to Acadia Healthcare, the parent company of Millcreek, Piney Ridge, and other programs across the nation that serve Maine youth.
- Here is a second article published by the Arkansas Democrat Gazette on November 17, 2019, Sex assault suit names behavioral health site in Arkansas
[3] For just one example of a large body of research, see Promoting Alternatives to the Use of Seclusion and Restraint: A National Strategy to Prevent Seclusion and Restraint in Behavioral Health Services, Issue Brief, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, March 2010, available at https://www.samhsa.gov/sites/default/files/topics/trauma_and_violence/seclusion-restraints-1.pdf.
[4] PCG report, page 31.
[5] This reason was cited in the PCG report on page 31.