–by Sara Borgstede [originally published on the author’s own blog, The Holy Mess, on October 7, 2017]
No one gives birth or adopts a child with the hope that he or she will need residential treatment someday. Coming to the conclusion that your child needs care in a facility is an incredibly difficult, painful process for any parent. These decisions are not made lightly. Yet, for many children there comes a time that more care is required than what can be provided in a home setting.
For many parents, the decision to pursue residential treatment comes after months of deliberating, discussion, and intense crisis moments in the home.
Imagine the shock and anger many parents feel when they realize that just because they need residential treatment for their child doesn’t mean they will be able to get residential treatment for their child.
In addition, most residential placements are only for a few months and the child will soon be expected to come back and live in the family situation.
Our son is currently living in a residential treatment setting so I appreciate this roller coaster of emotion. We knew years ago that he needed residential care and the process of getting it for him took two and a half years of more pain, struggle, and advocacy than what should be required.
If you believe your child needs residential treatment yet you find yourself facing many closed doors, know you aren’t alone.
The following information is from the perspective of a fellow parent who has walked this journey. Please understand that each state, county, and agency handles placement a bit differently and your situation might be different. I’ve also learned that different states have new names for what is essentially the same thing, so keep that in mind as well.
Because these are children with a very high level of need, keep in mind that this is not a direct process and what works for one child might not work for another.
How to Get Residential Treatment for Your Child
The following questions and answers will help guide your advocacy process. Knowledge is power. If you need additional direction, you are welcome to email me: sara@
What is residential treatment?
Residential treatment is when a child lives outside of the home situation 24/7 and lives in a controlled facility environment. Typically a child who needs this level of support has extreme behavior issues such as rage, aggression, acting out sexually, violence, crime, or very serious mental health issues.
Residential facilities are often locked, meaning the child cannot leave without permission, but this is not always true. Children attend school on or near the campus. Most residential treatment centers for children have a small, fully functioning school that operates within the treatment program. This school must follow all the same guidelines as any other school, such as following your child’s IEP.
Children in a residential treatment placement may go on outings and participate in sports and other events, or they may only stay at the facility. Sometimes this is determined by appropriate behavior.
Children often live within cottages or smaller units in order to promote a family-type environment.
Most facilities include a strict behavior system with positive reinforcement, rewards, and consequences for negative behaviors. Most facilities will restrain children physically if the child is raging to the point that he is dangerous to himself or others.
Family interaction is encouraged. Family visits and phone calls are allowed, although the number and duration varies depending on program and child and parent safety issues.
What is the success rate of residential treatment?
The truth is that residential treatment has poor success rates. Children do better in families and within the community. The goal is always to keep the family together and residential treatment is used as a last resort. Residential treatment is the highest level of care and so reserved for children who are most in need.
Mental health placements typically have a higher success rate while placements through the juvenile justice system typically have poor success rates and high recidivism rates.
Still, there are times when residential treatment is necessary. This is the case when a child needs crisis intervention or the child is too dangerous to live in a community setting.
What if people keep telling us, “it’s not bad enough?”
If you are parenting a child with extreme behaviors and you feel residential treatment is necessary, do not be surprised if the answer you hear time and again is, “It’s not bad enough for residential treatment.”
Residential treatment is expensive and because the success rate is low, most programs and systems strive to keep children within the community if at all possible.
One psychologist told me this grim story. He was working with a family where the mother woke up one night to find her son standing over her face with a butcher knife, threatening to kill her. This child was denied residential treatment because the insurance company said he was stable enough to continue living at home.
If this scares you, I get it.
I didn’t fully appreciate this reality until we lived it ourselves.
Due to early childhood trauma, our son has extreme aggression and violent behaviors. We had been living a miserable existence for a number of years as we did our best to manage, yet he only became more violent. The police knew our family (unfortunately) and did little to help. With each 911 call they took more and more time even coming to our house. Knowing you are a “frequent flyer” is not a good feeling.
The day our son seriously hurt another child, I called the CPS (Child Protective Services) hotline as well as the police to report what happened. Based on my foster care experiences, coupled with the long-time patterns of my son’s behavior, I was sure our son would be removed from our home that day, In fact my husband came home from work to wait with me for the CPS (Child Protective Services) worker to arrive.
What happened? Nothing.
The worker didn’t even come to visit until several days later and when she did, it was to tell us she felt we were a “good enough family” that she didn’t see the need to do anything further.
When my son repeated the same dangerous behavior in a respite home several months later, I was sure he then would be given a residential treatment placement.
Nope. I was told, “not even close”.
We came to the place as a family that my husband moved out of our home with my son because we didn’t want to put the other children in harm’s way. We were miserable and our marriage was strained. Yet even this was not enough.
How do residential treatment facilities determine which children get a placement?
What determines that a child needs a residential placement? The following may be what is necessary for a child to receive a long-term residential placement:
- Danger to self (suicidal or extreme self-harm) or others
- Safety issues
- A crime is committed
- Short-term hospitalization is not enough to stabilize the child’s mental health
- Drug and alcohol abuse
The exception to this would be a facility where you privately pay. Private residential treatment centers, wilderness programs, boot camps for youth, military schools, and boarding schools who specialize in behavior issues will often accommodate accepting a child if payment can be arranged.
What are the different types of residential treatment?
When determining what type of treatment is best for your child and where to get it, things get complicated so it’s important to understand differences. There are many types of residential treatment programs and each has advantages and disadvantages.
Most placements are made through either the department of mental health and are funded through insurance and Medicaid, or placement is made through the court system (often called JJ, Department of Juvenile Justice, or Family Court). There are other ways placements can be made, but these are the two primary ways.
When a child is placed in residential treatment through the state office of mental health, this means a diagnosis of a psychiatric disorder is in place and it’s been determined that the child needs the highest level of care. These facilities are focused on treatment, not punishment, and the goal is stabilization so that the patient can return to the community. Treatment typically lasts 3-9 months, but can be a year or longer.
When a child is placed through the juvenile justice program, a crime has been committed and a judge determines placement. These placements are typically more of a jail-type setting and less therapeutic, but this is not always true.
You will hear the terms RTF (Residential Treatment Facility) and RTC (Residential Treatment Center) and sometimes you might be asked, “Is your child in an RTF or RTC?” I’ve learned that in some states that term is used loosely and in others it carries more meaning because it’s stating if the placement is for mental health or juvenile justice.
Other types of placements include group homes (which generally have more freedom and are not on locked), drug and alcohol rehabilitation, and group homes and facilities specifically for children with a lower IQ.
Some therapeutic foster homes, or Teaching Family Homes, are similar to a residential setting in the amount of supervision, but children live in a home setting.
How do I pay for residential treatment?
Residential treatment is incredibly expensive and sadly, at the end of the day much of the conflict comes down to who will pay. There are several ways residential treatment is funded:
- Insurance. Because private insurance will eventually run out, children who are privately insured will need to apply for Medicaid. With a mental health diagnosis, a child can be placed in a residential setting if he meets certain strict criteria.
- Court systems. If charges are pressed, a judge can order placement in a residential setting.
- Foster care. Parents may voluntarily place a child in foster care. The foster care system will now have physical custody of the child but parents retain parental rights. If no suitable foster home is found, a child may be placed in a group home or residential setting. The goal is reunification after the child has received proper care. The child may also age out of the foster care system.
- Relinquishment of Parental Rights or Termination of Parental Rights (TPR). When parents no longer wish to maintain a relationship (most often this is the case with an adoption situation), they move to relinquish parental rights. Depending on the state, relinquishment is not easy to obtain. Typically another adoptive family needs to be arranged before a judge will grant relinquishment. Adoption is legally binding. However, in the case of a child with severe mental health or behavioral issues, a judge may grant relinquishment in order for the child to receive needed services.
- School districts. Although rare, it is possible for a school district to pay for an out-of-district placement if parents can prove this is the least restrictive option and no in-district option is suitable to meet the needs of the child.
- Private pay. Parents may pay privately for residential care.
If you have a residential treatment facility in mind, I suggest you call the director and ask some questions. I have done this quite a few times. Facilities have budgets and let’s face it – they want each bed full in order to operate most effectively. I have found that directors are very helpful in explaining how children come to their facility and what I needed to do to get my child a placement.
Will my child need Medicaid to get a residential placement?
Many families who have children who have private insurance find that it is necessary to apply for Medicaid for children who are in a residential treatment facility. This process can be lengthy, and some states only allow a certain number of waiting children to be admitted.
I’ve heard I have to pay child support while my child is in residential treatment. Is this true?
Yes, depending on the type of placement you may be required to pay for part of your child’s treatment. This varies by state but can be up to 19% of the total amount of the child’s care.
If your child is placed through voluntary foster care or juvenile justice, you will probably be asked to pay a portion of the care.
How do I choose the right facility for my child?
Choosing a residential treatment facility for your child is incredibly important. Because placements are hard to acquire (and you are likely totally exhausted), it might be tempting to think, “We will take whatever we can get.”
Don’t believe it. You are the parent and have the right to choose where you want your child to live. Understand that your options may be limited, or choosing a certain facility might mean a longer wait time, but know this is your right.
If your child is being placed through the juvenile justice system, the judge determines placement. However, you have the right to attend Family Court and present a request.
Any facility should be willing to meet with you and discuss their program. If possible, tour the facility. Because of privacy issues, the treatment center may request that you only visit rooms where children are not present.
Here are some helpful questions to ask when touring a residential facility for your child:
- What is the staff/child ratio?
- What does a typical day look like?
- What types of therapy are available?
- What happens when a child’s behavior gets out of control?
- What’s unique about this treatment facility?
- What is the school like?
- How often can I visit or speak with my child?
The absolute best way to find out about a facility is to speak with a fellow parent who has had a child there. You probably won’t know anyone personally, but if you look for online support groups, you will probably find someone who knows someone who has had a child at that facility. Keep digging for this very helpful information.
What about TPR (Termination of Parental Rights) or voluntary foster care placement?
Depending on the system in your state, you might consider voluntary foster care placement or even TRP, which ends the parent-child relationship legally. In some states, these steps are required in order to get the necessary funding for residential treatment, but the parent-child relationship remains in place. In other states, TPR ends the relationship.
Because adoption is legally binding, many states are becoming more strict about TPR. The assumption is that adoptive parents and other parents with troubled children are “dumping kids” on the state to handle. Because of this, TPR may be a lengthy process and you might be required to find a new adoptive family before TRP will be granted.
Now there are agencies that offer “second chance” adoptions for these children. This idea leads many in the adoption world to mixed feelings. Second adoptions should be an absolute last resort, but sometimes it is necessary. New adoptive parents should understand fully the challenges they face in bringing a child into their family with extreme behavior issues.
Should I hire an advocate or attorney?
Yes. If you feel strongly that you have tried every avenue for receiving residential care for your child and you still come up short, I recommend hiring an attorney or advocate. This can be expensive but when you have legal counsel, your situation will be taken more seriously. Ideally, find someone who specializes in adoption issues. Try one of these resources for assistance:
Building Bridges 4 Youth – helpful family tip sheets when your child is in residential treatment
SAMHA – substance abuse and mental health resources