Adolescent Day Treatment: A School and Community Based Alternative to Residential Care

Journal of Developmental and Physical Disabilities, Vol. 11, No. 3,1999

Adolescent Day Treatment: A School andCommunity Based Alternative to Residential Care

Shawn Powell,1,4 Carol Calkins,2 Diana Quealy-Berge,3 andAchilles N. Bardos1

This article describes a school and community based day treatment programwhich is the result of cooperative efforts between a school district and acommunity mental health agency. It is designed as the last, in-district place-ment available for students prior to residential care. Using a systemic ap-proach, the program serves students in grades 7 to 12, with a variety ofdisabilities including emotional and behavioral disorders, physical disabili-ties, and special education classifications. This article describes the program'streatment components, provides a case study of a student who attended theprogram, and presents the results of a 5-year review of the program's effec-tiveness.

KEY WORDS: day treatment; adolescent mental health; adolescent counseling; schoolbased services.

INTRODUCTION

Public schools are faced with the responsibility of providing educationalservices to students who exhibit emotional and behavioral difficulties. Whenthe severity of a student's emotional or behavioral involvement escalates,it can reduce the student's ability to be educated in public schools. Inproviding services to this population of students, many school districts haveresorted to residential placements (Kohen-Raz and Jonas, 1976; Zimmer-man, 1990). However, Wells (1991) reported that residential placements

1University of Northern Colorado, Greeley, Colorado 80631.2Wind River Institute, Cheyenne, Wyoming 82001.3University of Wyoming, Laramie, Wyoming 82070.4Laramie County School District #1, Cheyenne, Wyoming 82001.

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represent only one option for serving adolescents needs, and residentialplacements do not generally meet the needs of most children and adoles-cents. Moreover, alternatives to residential care have been developed. Anexample of such an alternative are school and community based day treat-ment programs which have grown in number (Dykeman, 1995; Erker etal., 1993). These programs are designed to meet the needs of students whoare unable to be educated in public schools (Suran and Rizzo, 1983) andrepresent a less restrictive environment than residential care. When studentsare placed in day treatment programs they remain in their communities(Ingram et al., 1991; Seelig, et al., 1992) which involves less disruption totheir relationships with family, friends and school as Comer (1985) reportedoccurs in many residential settings.

This article presents various aspects of the operation and effectivenessof an adolescent day treatment (ADT) program designed to serve studentswith severe emotional and/or behavioral needs in the 7th through 12thgrades. The program components, a case study of a student who attendedthe program, and the results of a 5-year review of services of the program'soperations are presented.

THE ADT PROGRAM

The ADT program was developed to provide school based educationaland therapeutic services for students with intensive psychological and edu-cational needs in their local community. The majority of the students inthe program are identified as having emotional and behavioral disorders andalso various educational disabilities (e.g., emotional disabilities, learningdisabilities, hearing impairments, and speech disabilities). The program'sprimary goal is to assist students in returning to public school settings asquickly as possible.

The specific ADT program presented is housed in its own facilitiesand provides services for approximately 20 students at any one time. Theprogram's objectives are to meet a student's specific needs through counsel-ing, special education, and vocational training, while the student remainsin the community. As recommended by Crespi (1988) the program employsa multidisciplinary team including: Special education teachers, educationalassistants, speech therapists, vocational counselors, mental health counsel-ors, clinical social workers, family therapists, and a school psychologist. Inspirit and function the ADT program is the result of cooperative effortsbetween a community mental health agency, and a local school district asits staff are contracted through both entities.

Following the suggestion of several researchers the program assists

276 Powell, Calkins, Quealy-Berge, and Bardos

students by addressing their needs through a multi-modal, systemic ap-proach (Collins and Collins, 1994; Grizenko et al., 1993; Short and Shapiro,1993; Stroul, 1988). Following this systems approach, each student's needsare addressed through the program's treatment components on four levelssimultaneously (e.g., individual, family, community, and school). In offeringthese services the ADT program provides five distinct treatment compo-nents: Individual counseling, group counseling, family therapy, special edu-cation, and community involvement.

Program Treatment Components

Individual Counseling

Individual counseling is designed to address each students' emotionaland behavioral situation, and usually consists of a combination of client-centered and cognitive-behavioral approaches. This counseling is per-formed within the school setting by a mental health counselor or clinicalsocial worker from the community agency. As in any therapeutic relation-ship, the therapy is directed at ameliorating the student's present level ofemotional and behavioral difficulty.

As Freedman (1982) indicated, the majority of students placed inseparate school facilities enter these programs with anger, hostility, andfear. Therefore, the importance of establishing therapeutic relationships,increasing trust, and improving the adolescent's insight is stressed. In ac-complishing this objective a client-centered approach is usually initiallyadopted to establish trust and to make the student feel secure and safe.Individual counseling also incorporates cognitive-behavioral methods de-signed to improve the student's ability to understand their own actions,thoughts, and feelings. The individual counseling provided through theADT program involves services not usually associated with traditionalschool counseling, (e.g., in-home services, monitoring family counseling,court appearances, and monitoring adult volunteer relationships).

Group Counseling

As students are primarily referred to the ADT program due to socialrelationship difficulties (e.g., oppositional behaviors, defiance, and difficultywith authority figures), group counseling is incorporated to improve theirsocial relationships. Group counseling emphasizes social skills acquisitionand is employed with a goal of increasing each student's self esteem as

A School Based Alternative to Residential Care 277

promoted by Murray (1995). Additionally, Herz and Reis (1987) held thatimproving decision-making and moral judgment is important in order toimprove adolescent interpersonal relationships. Therefore, an educationalapproach (Goldstein, 1988) is used to teach positive social skills to thestudents. This is accomplished through team building activities including:Peer process groups, cooperative learning, story telling exercises, experien-tial-based therapy/Ropes courses, and class outings to cultural events thestudents would not normally experience, (e.g. plays, museums, formal ban-quets, ski trips, and visits to local colleges).

Family Therapy

It has been suggested that adolescent treatment results are enhancedwhen therapy includes relevant family members, especially their parents(LeCroy, 1992; Waugh and Kjos, 1992). To this end, when a student entersthe ADT program, the family's involvement is stressed and can becomecrucial to the overall success of each adolescent. Therefore, to improve thestudents' opportunity for success, family services are provided by familytherapists from the community agency. For most of these students familytherapy follows a systemic or structural format and are individually designedby taking into account the family's current living situation. In addition totraditional family therapy, family members may be involved with in-homepoint of need family services, parent support groups, and parenting training.

Special Education

In providing community based services to adolescents, school servicesare an integral part of those interventions (Goddard and Carpenter, 1993).A special education teacher, employed by the school district, directs theclassroom instruction. Special education services form an essential aspectof the ADT program and are designed along behavioral lines.

The primary behavioral techniques utilized are antecedent controland contingency management. Antecedent control has been found to beeffective in reducing undesirable student behaviors (Powell and Nelson,1997). Accordingly, students are exposed to antecedent control by allowingthem a variety of choices regarding their academic work and classroombehaviors such as: Choice of assignments, choice of working location inthe facility, choice of rewards/incentives, and allowing students an opportu-nity to self initiate time out periods to reduce their levels of emotionality.

Contingency management is applied through positive reinforcementsin the form of incentives (e.g., weekly activities) designed to reduce the


amount of negative behaviors manifested by the students. The students'eligibility for earning these incentives is derived from their school workand behavior. These incentives are used to positively reinforce students whocomplete their assignments and display appropriate behaviors. A behavioraland academic charting process for these incentives takes places throughoutthe day on a class by class basis. The students are continually informed oftheir assessment status and the teacher meets with each student individuallyto discuss their performance on a daily basis. The daily assessments areaveraged over a week to determine if students are eligible to attend theweekly incentive activity, which is routinely held at the end of the week.

While enrolled in the ADT program students are jointly enrolled inregular junior or senior high schools. The transition from the ADT programto a regular school occurs on a gradual basis. The decision to begin thetransition process into a regular school setting is based on the student'smanifested behavior, academic performance, and willingness to attend aregular school. Prior to changing a student's placement, transitional place-ment decisions are made jointly by the staff of the school where the studentis to be placed, parents, the student, and the ADT staff.

After being placed in classes in regular school settings, a student'sbehavior and school performance are monitored on a weekly basis. Theprimary goal of such monitoring is to provide the support services necessaryto allow students to remain in regular school settings. If difficulties develop,the adolescent and public school staff are offered support by the ADTprogram staff. This support can take several forms: Consultation, individualcontact with the student, or crisis resolution. An example of this type ofsupport is a student from the ADT program who is refusing to follow thedirections of a teacher in a regular school. In this situation, a member ofthe ADT staff could serve as a mediator for the student and teacher, toassist them in reaching an acceptable compromise.

After exiting the ADT program, students and their families receivesupport from the program staff for a semester. If difficulties arise duringthis time, the adolescent, parents, and regular school personnel can call onthe ADT staff to assist them resolve problems. A full time return to theADT program is available if the student's needs require it during thismonitoring period. If a student is suspended during the monitoring period,rather than having an out of school suspension, the student could returnsto the ADT program until the suspension is completed.

Community Involvement: Adult Volunteers and Vocational Training

The community aspects of the program add a social learning theoryapproach (Bandura, 1977) to the ADT program through the presence of


positive adult role models and job coaches. In providing these services theprogram seeks to strengthen an adolescent's opportunity for success byusing available community resources. In this manner the community be-comes the adolescent's extended family, which was advocated by Friedmanet al. (1982), with a goal of serving the adolescents without having to resortto residential placements outside the local area.

Students served by the ADT program are individually matched withan adult volunteer from the local community mental health agency. Theseadult volunteers generally have contact with the student they are matchedwith on a weekly basis and receive supervision by a therapist employed bythe community mental health agency. Thus, volunteers are viewed as a partof the student's treatment regime. The purpose of this component is togive students exposure to positive adult role models through a social learn-ing context.

Brendtro (1990) held that vocational experiences are an essential partof youth care work. Additionally, Grubb and Kalman (1994) stated thatintegrating remedial instruction into vocational training can increase a stu-dent's basic skills. Therefore, the ADT program involves vocational trainingexperiences. The students can earn graduation credit and be paid for theirlabor through these work study experiences. A vocational counselor assistsstudents in their job placements and conducts weekly supervision of theiroccupational performance. Through this intervention, following a sociallearning methodology, adolescents in the program are afforded job shadow-ing and vocational training opportunities through exposure to a wide varietyof occupations.

CASE STUDY

A 13-year-old male in the seventh grade, "Dale," was referred to theADT program due to oppositional and defiant behaviors he was displayingin a junior high school. Dale was classified as having an emotional disabilityas a primary educational handicap, and a speech disability as a secondaryeducational handicap. Dale also had numerous mental health diagnosesand a physical concern: Conduct disorder, attention-deficit/hyperactivitydisorder, reactive attachment disorder, dysthymic disorder, and seizures.He also had a history of juvenile offenses: Breaking and entering, theft,running away, and curfew violations. He was prescribed antidepressant,psychostimulant, and seizure medications.

Dale was initially enrolled for the Fall term at a junior high schooland had been at this school for six weeks. He was receiving special educationservices in a self-contained program prior to his referral to the ADT pro-



gram. After receiving the referral an ADT program staff member went tothe junior high school to meet with Dale, his mother, and the referringschool's counselor. As this meeting started, Dale ran from the counselor'soffice into the parking lot, and stood next to his mother's car. When theADT staff member went to talk to him, Dale crawled under the car andbegan crying.

A review of Dale's records revealed that immediately prior to enrollingin the junior high school he had been in an out-of-state residential treatmentfacility for 8 months. He had been released from that facility, againstmedical advice, 2 weeks prior to the start of school. Prior to being placedin the residential facility Dale had lived with his biological mother andstepfather in a distant state. Following his discharge, and during the timeDale was enrolled in the ADT program, he resided with his biologicalfather, stepmother, and younger sister. He was involved with the ADTprogram for 2 years.

The initial treatment plan developed to address Dale's needs involvedfour of the six treatment components of the ADT program: Special educa-tion, individual therapy, group counseling, and family therapy. In planninghis initial treatment it was decided that Dale would be given time to adjustto his new environment prior to being involved with the other two treatmentcomponents (i.e., adult volunteers and work study).

Dale's progress in the school, group counseling and individual therapywas slow; however, as reported by his parents, his home behaviors improvedfrom the time he was enrolled (e.g., less oppositional behaviors and fewerrun aways). The family therapy followed a structural approach and wasconducted on a weekly basis over an 18-month period with the entire familyinvolved in the sessions. After 2 months Dale still had not made substantialprogress in school, group counseling, or in individual therapy. At that pointa psychiatric evaluation was conducted, which resulted in a change in hismedication regime. Changes in medication were effective in regard to Dale'sacademic work in the classroom, which improved in quantity and quality.

A month later Dale's therapeutic progress was reviewed. It was foundthat group counseling and individual therapy had not been effective indecreasing Dale's acting out or his ability to relate to others. At this pointa change in his individual therapy was implemented. Due to Dale's extensivepast therapeutic involvement the initial treatment modality used for hisindividual sessions had been cognitive-behavioral. Because this approachwas ineffective in reducing Dale's negative behaviors and due to his stateddislike for thinking about his feelings, the treatment modality was changedto a client-centered approach. Additionally, he was allowed to play boardgames during individual therapy. During the board games he was responsi-ble for establishing equitable rules. When he followed these rules Dale was

rewarded by being allowed extra time out of class to play the games. Inbehavioral terms, this extra time was used as a contingency managementtechnique to positively reinforce Dale for displaying cooperative gameplaying. He responded well to this change in treatment approaches, rapidlydeveloped rapport with his individual counselor, and improved his class-rooms behaviors (e.g., talk outs and interruptions both decreased).

In resolving some of his difficulties in interacting with others, particu-larly during group counseling, Dale was occasionally allowed to lead discus-sions and to choose the topic for the group. These modifications positivelyinfluenced Dale's classroom behaviors as he had fewer difficulties withother students in the classroom. After making gains in group and individualcounseling, approximately 3 months following his enrollment in the pro-gram, Dale was matched with an adult volunteer. He developed a favorablerelationship with this adult fairly quickly and looked forward to their meet-ings. The adult volunteer reported that their time together was enjoyable.This relationship lasted 1 year.

At this time Dale had been in the ADT program for approximately 4months. He exhibited appropriate school behaviors and began to transitionback to the junior high school. This transition started at the beginning ofthe Spring term, with Dale attending one special education class at thejunior high, and the rest of the day at the ADT program. Within 1 monthof starting this placement, Dale's levels of defiant and oppositional behav-iors at home and at school increased. Meetings between Dale's regularschool teachers and the ADT staff were held to design interventions toallow him to remain at the junior high for the class he was attending.Several interventions were implemented to assist him in being successfulin this setting (e.g., assigning an individual educational assistant, shorteninghis school day, and allowing Dale to decide when he left the public school)all of which failed. Due to a continued display of negative behaviors Dalereturned to the ADT program on a full time basis for the remainder ofthat school year.

When Dale started eighth grade the next school year, he attended thejunior high school half time, and the ADT program half-time. His morningschedule included two regular education classes and one special educationclass at the junior high school, while he attended the ADT program in theafternoon. He was successful in this placement for 3 months, when hisbehaviors at school again deteriorated shortly before his 14th birthday.Dale again returned to the ADT program on a full time basis. It was decidedto involve him in the vocational aspects of the program, as this interventionhad not yet been applied. Dale was placed at a work sight within the schooldistrict's printing office for which he received work-study credit and pay.He remained in the ADT program for the remainder of his eighth-grade


year and his school performance was marginal. However, his behaviorscontinued to improve at home and at work. His work reports were exem-plary, and Dale consistently responded positively to his supervisor's di-rection.

At the start of his ninth grade year Dale was placed in the junior highschool on a full time basis. He started the year with three general educationclasses and two special education classes. His teacher reported his schoolwork and behaviors were appropriate during the semester long monitoringperiod, with only one minor altercation occurring during the term, for whichhe was suspended from school for 1 day. He spent this day at the ADTprogram. A 1-year follow up revealed that Dale had remained in the juniorhigh school, was in one special education class, and four general educationclasses at the end of the year.

REVIEW OF SERVICES

A 5-year review of the effectiveness of the ADT program in meeting itsprimary goal of returning students to public school settings was conducted asa part of this study. During this 5-year period 69 students were involvedwith the ADT program. Of these 69 students, 10 were females and 59 weremale. In terms of ethnicity 4 students were African American, 7 wereHispanic, 1 was American Indian, and 57 were White. The average lengthof student enrollment at the ADT program was 1 year, with a 1 semestermonitoring period following their exit from the ADT program.

Of the 69 students served during the 5-year period, 58 students werereferred to the program from in district schools, 6 came from residentialplacements, 4 had previously been in public schools located outside thedistrict, and 1 had not been in school prior to attending ADT. Of the 58students who entered the program from in district schools 45 came fromjunior high schools, grades seven to nine, 12 were referred from high school,grades 10 to 12, and 1 student came to the ADT program from an elementaryschool where the student had been in the 6th grade.

In completing the 5-year review of services, 3 students were scheduledto return to the ADT program on a full time basis immediately followingthe review. As this review focused on exit placements, these students wereexcluded from the study. Additionally, during the 5-year period, 7 studentsmoved out of the school district and their next educational placement wasunknown. These students were also excluded from the study. Therefore,due to lacking information on these 10 students, the review of services wasperformed on the data from 59 students who had been enrolled in theADT program during the 5-years reviewed.

A School Bawd Alternative to Residential Care 283

Of the 59 students involved in the review, 37 (67%) returned to apublic school setting upon their immediate exit from the ADT programand 2 (3%) obtained their graduate equivalent diploma (GED). Elevenstudents (19%) went to residential placements following their enrollmentin the program, 2 (3%) went to Job Corps, and 7 (12%) students droppedout of school.

In compiling this information a Chi-square was performed. For thisanalysis, the null hypothesis was that the effectiveness of the ADT programin meeting its objective of returning students to public schools, or complet-ing their GEDs, would not exceed chance occurrence. The 59 students weredivided into two exhaustive categories, (1) those who returned to publicschools or completed their GEDs immediately following their ADT pro-gram involvement, and (2) those who went to a residential placement,including Job Corps, or dropped out of school immediately following theirADT program involvement. The results of the analysis were significant (.05X 2 (1) = 6.11, p < .05).

DISCUSSION

Day treatment programs represent viable treatment options for schooldistricts and communities. As the review of services indicate the ADTprogram described was successful in meeting the needs of its students intheir local community through its systemic treatment approach. However,as Coche and Thomas (1975) pointed out, some adolescents with severeneeds require residential care. Day treatment programs should be consid-ered as one of the placements available on the least restrictive environmentcontinuum. These programs should not be considered as the best placementoption for all students with severe educational difficulties.

The case study illustrates several aspects of the program which deserveconsideration. First of all, treatment is provided over an extended periodwith support services available for a semester after a student is no longerattending school at the ADT facility. This is not a time limited program.The severity of a student's difficulties and response to treatment dictatesthe length of involvement.

Second, the various treatment modalities the program offers are indi-vidually designed. With the exception of being involved in the specialeducation portions of the program, students are not treated in similar ways.The needs and abilities of the students dictate their involvement with theprogram's treatment components. Each student's treatment plan is there-fore designed to meet their specific needs.

Third, treatment failures are not seen as student or program failures.


LeCroy (1992) indicated that matching a child's problem to a program'streatment approach is important. Following this guidance, if a specific aspectof a student's treatment is not successful, the treatment plan needs to bemodified to address a student's needs in a different way.

The review of services also deserves comment. The analysis indicatedthe program's effectiveness in returning students to public schools, or com-pleting their GEDs, immediately following their exit from the ADT pro-gram. However, it does not include the long term effects of the programin terms of the students' progress through school to graduation, returns toADT, on to college, subsequent residential placement, or incarcerationrates. This type of longitudinal data is not currently available to determinethe lasting effects of the program, and is a limitation in this study. Futureresearch could be directed at studying the long term effects of such pro-grams.

As Wells (1991) reported, residential facilities do not generally meetthe needs of most children and adolescents with emotional or behavioralneeds. In replying to this statement, service delivery models designed toaddress the needs of adolescents who are not receiving treatment, or whohave been traditionally placed in residential facilities have been calledfor (Small et al., 1991). This ADT program, utilizing several treatmentinterventions applied in a systemic manner, has been effective over timein meeting the needs of adolescents with severe needs.

ACKNOWLEDGMENTS

The authors acknowledge and appreciate the efforts of John Cunning-ham, Mitzi Young, Tony Benson, and other ADT staff members. Apprecia-tion is also expressed to the students who attended the ADT program.Finally, acknowledgment is extended to Robert Calkins, M.D., who cri-tiqued an earlier version of this manuscript.

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Adolescent Day Treatment: A School and Community Based Alternative to Residential Care

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