How does Children’s Village reflect the components of a Qualified Residential Treatment Program?

Every Tuesday and Thursday morning at 8:25 sharp, Dr. Jeremy Kohomban, CEO of Children’s Village, joins members of his staff and leadership team at the entrance to the secondary school located on the residential treatment center’s campus. Young men, referred to the center by the child welfare, juvenile justice, and adult corrections systems, make their way over to the school from the cottages down the road where they stay. Dr. Kohomban and his team greet every resident with a smile, a handshake, and some variation of “Good morning! How are you feeling today?” The gesture may be simple, but the meaning and significance behind it conveys more than any handbook or mission statement ever could. It communicates to the young men that they are neither statistics nor problems to be solved. To the contrary, they are smart, talented, and full of potential. The morning greeting also serves as a reminder that adults care about them, believe in them, and want to support them on their journey to adulthood.

Leadership interacts with each of the 279 youth that reside at the Children’s Village campus as much as possible, Dr. Kohomban says. “I meet with them regularly because it reminds me every day about why this work is meaningful. The day I don’t is the day I forget, and that’s when everything goes wrong.”

It was not always this way at Children’s Village, which operates its campus just outside New York City. The history of Children’s Village, and that of orphanages and residential programs in general, is rooted in the separation of families that disproportionately were of color and poor — and therefore powerless. Fifteen years ago, Children’s Village recognized that it had to change its business model from one characterized by family and community separation to one focused on treatment. The team proceeded with its reform under a firm belief that every child deserved a sense of unconditional belonging with a family. It strove to build a quality therapeutic environment that was short-term, reflected evidence-based interventions, and utilized behavior management so that youth could heal and thrive. Most importantly, Children’s Village was committed to including families throughout this process. Leadership knew shifting the practice model and culture was going to be difficult, but also understood it was the only option because that was what children and families deserved.

Residential programs, while at times necessary, are not an effective long-term solution for children and families. They should be used sparingly, similar to … the emergency room, where patients receive short-term intensive interventions followed up with aftercare. They should be reserved only for those youth whose needs for care and treatment cannot be met safely and effectively in a family setting, and for short durations. Residential programs should be for treatment, not placement, and should reflect care and community, not custody and control.

– Dr. Jeremy Kohomban, CEO, Children’s Village

Over time, Children’s Village has successfully transformed from an entity focused exclusively on residential care to an organization directed toward community- and home-based services, with residential care used only as a short-term, targeted intervention. The agency has gone as far as to advocate for the federal government to require state child welfare systems to move away from residential care in favor of children living safely at home with their families.

With the 2018 passage of the federal Family First Prevention Services Act, the use of federal funding for congregate care will now be restricted to two weeks unless it serves specifically identified populations, such as pregnant and parenting youth or victims of sex trafficking, or it meets the requirements of a Qualified Residential Treatment Program (QRTP), which requires a trauma-informed treatment model, family engagement, an onsite licensed nurse, and national accreditation.

Transforming its business model to reflect the essential elements of a QRTP has not been easy, but Children’s Village has proved that it is possible. Here is the story of that journey.1

How Children’s Village meets the new QRTP Requirements

Treatment model

Children’s Village adopted and implemented the Integrated Treatment Model, which includes Dialectical Behavioral Therapy and Multisystemic Therapy-Family Integrated Transitions (MST-FIT) as evidence-based and trauma-informed behavioral interventions.

Assessment by a “qualified individual” within 30 days of the start of each placement

Children’s Village completes regular assessments within its current clinical structure, but is awaiting definitions from the State of New York to ensure compliance.

Family engagement

Families are engaged while children receive treatment and during family team meetings. Staff work with families two months prior to discharge to prepare for their transition home. Staff use formal Family Finding techniques for children who do not have existing connections to extended family.

Exit planning and aftercare supports

In addition to engaging with families two months before exit Children’s Village works with them for up to six months post-exit in a MST-FIT aftercare program. Parents are trained in behavioral interventions to support ongoing permanency.

Registered nurse onsite at all hours

Children’s Village has an around-the-clock medical facility. Staff include registered nurses, a nurse practitioner, and a medical director. Services currently are funded through Medicaid.

60-day court approval

Children’s Village currently works with the courts on placement and placement-extension actions, and is awaiting further clarification on definitions from the State of New York.

National accreditation

Children’s Village has been accredited by the Council on Accreditation since 2004.

Evidence-based treatment model

Fifteen years ago, Children’s Village used the term “eclectic” to describe its ill-defined treatment model. The model haphazardly incorporated a number of unrelated services, varying in levels of evidence. The leadership team’s first priority was to develop a comprehensive treatment model that was evidence-informed, targeted and brief, measurable in terms of outcomes, and customized to the child’s needs. And, whenever possible, the treatment practice would engage and involve the child’s family.

Members of the agency’s clinical leadership group each researched different evidence-informed models across the country. The team ended up winnowing the options down to the Sanctuary Model and Positive Behavioral Interventions and Supports (PBIS) before selecting PBIS as the foundational program model, with its treatment model as Integrated Treatment Model (ITM)

ITM is an evidence-informed approach developed originally in Washington state to serve youth in the juvenile justice system. It integrates two models, Dialectical Behavioral Therapy (DBT) and Multisystemic Therapy-Family Integrated Transitions (MST-FIT). DBT was developed specifically for youth with extensive histories of trauma and behavioral issues to help them with problem-solving, interpersonal relationships, and emotional skills. All Children’s Village staff are trained in DBT skills, and youth become proficient in talking about issues and working out problems using DBT. Staff also train parents how to use DBT strategies so that all family members are in unison when working out issues. When youth are ready to return home or move into a more family-like setting, Children’s Village provides four to six months of intensive support using MST-FIT. Highly trained MST-FIT therapists work side-by-side with parents or other caregivers in the home, helping them develop the skills and strategies needed to support their teenager during the transition.2

ITM was adopted and adapted to meet the specific needs of the center’s youth population, and was rolled out between 2013 and 2018. Through initial financial support from New York City and a private foundation, Children’s Village has been able to expand ITM by hiring a director, trainers, and consultants. While Children’s Village started ITM in a few residential cottages, ITM now has been fully implemented and the agency is working on creating a manual for its adapted model.

Clear philosophy

Another critical component of becoming a Qualified Residential Treatment Center is to adopt and articulate a clear philosophy about residential programming. The philosophy that Children’s Village adopted reflects its belief that residential care should be temporary and only for children in acute crisis. The philosophy emphasizes the facilitation of healing through evidence-based interventions and the involvement of family. Children’s Village leadership made sure that staff at all levels clearly understood its philosophy, also communicating the philosophy to the youth and sharing it internally and externally whenever possible.

Along with having a clear philosophy, a culture of persistence is necessary to accomplish the goal of short-term treatment followed by placement of children back with their families or in other family-like settings. It is easy to believe all children deserve families where they feel a sense of unconditional belonging; however, making it happen requires dedication and a sense of responsibility for all youth at Children’s Village, Dr. Kohomban says. “These children deserve our persistence. We must struggle long and hard on their behalf.” Many youth are coming to Children’s Village prior to or after stays in juvenile detention, from the streets, or from a psychiatric hospital. To be effective, staff must have the determination to break this pipeline and help set up youth for successful, productive futures.

Strong staff, positive culture

The culture shift begins and ends with frontline staff. “Everything good that happens in residential care happens because of the frontline staff,” Dr. Kohomban says. “They are the game changers.” Frontline staff are with youth the 23 hours of the day that they are not in therapy, and should be seen as equal partners in addressing the clinical needs of youth and helping them move beyond the pains of their past. Everyone is viewed as having a clinical role to play in the ITM model, and direct staff are trained on how to work with youth to facilitate healing and build their coping and relational skills. In addition, staff are encouraged to practice on themselves the evidence-based behavioral interventions they have learned, such as mindfulness, to support changes in their own lives and build confidence across staff and youth that ITM activities are relevant and useful regardless of age or setting.

Because frontline work in the treatment milieu is difficult, and many staff are dealing with their own life challenges, agency leaders apply a parallel process — treating staff with the same standard of respect and care that they want the staff to use with youth. For example, state and county subsidized onsite child care is available for staff as well as state and county subsidized housing for staff that is affordable and close to the campus. Even with those perks, turnover among frontline staff is high, which is something the management team at Children’s Village is always working to improve.

Youth leadership

The agency is committed to engaging those with lived experiences to inform its practice and policies and promote accountability. For example, the inclusion of parent advocates has led to candid conversations about race and disparities in the Children’s Village programs. Children’s Village also has become an organizational mentor to Bravehearts, a youth-run program that strives to increase the self-awareness and esteem of young adults who were involved with the child welfare system and help them develop resiliency and leadership skills. Children’s Village helps Bravehearts apply for grants, manage its budget, and hire and train young people.

Lifting the veil

Residential treatment programs often have cultures that focus on control and containment, not community building and connection. Historically, practice reflected the belief that “bad” children and youth needed to be removed from families and communities, most of which were also considered “bad,” and that residential placement far away from public view was the only option. In addition, residential settings were considered appropriate for young children. For decades at Children’s Village, almost half of the children were younger than 12 and more than 300 children were younger than 6. Many remained there until they transitioned out of the system at 18 years old, without a family to call their own. Despite the best intentions of staff, instead of gaining the skills needed to heal and recover, children in the agency’s residential program became system-dependent, forgetting what it meant to belong to a family or live with others in a community. But now, core values of transparency and inclusion are part of the Children’s Village practice model. The agency invites visitors to its campus and solicits feedback from current and former youth residents to inform changes.

We need to move from risk-averse to what really works.

– Dr. Jeremy Kohomban, CEO, Children’s Village

Beauty on campus

Dr. Kohomban believes that the environment in which youth live should be beautiful, welcoming, and engaging. “Programs that serve the poor often look and feel poor, and we need to change that,” he says. When he tried to beautify the grounds of the Children’s Village campus and upgrade the facilities, he experienced initial resistance from staff. For example, when he suggested that they plant a flower garden and add new glass windows to the athletic center, staff immediately assumed that the residents would break the windows and trample all over the flowers. Instead, the youth take good care of the garden and there has been minimal damage to the windows.

The youth live in renovated Tudor-style cottages, each housing up to 10 residents, mostly in one- to two-person rooms with a common living area. The cottages are designed to foster a sense of community and fellowship between the residents. In addition to the cottages, one of the first steps Dr. Kohomban took as CEO was to secure a multi-million dollar donation to create a modern new community center that features an indoor pool, outdoor basketball courts, and recreation rooms for chess clubs, art, music, and much more.

Comprehensive continuum of services

Over the last 15 years, Children’s Village has embraced change to support a robust array of services that wrap around children and families in the communities where they live, seeking to prevent disruption once youth transition home — and to prevent removal from the family in the first place. According to Dr. Kohomban, “Residential treatment programs need to go out and work within their community to build their own network of services, beyond the campus-based programming.” Using this approach, the agency has shifted from mostly residential treatment to a comprehensive continuum of services consisting of: prevention; family finding; foster parent recruitment and support; and aftercare support.

Prevention

The best alternative to residential care is to keep children safe at home with their families. Children’s Village operates a number of short-term in-home programs designed to wrap supports around families. The most common intervention is Multisystemic Therapy-Family Integrated Transitions (MST-FIT), an evidence-based program that helps families struggling with the behaviors of their children. In addition to therapists who work in the home to provide caregivers the skills they need to be successful, resource workers are assigned to address each family’s concrete needs. Most families receive prevention services for an average of six to nine months. With the passage of the federal Family First Prevention Services Act, Children’s Village will be exploring the opportunity of using Title IV-E dollars to fund its prevention services. In 2018, 90 percent of youth receiving MST-FIT services were able to remain in their home.

One challenge with prevention services is that families need to have an open case with the child protection agency to be eligible for services. This can lead to the case staying open for longer periods of time and families feeling that they are being monitored by a government agency. When families are primarily in need of concrete services to help them meet their basic needs, this may feel especially punitive.

If you help the parents, you help the child — and build a working family.

– Vincent Madera, Director, Children’s Village

Family finding

Children’s Village leaders believe that “every child has family, and it is our moral obligation to find them.” While residential staff may be caring adults, they are no substitutes for adults who will give youth a sense of unconditional belonging and an extended family. The agency’s Family Finding unit is assigned to assist youth who have no identified adult connection in order to help them find a lifelong network of support. Many of these youth have been in the child welfare system for most of their lives and therefore have lost any connections they may once have had with kin. Family Finding staff engage youth in a conversation about what family means to them, then help them identify available and potential family connections. The goal is to identify as many family members and other potential adult connections as possible. Family Finding staff use formal search technologies, family engagement strategies, and other creative methods of locating and working with biological family members, relatives, and other important adults. After identifying these individuals, the team works toward establishing or re-establishing relationships and facilitating permanent placements. By using these strategies and remaining persistent, Children’s Village has been able to find family connections for approximately 90 percent of the youth that it serves.

Foster parent recruitment and support

Believing that every child does best with a family, but knowing that not every child has a birth family network that can be tapped to provide placement, Children’s Village has invested deeply in the recruitment and retention of a strong network of foster parents. Each Children’s Village foster parent receives intensive and specialized training on how to parent unattached teenagers, and are provided with support, tools, and strategies to help them when there is an escalation in behavior. In addition, a clear expectation is communicated to foster parents that they need to be wholly invested in parenting these youth as if they were their own children vs. operating as just temporary caregivers. 

All foster and adoptive parents receive the Family and Adoption Support Training (FAST) curriculum, intended to assist caregivers in adapting their parenting approaches to meet the individual needs of the children placed in their homes, and to prevent disruptions through the use of de-escalation strategies. FAST uses a trauma-informed, team-based model, comprised of a behavioral therapist, case planner, and the foster parents, with a goal that the foster parents will eventually be able to assume the role of the behavioral therapist in the home. Foster parents have the support of Children’s Village staff at any time of the day, on any day of the year. An evaluation of the FAST program found that out of more than 70 youth placed in foster care, 91 percent remained in the same home for one year or more, 100 percent remained in the same school, and 54 percent attended college.

Aftercare support

The transition home is a high-risk period for youth who have moved out of residential care. After an initial honeymoon phase, youth may start resuming old behavior patterns. Children Village’s aftercare program provides support to youth in foster care who exit from residential treatment or therapeutic foster care to reunite with their families. A family reunification specialist trained in MST-FIT and DBT works with families in their homes at least two times per month for about four to six months. The program is flexible, providing individualized treatment to families in many different ways, including family therapy, skills groups, phone coaching, and consultation. Aftercare staff are available around-the-clock to handle crises as they arise. In 2016, 97 percent of youth in Children Village’s aftercare programs remained safe and stable at home for at least one year.

1 The content in this brief is based on interviews with Children’s Village staff David Collins, Hewton Fider, Jessica Grimm, Jeremy Kohomban, Vincent Madera, Mona Swanson, and Earl Whitted on April 2, 2019, unless otherwise noted.
2 Retrieved from: https://childrensvillage.org/our-programs/residential-programs/juvenilejustice/

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