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Behavior modification facility

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A behavior modification facility (or youth residential program) is a residential educational and treatment institution enrolling adolescents who are perceived as displaying antisocial behavior, in an attempt to alter their conduct. As of 2008 there were about 650 nongovernmental, residential programs in the United States offering treatment services for adolescents.[1] Some similar institutions are operated as components of governmental education or correctional systems.

Methodologies used in such programs

Practices and service quality in such program vary greatly. The behavior modification methodologies used vary, but a combination of positive and negative reinforcement is typically used.[2] Often these methods are delivered in a contingency management format such as a point system or level system.[3] Such methodology has been found to be highly effective in the treatment of disruptive disorders (see meta-analysis of Chen & Ma (2007).[4]

Positive reinforcement mechanisms include points, rewards and signs of status,[5] while punishment procedures may include time-outs,[6] point deductions, reversal of status, prolonged stays at a facility, physical restraint, or even corporal punishment. Research showed that time out length was not a factor and suggestions were made to limit time out to five minute durations.[6] A newer approach uses graduated sanctions.[7] Staff appear easily trained in behavioral intervention, such training is maintained and does lead to improved consumer outcomes, as well as reduce turn over.[8] More restrictive punishment procedures in general are less appealing to staff and administrators.[9]

Behavioral programs were found to lessen the need for medication [10] Several studies have found that gains made in residential treatment programs are maintained from 1–5 years post discharge.[11] Therapeutic boarding schools are boarding schools based on the therapeutic community model that offers an educational program together with specialized structure and supervision for students with emotional and behavioral problems, substance abuse problems, or learning difficulties. Some schools are accredited as residential treatment centers. [4][5]

Behavioral residential treatment became so popular in the 1970s and 1980s that a journal was formed called "Behavioral residential Treatment", which later changed its name to "Behavioral Intervention." Behavioral Intervention continues to be published today.

History and Controversy

In the late 1960s behavior modification or practice referred to as applied behavior analysis began to move rapidly into residential treatment facilities.[12][13] The goal was to redesign the behavioral architecture around delinquent teens to lessen chances of recidivism [14] and improve academics [15] Harold Cohen and James Filipczak (1971) published a book hailing the successes of such programs in doubling learning rates and reducing recidivism [16] This book even contained an introduction from the leading behaviorist at the time, B.F. Skinner hailing the achievements. Independent analysis of multiple sites with thousands of adolescents found behavior modification to be more effective then treatment as usual, a therapeutic milieu, and as effective as more psychologically intense programs such as transactional analysis with better outcomes on behavioral measures;[17] however, these authors found that behavior modification was more prone to leading to poor relationships with the clients.[18] Over time interest faded in Cohen's CASE project [19] Other studies found that in proper supervision of staff in behavior modification facilities could lead to greater use of punishment procedures [20]

Under the leadership of Montrose Wolf, Achievement place, the first Teaching Family Home became the prototype for behavioral programs.[21] Achievement place opened in 1967. Each home has from 6-8 boys in it with two "parents" trained in behavior modification principles. The token system for the program was divided into 3 levels. Outcome studies have found that Achievement place and other teaching family homes reduce recidivism and increase pro-social behavior, as well as self esteem.[22][23] While initial research suggested the effects of the program only lasted for one year post discharge, recent review of the data suggests the program lasts longer in effect [24]

Gradually, behavior modification /applied behavior analysis within the penal system including residential facilities for delinquent youth lost popularity in the 1970s-1980s due to a large number of abuses (see Cautilli & Weinberg (2007) [25]), but recent trends in the increase in U.S. crime and recent focus on reduction of recidivism have given such programs a second look [6].[26][27] Indeed, because of societal needs the number of youth residential facilities has grown over recent years to close to 39,950 in 2000.[28] The use of functional analysis has been shown to be teachable to staff and able to reduce use of punishment procedures.[29] Rutherford's (2009) review from interviews and archival materials documents the decline from treatment of behavior analysis with criminal justice populations.[19]

One recent acknowledgement has been that long term care does not equate with better outcomes.[28] To reduce the tendency for abuse, a strong push has occurred to certify or license behavior modifiers[30][dead link‍][31] or to have such practices limited to licensed psychologists.[7][dead link‍] In particular psychologists with behavioral training [32] American psychological association offers a diplomat (post Ph.D. and licensed certification) in behavioral psychology [33]

Often the practice of behavior modification in facilities comes into question (see recent interest in Judge Rotenberg Educational Center, Aspen Education Group and the World Wide Association of Specialty Programs and Schools). Often these types of restrictive issues are discussed as part of ethical and legal standards (see Professional practice of behavior analysis). Recent research has identified some best practices for use in such facilities[28] In general policies in such facilities require the presence of a treatment team to ensure that abuses do not occur especially if facilities are attempting to use punishment programs.[34]

Some Model Programs

While boot camp type programs have not been shown to be successful, largely because they represent punishment devoid of context (unlike in the military, where passing boot camp initiates one into the service),[35] programs such as teaching family homes based on the Teaching-Family Model have been extensively researched and show positive gains. Research shows that they can be used to reduce delinquency while adolescents are in the home and post release {see Kingsley (2006) [36]}. In general, these types of programs take a behavioral engineering approach to reducing problem behavior and building skills.

In general, behavior modification programs that are used in facilities or in the natural environment have the largest effect size and lead to an estimated 15% reduction in recidivism.[37] While this reduction appears to be modest, it holds potention in the U.S. given the large number of people in the prison system. Increasingly behavior modification models based on the principles of applied behavior analysis are being developed to model and reduce delinquency[38]

Controversy

This industry is not without controversy, however. The U.S. Surgeon General (1999) discussed the need to clarify admission criteria to residential treatment programs.[39][dead link‍] Included in the same report was the call for more updated research as most of the residential research had been completed in the 1960s and 1970s.[39][dead link‍]. Disability rights organizations, such as the Bazelon Center for Mental Health Law, oppose placement in such programs and call into question the appropriateness and efficacy of such group placements, the failure of such programs to address problems in the child’s home and community environment, the limited or no mental health services offered and substandard educational programs.

Bazelon promotes community-based services on the basis that it considers more effective and less costly than residential placement.[40][dead link‍] While the behavior modification programs can be delivered as easily in residential programs as in community based programs [41][42] overall community based programs continue to lack empirical support especially with respect to long term outcomes for severe cases [43] with the notable exception of Hinckley and Ellis (1985).[44] Even with this said, in 1999 the surgeon general clearly stated "...it is premature to endorse the effectiveness of residential treatment for adolescents.".[39][dead link‍]

From late 2007 through 2008, a broad coalition of grass roots efforts, prominent medical and psychological organizations that including members of Alliance for the Safe, Therapeutic and Appropriate use of Residential Treatment (ASTART) and the Community Alliance for the Ethical Treatment of Youth (CAFETY), provided testimony and support that led to the creation of the Stop Child Abuse in Residential Programs for Teens Act of 2008 by the United States Congress Committee on Education and Labor.[45]

Jon Martin-Crawford and Kathryn Whitehead of CAFETY testified at a hearing of the United States Congress Committee on Education and Labor on April 24, 2008,[46] where they described abusive practices they had experienced at the Family Foundation School and Mission Mountain School, both therapeutic boarding schools.[47][48]

Regulations

In the U.S. residential treatment programs are all monitored at the state level and many are JACHO accredited. States vary in requirements to open such centers. Due to the absence of regulation of these programs by the federal government and because many are not subject to state licensing or monitoring,[49] the Federal Trade Commission has issued a guide for parents considering such placement [50]

Organizations

Residential therapist who are behavior modifiers should join professional organizations and be professionally affiliated. Many organizations exist for behaviour therapists around the world. The World Association for Behavior Analysis offers a certification in behavior therapy [8] In the United States, the American Psychological Association's Division 25 is the division for behaviour analysis. The Association for Contextual Behavior Therapy is another professional organization. ACBS is home to many clinicians with specific interest in third generation behaviour therapy. The Association for Behavioral and Cognitive Therapies (formerly the Association for the Advancement of Behavior Therapy) is for those with a more cognitive orientation. Internationally, most behaviour therapists find a core intellectual home in the International Association for Behavior Analysis (ABA:I) [9].

See also

References

  1. ^ Lon Woodbury, Are We Ready for the Panic Button Yet?, by Lon Woodbury, strugglingteens.com website, October 24, 2008
  2. ^ Martin, G., & Pear, J. (2007). Behavior modification: What it is and how to do it (Eighth Edition). Upper Saddle River, NJ: Pearson Prentice Hall.
  3. ^ McKee, J.M. (1971). Contingency management in a correctional institution. Educational Technology, 11(4), 51-54.
  4. ^ Chen & Ma (2007) Effectiveness of treatments on disruptive disorders: A quantitative synthesis of single subject methods using the PEM approach. The Behavior Analyst Today 8(4), 380-397 Behavior Analyst Online
  5. ^ Cancio, E. & Johnson, J.W. (2007). Level Systems Revisited: An Impact Tool For Educating Students with Emotional and Behavioral Disorders. International Journal of Behavioral Consultation and Therapy, 3(4), 512-527 [1]
  6. ^ a b McGuffin,P.W. (1991).The effect of timeout duration on frequency of aggression in hospitalized children with conduct disorders. Behavioral Intervention, 6(4), 279-288
  7. ^ Howell, J.C. (Sept., 1998). “A new approach to juvenile crime: The promise of graduated sanctions in a juvenile justice system.” Corrections Compendium, Vol 23, No 9
  8. ^ Howard S. Rosen, Cydney J. Yerushalmi, & Jane C. Walker (1986)Training community residential staff: Evaluation and follow-up. Behavioral Intervention, 1, 15-38
  9. ^ David P. Lindeman, Raymond G. Miltenberger, David B. Lennox (1992). Acceptability of behavioral interventions: Perceptions of superintendents of public residential facilities. Behavioral Intervention, 7(1), 35-44.
  10. ^ Foxx, R.M. (1998).A comprehensive treatment program for inpatient adolescents. Behavioral Intervention, 13(1), 67-77.
  11. ^ U.S. Surgeon General (1999). Mental Health. Chapter 3
  12. ^ Cohen, H.L., Filipczak, J., Bis, J., Cohen, J., Golddiamond, I. & Larkin, P. (1968). Case II- Model: A contingency oriented twenty-four-hour learning environment in a juvenile correctional Institution. Silver Spring, Md IBR Press
  13. ^ Milan, M.A. & McKee, J.M. (1974). Behavior modification: Principles and applications in corrections. In D. Glasser (Ed.), Handbook of Criminology. Chicago: Rand McNally
  14. ^ Cohen, H.L. June, 1964). Behavioral architecture. Architectural Association Journal. London,
  15. ^ Tyler, V.O. & Brown, G.D.(1968). Token reinforcement of academic performance with institutionalized delinquents. Journal of Educational Psychology, 59, 164-168.
  16. ^ Cohen, H.L. & Filipczak, J. (1971). A new learning environment. Jossey Bass
  17. ^ Jesness, C.F. (1975). Comparative effectiveness of behavior modification and transactional analysis programs for delinquents. Journal of Consulting and Clinical Psychology, 43(6), 758-779.
  18. ^ Jesness, C.F. (1975). Comparative effectiveness of behavior modification and transactional analysis programs for delinquents. Journal of Consulting and Clinical Psychology, 43(6),758-779.
  19. ^ a b Rutherford, A. (2009). Beyond the Box: B. F. Skinner's Technology of behavior from laboratory to life, 1950s-1970s. Toronto: University of Toronto Press
  20. ^ Bassett, J. E., & Blanchard, E. B. (1977). "The effect of the absence of close supervision on the use of response cost in a prison token economy". Journal of Applied Behavior Analysis, 10, 375–380.
  21. ^ Philips, (1968). Achievement place: Token reinforcement procedures in a home style rehabilitation setting for pre-delinquent boys. Journal of Applied Behavior Analysis, 1, 213-223.
  22. ^ Braukenmann, C.J., Wolf, M.M., Kirgin- Ramp, K.A (1985). Follow up of group home youth into young adulthood (Progress Report, Grant MH20030). Lawrence: Achievement Place Research Project.
  23. ^ Maloney, D.M., Fixsen, D.L., & Phillips, E.L. (1981) The teaching family model: Research and dissemination in a service program. Children and Youth Services Review, 3, 343-355
  24. ^ Kingsley, D., (2006). The Teaching-Family Model and Post-Treatment Recidivism: A Critical Review of the Conventional Wisdom. International Journal of Behavioral and Consultation Therapy,2, 481- 496 BAO
  25. ^ Cautilli, J.D. & Weinberg, M. (2007). Editorial: To license or not to license? That is the question: Or, if we make a profession, will they come? The Behavior Analyst Today 8 (1), 1-8 Behavior Analyst Online
  26. ^ Redding, R.E., “Characteristics of Effective Treatments and Interventions for Juvenile Offenders.” Juvenile Justice Fact Sheet, Institute of Law, Psychiatry & Public Policy, University of Virginia.
  27. ^ Lipsey, M., & Wilson, D. (1998). Effective intervention for serious juvenile offenders: A synthesis of research. In R. Loeber & D. Farrington(Eds.), Serious and Violent Juvenile Offenders. Sage Publications: Thousand Oaks, CA.
  28. ^ a b c Underwood, L.E., Tallbott, L.B., Mosholder, E, & von Dresen, K. (2008). Methodological concerns of residential treatment facilities and recidivism for juvenile offenders with disruptive behavior disorders. The Journal of Behavior Analysis of Offender and Victim: Treatment and Prevention, 1(2), 214-228. BAO
  29. ^ Phillips,K.J. & Mudford, O.C.(2008). Functional analysis skills training for residential caregivers. Behavioral Intervention, 23(1), 1-12
  30. ^ BACB
  31. ^ [2]
  32. ^ Hunter, R.D. (2001) Improving Outcomes Requires More, Not Less, From Psychology. The Behavior Analyst Today, 2 (1), 4 -14 BAO
  33. ^ Dowd, E.T. (2001) Board Certification (Diplomat) in Behavioral Psychology The Behavior Analyst Today, 2 (1), l5- 28 BAO
  34. ^ Spreat, S. & Lipinski, D.P. (1986).A survey of state policies regarding the use of restrictive/aversive behavior modification procedures. Behavioral Intervention, 1(2), 137-152
  35. ^ Daly, D. L. (1994). Do boot camps work? Caring, 10, 7-9.
  36. ^ Kingsley, D.E. (2006): The Teaching-Family Model and Post-Treatment Recidivism: A Critical Review of the Conventional Wisdom - IJBCT, 2.(4), 481-497.International Journal of Behavioral Consultation and Therapy
  37. ^ TREATMENT OF OFFENDERS AND RECIDIVISM: ASSESSMENT OF THE EFFECTIVENESS OF PROGRAMMES APPLIED IN EUROPE Santiago Redondo Illescas, Julio Sánchez-Meca and Vicente Garrido Genovés Psychology in Spain, 2001, Vol. 5 47-62.[3]
  38. ^ Stumphauzer, J. S.(1985). Understanding Delinquency: A Behavioral Analysis.Child and Youth Services, v8 n1-2 p. 1-15
  39. ^ a b c U.S. Surgeon General (1999). Mental Health. Chapter 3
  40. ^ U.S. Supreme Court to Decide Forest Grove v. T.A.: Parents Should Win, But Bazelon Center Opposes Therapeutic Boarding Schools, Bazelon Center for Mental Health Law, Retrieved May 1, 2009
  41. ^ Thoder, V., Hesky, J. & Cautilli, J.D. (2010).Using Reliable Change to Calculate Clinically Significant Progress in Children with EBD: A BHRS Program Evaluation. International Journal of Behavioral Consultation and Therapy, 6(1), 45-66 BAO
  42. ^ Fuoco, F.J. (1993).Behavioral interventions: Theory and practice in residential and community-based clinical programs . Behavioral Intervention, 8(4), 227-228.
  43. ^ Wells, K. (1991). Placement of emotionally disturbed children in residential treatment: A review of placement criteria. American Journal of Orthopsychiatry, 61, 339–347.
  44. ^ Hinckley, E. C., & Ellis, W. F. (1985). An effective alternative to residential placement: Home-based services. Journal of Clinical Child Psychology, 14, 209–213.
  45. ^ "Stop Child Abuse in Residential Programs for Teens Act of 2008." Official bill language from the U.S. Congress. Retrieved May 1, 2009.
  46. ^ "Child Abuse and Deceptive Marketing by Residential Programs for Teens." Official testimony to the U.S. Congress. Retrieved May 1, 2009.
  47. ^ "Transcript of testimony of Jon Martin-Crawford." Official transcript from the U.S. Congress. Retrieved May 1, 2009.
  48. ^ "Transcript of testimony of Kathryn Whitehead." Official transcript from the U.S. Congress. Retrieved May 1, 2009.
  49. ^ Evaluating Private Residential Treatment Programs for Troubled Teens, FTC Urges Caution When Considering 'Boot Camps', FTC Federal Trade Commission, Retrieved May 1, 2009
  50. ^ Considering a Private Residential Treatment Program for a Troubled Teen? Questions for Parents and Guardians to Ask, FTC Federal Trade Commission, Retrieved May 1, 2009
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