Is Residential Treatment the Right Level of Care for My Child?

When stepping down from an inpatient psychiatric admission or being at imminent risk for hospitalization, there are 4 levels of care you can consider to help increase support and services for your struggling child. These levels of care are selected based on various factors, such as health severity, environmental support, disruption to every-day-life, insurance, and more. They are:

  1. Residential Treatment Centers (RTC)
  2. Partial Hospitalization Programs (PHP)
  3. Intensive Outpatient Programs (IOP)
  4. Outpatient Care Programs 

Deciding if the residential treatment level of care is right for your teenager is stressful and requires a lot of research. Sometimes it’s hard to tell what is right and what is wrong. In this article, we will provide the information you need about each of the four levels of care. We broke up each level of care into four primary considerations—the medical criteria for insurance coverage, the treatment components, the advantages and disadvantages of services, and scenarios in which each level of care is appropriate. But your biggest, most pressing question is probably the first one.

As a Parent, How Do I Know I’m Doing The Right Thing?

Deciding which treatment is suitable for your teenager may feel overwhelming, but it’s not a decision you have to make alone. While having a hand in the decision-making process is important, it’s also essential to listen to mental health professionals trained to determine the right fit for the sake of yourself and your child’s health and safety. It’s important to remember that there is no one-size-fits-all solution, and it’s common for a teenager to jump around the levels of care when needed.

Your child’s mental health professional can comprehensively evaluate their needs, the severity of their condition, and available support systems. As the parent, your input will also help determine the required level of care. A few considerations that you may want to take into account when speaking with a mental health professional include:

  • The impact treatment will have on your child’s daily life and routines
  • The amount of support that is available in your family and community
  • Your financial considerations and options

It’s essential to weigh the benefits of an immersive and structured environment provided by the residential treatment level of care vs. outpatient care’s flexibility and familiarity. Prioritize your child’s well-being and long-term recovery, and consider their readiness for a specific treatment setting and the potential impact on their overall growth and development. Remember, you are not alone; seeking professional guidance and support can provide invaluable insight and perspective.

Comparing the Residential Treatment Level of Care to Other Options 

It is essential to identify the difference between the residential treatment level of care and other options for your teenager or adolescent when they are struggling with mental health issues. Before going into further details, we’ve provided a broken-down, simplified version of each level of care for additional comprehension.

4 Levels of Care
Outpatient Care Intensive Outpatient PHP/Day Treatment Residential Treatment
Outpatient care is treatment provided while the patient remains at home. Treatment includes scheduled outpatient therapy sessions which may include a combination of individual therapy, family therapy, and group therapy. Intensive outpatient care is a structured and comprehensive treatment program that offers individuals intensive therapy and support while allowing them to live at home and maintain their daily responsibilities. A partial hospitalization program (PHP) is a structured and intensive mental health treatment program providing individuals with comprehensive therapy and support during the day while allowing them to return home in the evenings. Residential treatment programs offer intensive treatment  for teenagers to live full-time in a supportive, structured community built for care with full-time caretakers.
Recommended Treatment Schedule Recommended Treatment Schedule  Recommended Treatment Schedule  Recommended Treatment Schedule
1-2 therapy sessions per week in a provider’s office setting 3-5 days per week, 3 hours per day, in a clinic setting 3-5 days per week, 5 hours per day, in a clinic setting 24 hour awake professional care, including nursing and physician services

We’ve described the difference between the residential treatment level of care and other options—now, let’s explore the main components of each.

Residential Treatment Centers (RTC)

Mental health professionals (MHPs) typically recommend residential treatment for teenagers who require intensive and immersive care due to the severity of their mental health condition. Residential treatment can benefit teenagers who have struggled to progress in partial hospitalization programs (PHP) or those whose lives are unmanageable with out-of-control behavior.

RTC Treatment Components

  1. Intensity and Frequency of Services: 7 days a week, 24 hours a day
  2. Nursing: 8- to 24-hour nursing observation and medication administration
  3. Milieu Counseling: 7 days a week, 24 hours a day, with awake supervision, skills coaching, and behavior modification
  4. School: Onsite educational programming
  5. Psychiatry: Once weekly
  6. Group Therapy: 1-6 hours a day
  7. Family Therapy: 1-3 hours a week 
  8. Individual Therapy: 1-3 hours a week
Residential Treatment Advantages and Disadvantages
Pros Cons
  • More robust therapy; hospitals are for crisis stabilization
  • School programming present (getting less “behind”)
  • Less “institutional” and more therapeutic environment than a hospital
  • 24/7 skills coaching available and removal from troublesome environments
  • More intensive individual therapy, family therapy, and individual skills coaching
  • Can provide a one-to-one for safety and set contingencies to “drag out” new skillful behavior
  • School programming in RTC is less than in regular school, and your child may get behind academically.
  • Residential removes a child from their environment, so there is little opportunity to generalize skills to home, school, and social groups.
  • Residential programs may be highly reinforcing as a break from “real life” in a supportive environment.

When Is It Appropriate to Select a Residential Treatment Program?

  1. If your child is a danger to themselves, they require 24/7 awake supervision by skilled professionals.
  2. If your child is refusing to get in the car and go to treatment, treatment needs to come to your child.
  3. If your child’s level of functioning is so low, they have difficulty getting out of bed and leaving the house and report no or low motivation for recovery.
  4. If your child requires significant medication changes, it is best to be facilitated under skilled nursing observation.
  5. If your child has multiple severe problems, it is more conducive to treat them under 24/7 observation for response prevention (such as for severe eating disorder behaviors, OCD behaviors, substance abuse, etc.).
  6. If your child has severe behavioral dysregulation, this requires 24/7 behavior modification interventions by skilled professionals.

Medical Criteria For RTC Coverage

To admit your teen into a residential treatment center (RTC) with insurance coverage, the insurance company will assess specific medical criteria. Insurance companies will likely cover RTC if your teen possesses the following criteria. 

 

  • Serious Risk of Harm
    • High risk for suicide attempts with impulsivity and poor insight or judgment
    • The patient or family can not commit to and carry out a safety plan.
    • Cannot care for themself or use the environment for safety
  • Serious Functional Impairment
    • Has high relationship conflict and significant avoidance (school and socially)
    • Has poor habits for hygiene, sleeping, or eating
  • Major Co-Occurrence
    • The patient has medical conditions that impact the disorder, impair functioning, persist in the absence of stressors, and seriously impair recovery from the presenting problem. Examples include: 
      • Substance use issues
      • Developmental delays
      • Psychiatric symptoms
  • Highly Stressful Home Environment
    • Serious disruption of family or social support due to illness, death, divorce, or separation of parent and child or adolescent
    • The patient suffers from severe conflict, torment, physical/sexual abuse, or maltreatment.
    • The patient’s need for physical or material well-being is unmet.
    • The patient has substantial difficulty immersing themselves into a new culture.
  • Minimal Environmental Support
    • The family/primary caretaker is seriously limited in the ability to provide for the patient’s needs and has a limited ability to maintain the patient’s service plan or cannot participate in treatment. 
    • There is limited support within the patient’s community or severe limitations in access to sources of support, causing the patient’s needs to be unmet. 
  • Poor Resiliency
    • The patient has demonstrated frequent difficulty while under stress, which interferes with progress toward the expected developmental level. 
    • Previous services have not achieved complete remission or control of symptoms, even with intensive or repeated interventions. 
    • Attempts to maintain gains attained with intensive services have limited success, even for limited periods or in structured settings.
    • Developmental pressures and life changes have created turmoil or sustained distress episodes. 
    • Changes are difficult even with a high degree of support.
  • Minimal Involvement in Services
    • Unsuccessful at PHP level of care
    • Has a difficult and unproductive relationship with the clinician and other care providers
    • Will not accept an age-appropriate responsibility role in the development, perpetuation, or consequences of the problem
    • Frequently disrupts assessment and services

    Partial Hospitalization Programs (PHP)

    Partial hospitalization programs are recommended for teenagers who require intensive mental health or substance abuse care but do not require 24-hour supervision in an inpatient setting. It provides structured programming and support while allowing patients to return home at the end of the day. Partial hospitalization programs can benefit teenagers transitioning from IOP or RTC and require more structure than outpatient care.

    PHP Treatment Components

      1. Intensity and Frequency of Services: 3-5 days a week, 5 hours a day
      2. Nursing: None
      3. Milieu Counseling: Supervision, skills coaching, and behavior modification are offered during programming hours.
      4. School: Optional component
      5. Psychiatry: Once weekly
      6. Group Therapy: 5 hours a day
      7. Family Therapy: 1-3 hours a week 
      8. Individual Therapy: 1-3 hours a week
    Partial Hospitalization Advantages and Disadvantages
    Pros Cons
    • Living at home is more conducive to skills generalization at the end of the treatment day
    • Continues to allow a high level of structure and skills without needing overnight care
    • Real life triggers can happen and be processed the next day in program for skills development
    • Continued missing of school or significantly reduced academic programming
    • If a child has treatment refusal or low motivation for recovery, this can “saturate” them and make them more treatment-resistant. This child would need intensive individual therapy and contingency management of the environment that an RTC can provide.

    When Is It Appropriate to Select a Partial Hospitalization Program?

    1. PHP is a good “step-down” choice from either inpatient or residential when your child is still at a high risk of suicide, serious self-harm, or other high-risk behaviors.
    2. If your child’s functioning is low due to high avoidance, like school refusal, paralyzing social anxiety, or debilitating depression
    3. If your child’s mental health is so acute that school must be a secondary consideration
    4. If your child needs a high degree of structure and skills training that a lower level of care cannot provide

    Medical Criteria For PHP Coverage

    To admit your teen into a partial hospitalization program (PHP) with insurance coverage, the insurance company will assess specific medical criteria. Insurance companies will cover PHP if your teen possesses the following criteria. 

    • Significant Risk of Harm
      • Significant suicide thoughts are present.
      • The patient or family can commit to and carry out a safety plan.
    • Moderate Functional Impairment
      • Has high relationship conflict and significant avoidance (school and socially)
      • Has less than normal habits for hygiene, sleeping, or eating
      • Has recently gained or stabilized some functioning while participating in structured, protected, or enriched services
    • Significant Co-Occurrence
      • The patient presently has conditions, signs, or symptoms that may adversely affect the presenting problem or require significant alteration of services for the presenting problem, are present and persist without stress, and are moderately debilitating. Examples include:
        • Developmental disabilities
        • Medical conditions
        • Substance use issues
    • Moderate Stressful Home Environment
      • Moderate disruption of family or social support due to illness, death, divorce, sustained harassment by peers, exposure to substance abuse, or separation of parent and child or adolescent
    • Limited Environmental Support
      • The family/primary caretaker is limited in the ability or is ambivalent about providing for the patient’s needs or problems and demonstrates only a partial ability to make necessary changes during treatment. 
      • There are community resources for support, but they only partially compensate for unmet needs.
    • Moderate Resiliency
      • The patient has demonstrated an inconsistent ability to deal with stress and maintain normal development. 
      • Previous services are at low-intensity levels and have not successfully relieved or controlled symptoms.  
      • Attempts to maintain the gains attained with intensive services have moderate success for a limited period, but only with strong support or in structured settings. 
      • Developmental pressures and life changes create temporary distress. 
      • Change and transition require moderate support. 
    • Limited Involvement in Services
      • Unsuccessful at IOP level of care
      • The patient is ambivalent, avoidant, or distrustful of their relationship with clinicians and other care providers. 
      • While acknowledging the problem, they still have trouble accepting limited age-appropriate responsibility for the development, perpetuation, or consequences of the problem. 
      • Minimizes or rationalizes problem behaviors and consequences and cannot accept others’ definition of the problem and its consequences
      • Frequently misses or is late for appointments or does not follow the service plan

    Intensive Outpatient Programs (IOP)

    Intensive outpatient programs are typically recommended for teenagers in various situations where more structured and intensive treatment is necessary but does not require inpatient care. Intensive outpatient programs can benefit teenagers transitioning from PHP or RTC or need more structure and support than outpatient care can provide.

    RTC Treatment Components

    It’s suggested to select an IOP that offers 1-2 individual sessions a week and has a minimum of 1 family therapy session a week.

    1. Intensity and Frequency of Services: 2-3 hours daily, 3-5 days a week
    2. Nursing: None
    3. Milieu Counseling: Supervision, skills coaching, behavior modification during programming hours only
    4. School: None
    5. Psychiatry: Typically NOT included
    6. Group Therapy: 2-3 hours a day
    7. Family Therapy: 0-1 hour(s) a week
    8. Individual Therapy: 0-2 hours a week
    Intensive Outpatient Advantages and Disadvantages
    Pros Cons
    • The patient receives robust therapy and skills training while still attending school, generalizing skills to school, peers, and home.
    • Treatment times are more flexible to your schedule, and patients can select the number of therapy sessions and services they need.
    • If a kid has low motivation for recovery, feels burned out by treatment, or feels that the treatment is ineffective, IOP may not be enough to break out of this cycle and obtain traction.
    • A lot of IOPs are group-only. Group IOP is not an adequate level of care for kids with life-threatening behaviors or who have low motivation for recovery.

    When Is It Appropriate to Select an Intensive Outpatient Program?

    1. If your child can contract for safety (agree to no self-harm) and is engaged in treatment, intensive outpatient care is an ideal level of care because it does not disrupt school. Skills can be generalized to home, peers, and school.

    Intensive Outpatient Programs (IOP)

    Intensive outpatient programs are typically recommended for teenagers in various situations where more structured and intensive treatment is necessary but does not require inpatient care. Intensive outpatient programs can benefit teenagers transitioning from PHP or RTC or need more structure and support than outpatient care can provide.

    Medical Criteria For IOP Coverage

    To admit your teen into an intensive outpatient program (IOP) with insurance coverage, the insurance company will assess specific medical criteria. Insurance companies will cover IOP if your teen possesses the following criteria. 

    • Some Risk of Harm
      • History of suicidal thoughts with no intent, plan, or significant distress
      • Brief lapses in the ability to care for self or use environment for safety 
    • Mild Functional Impairment
      • Has minor deterioration in relationships (school and socially)
      • Has minor disruption of habits in hygiene, sleeping, and eating
    • Minor Co-Occurrence
      • The patient has minimal developmental delays or disorders, limited medical conditions, and occasional substance use is present with no impact on the presenting problem. Transient, occasional, stress-related psychiatric symptoms are present but have no impact on the presenting problem.
    • Mild Stressful Home Environment
      • Normative transitions occur, and the patient has minor interpersonal conflict. Death or loss has a minor impact on the child and family. Illnesses are transient, there are inadequate resources or the threat of losing resources, performance expectations create discomfort, and the potential for exposure to substance use exists.
    • Supportive Environmental Support
      • The family/primary caretaker is only occasionally disrupted or only occasionally inconsistent. 
      • The family/primary caretakers are willing and able to participate in treatment if requested and have the capacity to effect needed changes. 
      • Special needs are addressed through successful involvement in systems of care.
      • Community resources are sufficient to address the child’s needs.
    • Significant Resiliency
      • Patient has demonstrated an average ability to deal with stressors and maintain developmental progress. 
      • Prior experience with services has successfully controlled symptoms, but more lengthy intervention is needed. 
      • Can sustain recovery for extended periods but needs a structured setting, ongoing care, and support. 
      • Recovery has been managed for short periods with limited support or structure. 
      • Can adapt to changes with minimal support.
    • Adequate Involvement in Services
      • Unsuccessful at an outpatient level of care. 
      • The patient can develop a trusting, positive relationship with clinicians and other care providers. 
      • Patient is unable to define the problem as developmentally appropriate. Still, they accept others’ definitions of the problem and its consequences while accepting limited age-appropriate responsibility for behavior and passively cooperating in services.

      Outpatient Care Programs

      Outpatient treatment is well-suited for teenagers with moderate mental health concerns who can effectively manage their symptoms while residing at home. It is suitable for adolescents who do not require round-the-clock supervision or intensive intervention but still benefit from regular therapy sessions and ongoing support. Outpatient programs can benefit teenagers with a strong support system at home and in their social networks, as outpatient care often relies on active family involvement and existing community resources. 

      Outpatient Treatment Components

      Dialectical behavioral therapy (DBT) was designed to treat chronic suicide behaviors at this level of care. However, to increase the likelihood of obtaining treatment gains, work with a DBT-LBC Certified Program™ or DBT-LBC Certified Clinician™. 

      1. Intensity and Frequency of Services: 1-2 sessions per week
      2. Nursing: None
      3. Milieu Counseling: None 
      4. School: None
      5. Psychiatry: None or a separate service
      6. Group Therapy: 0-2 hours a week
      7. Family Therapy: 0-1 hour(s) a week
      8. Individual Therapy: 1-2 hours a week
      Outpatient Advantages and Disadvantages
      Pros Cons
      • Outpatient care is the most effective at preventing treatment burnout and allows kids to pursue important life-worth-living goals like school and other extracurricular activities.
      • A DBT-Linehan Certified Program™ will offer 24/7 phone coaching access, providing care support without inpatient living.
      • Kids with significant social skills deficits and a high degree of shame often under report (or don’t talk about at all) interpersonal skills deficits. In these cases, group work where clinicians can directly observe and intervene in deficits are necessary.
      • For kids with high risk, or high acuity behaviors, poor memory, and poor self-awareness—like OCD/ ADHD/ and active suicidal thoughts symptom profile—it is hard to get traction due to poor memory, and low self-awareness at this level of care.

      When Is It Appropriate to Select an Outpatient Program?

      1. If your child’s mental health would decline by removing them from school and extracurriculars, outpatient care may be appropriate. 
      2. If your child needs solutions for mitigating problems, but the problems are not life-threatening
      3. Outpatient care can work for life-threatening behaviors if your child can contract for safety (agree to no self-harm), engage in a supportive relationship with a parent, monitor their safety, and stay motivated to get better by staying engaged in treatment. 

      Outpatient Care Programs

      Outpatient treatment is well-suited for teenagers with moderate mental health concerns who can effectively manage their symptoms while residing at home. It is suitable for adolescents who do not require round-the-clock supervision or intensive intervention but still benefit from regular therapy sessions and ongoing support. Outpatient programs can benefit teenagers with a strong support system at home and in their social networks, as outpatient care often relies on active family involvement and existing community resources. 

      Medical Criteria For Outpatient Coverage

      • Low Risk of Harm
        • No suicidal thoughts
        • No high-risk impulsive behaviors
      • Minimal Functional Impairment
        • Developmentally appropriate behaviors in relationships, school, and self-care
        • No more than temporary, stress-related deterioration
      • No Co-Occurrence
        • Consistent functioning appropriate to age and developmental level 
        • No more than transient impairment in functioning following exposure to an identifiable stressor
      • Minimal Stressful Home Environment
        • Absence of significant or enduring difficulties in their environment, and life circumstances are stable
        • The living environment is conducive to normative growth, development, and recovery.
      • Highly Supportive Environmental Support
        • The family/primary caretaker and ordinary community resources are adequate to address the developmental and material needs. 
        • With at least one caretaker, there is a continuity of active engagement in a warm and caring relationship
      • Full Resiliency
        • The patient has no previous experience with services and has demonstrated the ability to maintain development in the face of everyday challenges. 
        • Prior experience indicates that most services have helped control the presenting problem in a short time. There has been successful management and extended recovery with few periods of relapse, even in unstructured environments or without frequent services. 
        • The patient can transition successfully and accept changes in routine without support.
      • Optimal Involvement in Services
        • The patient quickly forms a trusting and respectful positive therapeutic relationship with clinicians and other care providers.
        • The patient can define a problem as developmentally appropriate and accept others’ definitions of it and its consequences. The patient also accepts age-appropriate responsibility for behavior that causes or exacerbates the primary problem while cooperating and actively participating in services.

        Whether the residential treatment level of care is appropriate for your child is about more than medical criteria and objective measures. This crucial decision is best arrived at through a collaborative effort between you and a qualified, compassionate medical team.

        At Compass Behavioral Health, we treat depressed and anxious children and young adults with gold-standard, evidence-based treatments that create mastery, a sense of belonging, and a purpose-focused life. Our residential program is overseen by clinicians certified by the DBT -Linehan Board of Certification™, meaning only the most experienced therapists and medical staff will provide your child with individualized treatment at our employee-owned facility. We also teach valuable dialectical behavior therapy (DBT) skills for parents to use at home to help their children understand and respond to their emotions. 

        Schedule your free consultation today to learn more about our teen residential treatment vs. outpatient programs.

        Marissa Colangelo, LCSW, DBT-Linehan Board of Certification, Certified Clinician™

        Associate Director of Compass Research & Training Institute

        Marissa Colangelo is the associate director of Compass Research & Training Institute (CR&TI), teaching DBT didactics to UCI’s Psychiatry Fellows as well as providing DBT training and managing CR&TI’s continuing education program. She also serves as a Field Instructor with the Columbia School of Social Work.

        Marissa became interested in emotional regulation and substance abuse while finishing up her M.A. It was during this time that she completed her initial DBT training under Dr. Andre Ivanoff. Her subsequent experiences providing DBT treatment to prisoners on Riker’s Island led her to pursue providing affordable DBT to traditionally underserved communities.

        This is a passion project for all of us here at Compass, and the knowledge contained above comes from 25 years of referring our outpatient teens to residential care all over the country.

        For more information regarding how to choose a residential treatment center for teens, or to inquire about the residential program at Compass, please contact us today for a free consultation.