Services for High-Acuity Youth

Understanding High-Acuity Needs

High-acuity youth are young people facing complex challenges that require intensive support. These challenges can be emotional, behavioral, or a combination of both and may also include physical health issues or developmental disorders that further complicate their care. They may have experienced suicidality, trauma, commercial sexual exploitation, child maltreatment, family dysfunction, and involvement in the juvenile and/or adult justice system. High-acuity youth require immediate and specialized care to ensure their safety and well-being, such as intensive outpatient services, therapeutic foster care, congregate or residential care, and inpatient treatment. High-acuity youth may also act out in harmful and disruptive ways in response to their trauma, frustration, and difficulty in having their needs met.

Over the past decade, child welfare systems have worked to reduce reliance on residential and group care, recognizing that a family-based setting is best for healthy development and positive outcomes. Congregate care settings are now seen primarily as short-term placements to avoid the use of, or step down from, inpatient services or to serve as a short-term treatment option. In California, they are called Short-Term Residential Therapeutic Programs (STRTPs).

One consequence of the reduced use and availability of congregate care is that the youth remaining in these settings often present with high-acuity needs, which have prevented them from moving to lower levels of care. High-acuity youth in group settings may act out in ways that programs are not designed to manage, such as running away; threatening or assaulting other youth or staff; self-harming; putting themselves at risk for sexual assault or trafficking; and drug use. These behaviors impact other youth in the placement setting, causing disruption in care and healing, risk of harm, and significant trauma. High-acuity youth often end up moving through multiple failed placements and treatment settings and may end up waiting for days or weeks in an emergency department or inpatient unit until a more appropriate setting is located and available. Staff can feel frustrated, overwhelmed, and powerless, exacerbating burnout and increasing turnover in a workforce with substantial retention issues.

Building a Supportive Framework for High-Acuity Youth

Successfully meeting the needs of high-acuity youth requires a multifaceted and coordinated team approach involving all service providers, caregivers, and stakeholders. Key services and supports to consider include:

Provide Crisis Intervention, Stabilization, and Treatment Sufficient to Meet Local Needs:

• Access to 24/7 crisis hotlines like 988 or local equivalents
• Mobile crisis response teams for immediate intervention
• Day treatment, intensive outpatient programs, and partial hospitalization programs to support stepdown from inpatient settings
• Short-term residential programs for stabilization, assessment, and treatment
• On-going collaboration with local emergency departments to ensure appropriate referrals and assess capacity
• Treatment and Intensive Services foster care
• Proactive safety planning with the youth, family, and team
• Utilization of evidence-based interventions to address trauma and mental health needs

Develop Individualized Treatment Plans:

• Comprehensive assessments to identify specific needs and strengths
• Development of individualized treatment plans addressing behavioral and physical health, education, and social support
• Inclusion of youth and families in treatment planning, when possible
• Formal care coordination across service providers and systems
• Support for youth and families to access the planned services
• On-going collaboration with all therapists, psychiatrists, caseworkers, and other service providers
• Culturally competent care that considers the youth's background and identity

Provide Trauma-Informed and Culturally Competent Care:

• Offered in a safe and predictable environment
• Establishing trust and rapport with youth
• Understanding and respect of diverse cultural backgrounds
• Utilizing culturally competent staff and resources to meet the unique needs of youth from different backgrounds

Build Family Involvement:

• Family therapy and support services to strengthen family relationships
• Psychoeducation for families to understand trauma and mental health challenges
• Training in positive parenting techniques and communication skills
• Culturally competent care that considers the family’s background and identity
• Provide parent partner and peer support services

Provide Staff Training and Support:

• All staff trained in trauma recognition and de-escalation techniques, crisis intervention, and trauma-informed care on a regular basis
• Trained on evidence-based interventions to address trauma and mental health needs and delivered with fidelity
• All staff given ongoing support and self-care practices to address the challenges of working with high-acuity youth
• Retention of staff through sufficient compensation and benefits

Regular Collaboration and Communication between all treatment partners:

• Families included as part of the treatment team whenever possible
• Strong communication and collaboration between different service providers key to ensuring a seamless continuum of care
• Developing a coordinated support system through regular case reviews and information sharing
• Improving the working relationships and communication among all adults responsible for youth supervision and caregiving

Educational Support:

• Collaborating with local schools to develop Individualized Education Plans (IEPs) if needed
• Providing access to in-school support services like counselors and social workers
• Offering alternative education programs for youth struggling in traditional settings

Community-Based Resources:

• Connection to community resources like housing assistance, job training, and mentorship programs
• Advocacy for youth in legal or social service systems
• Partnerships with community organizations to provide holistic support

Technology and Innovation:

• Exploring the use of technology to provide telehealth services, crisis support apps, and educational resources
• Looking for innovative approaches like peer support programs and mindfulness training for youth

System Reform and Advocacy

Meeting the needs of high-acuity youth will require changes to the service system itself, as well as advocacy to ensure that their needs are a priority for legislators, policymakers, and system administrators. Key efforts include:

• Advocating for increased funding and resources for programs serving high-acuity youth
• Supporting efforts to reform systems like child welfare and juvenile justice to better serve these youth
• Creating new settings that meet the varying needs of high-acuity youth and include steps between levels of care, as well as the transition into adulthood
• Addressing the ongoing challenges of the acute care needs of children and adolescents, including shortage of beds and emergency room boarding, by expanding access to step-down programs from inpatient units, short-stay stabilization units, and community-based response teams.
• Accelerating strategies to address longstanding workforce challenges in child mental health, including innovative training programs, loan repayment, and intensified efforts to recruit underrepresented populations into mental health professions, as well as attending to the impact that serving high-acuity youth has on the well-being of staff

Conclusion

Effectively supporting high-acuity youth requires a commitment to providing a comprehensive, trauma-informed continuum of care that integrates multiple systems and levels of care and numerous treatment providers while also meaningfully involving families and the youth themselves. Advocacy for systemic reforms and increased resources is crucial to address ongoing challenges and ensure these youth receive the specialized care needed for their complex needs, fostering their safety, healing, and long-term positive outcomes.

Key CEBC topic areas:

• Alternatives to Long-Term Residential Care Programs
• Behavioral Management Programs for Adolescents in Child Welfare
• Bipolar Disorder Treatment (Child & Adolescent)
• Commercial Sexual Exploitation of Children and Adolescents: Services for Victims
• Multiproblem Approaches (Child & Adolescent)
• Placement Stabilization Programs
• Permanency Enhancement Interventions for Adolescents

Key Resources and References

California Department of Health Care Services. (n.d.) Mental health program certification section. https://www.dhcs.ca.gov/services/MH/Pages/Mental-Health-Program-Certification-Section.aspx

California Department of Social Services. (2024). Children’s crisis continuum pilot program. https://cdss.ca.gov/inforesources/childrenscrisiscontinuumpilotprogram

California Department of Social Services. (2021, October 1). Executive summary - All county letter no. 21-119. https://www.cdss.ca.gov/Portals/9/Additional-Resources/Letters-and-Notices/ACLs/2021/21-119.pdf?ver=2021-10-01-164028-800

Children’s League. (2023, March). Where do we belong? Profiles of “high acuity” adolescents in congregate care and the system’s struggle to meet their needs. https://www.childrensleague.org/wp-content/uploads/2023/03/CLM-Report-on-High-Acuity-Youth-March-2023-1.pdf

Mackey, R. (2024, June 25). County policy priorities for transforming the child welfare system. National Association of Counties. https://www.naco.org/resource/county-policy-priorities-transforming-child-welfare-system

Page last updated on 8/9/24.