This review article is part of a special issue of Residential Treatment for Children and Youth celebrating the 50th anniversary of the Teaching-Family Model (TFM) at Father Flanagan's Boys' Home, Boys Town, Nebraska. The manuscript provides a historical account from experts of the TFM who initially created the organizational changes at Boys Town for the TFM to be used as intended and sustain for 50 years. Resources that were essential for the organizational changes included the technology of the TFM (i.e. administration, training, consultation, and evaluation systems), consumer orientation, feedback, and teaching skills. Additionally, the article describes five factors that have contributed to sustainability such as 1) using data effectively, 2) culture of success, 3) model expertise, 4) quality standards, and 5) research focus. The review concludes with implications for future practice and research.

Residential childcare workers provide critical support to vulnerable children around the world. Building and maintaining a qualified residential childcare workforce is challenged by myriad forces, the foremost of which is recruiting and retaining staff for valuable work often misaligned with available compensation; making individual qualifications at hiring; ongoing training; supervision; and data support systems to monitor performance critical for quality care. This study explored the similarities and differences among these essential elements of staffing across distinct programs: Youth Education Centers (YEC) in Poland, CiudadEscuela Muchachos (CEMU) in Spain, and the Boys Town Family Home Program (BTFHP) in the United States. Using an autoethnographic approach, the authors, who are a diverse team of practitioners and researchers, provide insights guided by personal experience about the programs as they compared and contrasted program training and evaluation manuals and materials, job descriptions, etc. The focal programs shared several similarities, most notably prioritizing children's dignity. However, notable differences also offer possible solutions for region-specific challenges in building and sustaining a qualified residential childcare workforce. Future implications for ongoing international collaboration to establish training standards are discussed.

Communities have different neighborhood factors, such as economic, educational, and healthcare resources that can influence child development. This study evaluated the relationship between neighborhood factors and the clinical needs and treatment response of youth in a residential program. The Child Opportunity Index was used to gain a better understanding of the relationship between neighborhood factors and youth presenting problems, behavioral incidents, changes in total difficulties from intake to discharge, residential placement safety and stability, and discharge placement. The sample included 1773 youth from 34 states in the U.S. who resided in the Boys Town Family Home Program from 2013 to 2023. Including neighborhood factors in the clinical assessment provided new insights into youth treatment needs and response to services. Youth who came from neighborhoods with better community resources had more severe clinical needs, with mixed internalizing and externalizing problems, while greater proportion of youth from communities with poorer quality of resources presented with truancy and legal problems. Youth from different communities with varying neighborhood resources made progress in the program, but youth from neighborhoods with better resources made greater gains because they started with more significant clinical needs. Limitations and recommendations for further research are also discussed.

The School Support Program is a multi-tiered school behavioral intervention that incorporates components of the Teaching Family Model to decrease negative behaviors while increasing positive ones in the school setting. This program utilizes trained staff called School Support Specialists that work with teachers and administration to identify and refer students in need. Specialists are also trained to work with students, staff, and families to refer students and their families to programs within a larger array of services if additional family-based support is needed. Over the 2022-23 and 2023-24 school years, services were delivered to more than 12,500 unique students at over 100 elementary, middle, and high schools in the United States. This equated to approximately 22,000 hours directly serving students and approximately 2,700 parent contact hours. In aggregate, served students received approximately 1.76 hours of direct service. Further, approximately three percent of families of students served by the program received additional Boys Town services. Ratings of school climate were also associated with satisfaction with their Specialist. Data from a small pilot study indicated that improved attendance and grades were positively related to services received. Limitations and future research are discussed.

Childhood abuse is associated with neuro-developmental disruption, including heightened threat sensitivity. It is often assumed that this disruption is semi-permanent and resistant to change. Here we examine whether the exaggerated threat response seen in adolescents who have experienced past abuse was modified after a 7-month stay in a trauma-informed residential program. The sample included thirty-six adolescents who were placed into residential care and had either prior exposure to high levels of abuse (n = 36) or lower levels of abuse (n = 25). Groups (aged 12.7-18.9 years, 57 male) were matched on age, sex, IQ, and prescribed medications and were scanned twice (shortly after intake and after 7 months) on a looming threat task. Results indicated (i) trauma-informed residential care was associated with significant decline in depression, anxiety, aggression, and callous-unemotional trait symptoms irrespective of severity of prior abuse exposure; (ii) Participants who had been subjected to high levels of abuse showed heightened neural responsiveness to threats in both the posterior cingulate cortex/precuneus and the amygdala/hippocampus at intake that reduced after 7 months; (iii) Both groups showed declines in responsiveness within the rostromedial frontal cortex and the lingual gyrus and fusiform cortex after a 7-month treatment. These data demonstrate that intervention can ameliorate heightened neural threat responsiveness and symptom severity in adolescents who have been exposed to high levels of abuse.

Background Youth in residential care are highly prone to childhood adversity (CA) and specific patterns of CA are uniquely associated with distinct clinical and behavioral functioning. Few studies have examined how these associations may differ in minority youth. Objective We explore patterns of CA in Black and Hispanic/Latinx youth entering residential care. We also examine the association between these patterns and key indicators of clinical and behavioral functioning, including emotional problems, conduct problems, hyperactivity/inattention, prosocial behavior, peer problems, and trauma symptoms. Participants and setting 534 Black youth (Mean Age = 15.78, SD = 1.42; 73 % male) and 257 Hispanic/Latinx youth (Mean Age = 15.59, SD = 1.61; 67 % male) in a residential program. Methods Latent class analysis was used on archival data to identify patterns of CA and examine their association with clinical and behavioral functioning. Results Five patterns of CA exposure were identified in Black youth and four patterns were identified in Hispanic/Latinx youth. While both groups had “high” and “low” patterns, the composition of these patterns varied between the groups and was associated with different clinical and behavioral functioning. Conclusions This study highlights the importance of considering youth's cultural and ethnic/racial background when examining CA exposure. Youth may be prone to patterns of CA and the implications of these patterns are unique depending on their ethnicity/race. Furthermore, commonly used CA assessments, e.g., those based on the original ACEs study, may not adequately capture the experience of youth from all ethnic/racial groups.

This pilot study evaluated effects of parents’ participation in a 6-week online Boys Town Common Sense Parenting (CSP) program on parent and youth executive function (EF) and youth behavior problems using pre-, post-, and 30 days follow-up single-group design. Fifty parents (92

Social skills teaching is an effective intervention to support students with emotional and behavioral disorders. This paper describes the initial development and psychometric properties of the Boys Town Social Skills Assessment for Schools (BTSSA-S), a 15-item assessment intended to identify students' social skill strengths and needs. Fifteen educators at an educational center for a residential program for at-risk youth completed the instrument. A total of 150 students were rated at two points in time, approximately 30 days apart (129 students were matched). The BTSSA-S demonstrated good test-retest reliability (ICC = .83) as well as adequate internal consistency (alpha = .85) for a multi-dimensional scale (three factors: behavioral compliance, on-task, and sociability). Further, scale scores are significantly correlated (r = .76) with another social skills screener, indicating convergent validity. Finally, a ROC curve discriminated significantly between students with and without a disruptive school incident and was used to determine a preliminary cutoff score for identifying those at risk for such incidents. Limitations, implications, and future research are discussed.

Schools in the United States have experienced an increase in student classroom behavioral issues and mental health struggles since the COVID- 19 pandemic. Educators who remained in the teaching profession through the pandemic possess valuable insights into the techniques used to address the increased emotional and behavioral needs of students both during and after the pandemic. The current study used multiple methods to explore the challenges faced by upper elementary and middle school teachers, as well as solutions and techniques these teachers found helpful. The study also examined teacher ratings of school climate and social and emotional learning (SEL). Electronic surveys on school climate and SEL were collected from 109 teachers across the United States. Teacher ratings were compared based on grade level (i.e., upper elementary, middle) and school location (i.e., metropolitan, non-metropolitan). Online focus groups, using a nominal group technique, were also conducted with 50 of the teachers. Results showed that teachers identified a lack of time, resources, and support to address the increased academic and behavioral needs of students. Teachers also shared strategies to improve teacher–student relationships, student socialization and motivation, and parent engagement. Implications for practice, recommendations for future research, and considerations for teacher development are discussed.

The use of evidence-based programs to improve the quality of residential care is not common, and, to the extent they are used, there is little evidence that those programs are used with fidelity. Fidelity is defined as the extent to which the essential components of an innovation are used in practice. Fidelity was used as the standard to assess progress of organization change and quality of youth services as the Teaching-Family Model was established at Father Flanagan's Boys' Home, Boys Town, Nebraska. The organization change process was initiated in 1975, fundamental changes were completed in 1979, and the new organization functions, roles, and structures were fully in place in 1984. The sustainability of the change is assessed after 50 years. The Implementation Quotient was used to track the progress of organization change from 1975 to 1984 and sustainability in 2025. Data from hundreds of Teaching-Family Model Fidelity Assessments (collected as part of the Teaching-Parent Certification process) documented the improvements in quality of care within years and across years from 1979 to 1984 and again in 2022-2024. The data from Boys Town provide evidence that quality care can be established and sustained for dependent youths who are involuntarily placed in residential care organizations.

A better understanding of how childhood adversity (CA) patterns influence the effectiveness of Trauma Informed Care (TIC) for youth in residential programs is needed. Utilizing a longitudinal design, the study examined how CA patterns influenced aggression and self-injurious behavior during treatment and emotional and conduct outcomes for 1,343 racially diverse adolescents in a TIC residential program. Latent class analysis identified five CA patterns. Subsequent mixed, two-factor ANCOVAs indicated youth from all CA patterns experienced parallel decreases in emotional problems from intake to discharge while changes in conduct problems during this same period differed by CA pattern. Likewise, Hierarchical Linear Modeling revealed that youths' self-injurious behavior and aggressive behaviors over the first 12 months of the program also differed by CA pattern. Some demographic differences based on sex and race were found, which are discussed in turn. Findings indicate that while the program is functioning as TIC, more tailored support is needed for youth with specific CA patterns and demographics. Trauma-informed practices are important for improving emotional well-being in residential care.Tailored interventions for youth with specific trauma histories may help reduce self-injurious behavior and behavior problems.TIC programs may better serve youth with a variety of trauma histories by incorporating interventions that target social development.

Resilience is a process that involves positive adaptation to trauma through protective factors. How resilience differs based on race and ethnicity is less known for youths in residential treatment programs. This study collected views from culturally diverse youths in a residential program on ways they have overcome adversity. The findings were used to develop a culturally informed screen of activities related to resilience for youths in residential programs. This study included 32 youths ages 12–18 residing in a residential program; 66

Background: Suicide is the second leading cause of death for adolescents in the United States. However, relatively little is known about the forms of atypical neuro-cognitive function that are correlates of suicidal ideation (SI). One form of cognitive/affective function that, when dysfunctional, is associated with SI is emotion regulation. However, very little work has investigated the neural correlates of emotion dysregulation in adolescents with SI. Methods: Participants (N = 111 aged 12-18, 32 females, 31 [27.9%] reporting SI) were recruited shortly after their arrival at a residential care facility where they had been referred for behavioral and mental health problems. Daily reports of SI were collected during the participants’ first 90-days in residential care. Participants were presented with a task-fMRI measure of emotion regulation – the Affective Number Stroop task shortly after recruitment. Participants were divided into two groups matched for age, sex and IQ based on whether they demonstrated SI. Results: Participants who demonstrated SI showed increased recruitment of regions including dorsomedial prefrontal cortex/supplemental motor area and parietal cortex during task (congruent and incongruent) relative to view trials in the context of emotional relative to neutral distracters. Conclusions: Participants with SI showed increased recruitment of regions implicated in executive control during the performance of a task indexing automatic emotion regulation. Such data might suggest a relative inefficiency in the recruitment of these regions in individuals with SI.

OBJECTIVE:The goal of the current study was to determine the extent to which atypical neural responsiveness during retaliation is associated with observed aggression in youth in residential care. METHOD:This functional magnetic resonance imaging study involved 83 adolescents (56 male and 27 female; mean age, 16.18 years) in residential care performing a retaliation task. Of the 83 adolescents, 42 displayed aggressive behavior within the first 3 months of residential care, whereas 41 did not. During the retaliation task, participants were offered either fair or unfair divisions of $20 pots (allocation phase) and could either accept the offer or reject it, and, by spending $1, $2, or $3, punish the partner (retaliation phase). RESULTS:The study's main findings were that aggressive adolescent showed the following: reduced down-regulation of activity within regions involved in representing the expected value of choice options (left ventromedial prefrontal cortex and left posterior cingulate cortex) as a function of offer unfairness and retaliation level; and reduced recruitment of regions implicated in response control (right inferior frontal gyrus and bilateral anterior insular cortex) and associated fronto-parietal regions as a function of retaliation level. The aggressive adolescents were also significantly more likely to have been aggressive prior to residential care and showed a strong trend for increased retaliation on the task. CONCLUSION:We suggest that individuals with a greater propensity for aggression show reduced representation of the negative consequences of retaliation and associated reduced recruitment of regions potentially involved in over-ruling these negative consequences to engage in retaliation. DIVERSITY & INCLUSION STATEMENT:We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We worked to ensure sex balance in the selection of non-human subjects. We actively worked to promote sex and gender balance in our author group. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list. While citing references scientifically relevant for this work, we also actively worked to promote sex and gender balance in our reference list. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group.

Suicide is the third leading cause of death for individuals between 15 and 19 years of age. The high suicide mortality rate and limited prior success in identifying neuroimaging biomarkers indicate that it is crucial to improve the accuracy of clinical neural signatures underlying suicide risk. The current study implements machine-learning (ML) algorithms to examine structural brain alterations in adolescents that can discriminate individuals with suicide risk from typically developing (TD) adolescents at the individual level. Structural MRI data were collected from 79 adolescents who demonstrated clinical levels of suicide risk and 79 demographically matched TD adolescents. Region-specific cortical/subcortical volume (CV/SCV) was evaluated following whole-brain parcellation into 1000 cortical and 12 subcortical regions. CV/SCV parameters were used as inputs for feature selection and three ML algorithms (i.e., support vector machine [SVM], K-nearest neighbors, and ensemble) to classify adolescents at suicide risk from TD adolescents. The highest classification accuracy of 74.79% (with sensitivity = 75.90%, specificity = 74.07%, and area under the receiver operating characteristic curve = 87.18%) was obtained for CV/SCV data using the SVM classifier. Identified bilateral regions that contributed to the classification mainly included reduced CV within the frontal and temporal cortices but increased volume within the cuneus/precuneus for adolescents at suicide risk relative to TD adolescents. The current data demonstrate an unbiased region-specific ML framework to effectively assess the structural biomarkers of suicide risk. Future studies with larger sample sizes and the inclusion of clinical controls and independent validation data sets are needed to confirm our findings.

Aggression is increased in individuals with psychiatric diagnoses. Existing work displays associations between aggression and grey matter volume (GMV) in frontal, limbic, and striatal brain areas. Most studies assess aggression using self-report. However, real-time data may provide a more accurate representation of aggression. The objective is to assess region-specific structural brain alterations underlying real-time aggressive behavior. We propose that volume will be decreased in our prehypothesized regions of interest (ROIs) (ie, middle prefrontal cortex, orbitofrontal cortex [OFC], anterior cingulate cortex [ACC], pericalcarine, insula, amygdala, and striatum). Structural MRI data were collected from 97 youth (32 females, 65 males) in the aggression group (mean age: 16.22 [SD = 1.10], mean IQ: 97.67 [SD = 12.33]) and 88 youth (36 females, 52 males) in the nonaggressive group (mean age: 16.29 [SD = 1.31], mean IQ: 99.70 [SD = 12.14]). Groups were matched on age, sex, and IQ and were determined by whether youth had at least 1 aggressive episode. FreeSurfer was used to estimate volumetric parameters after whole-brain parcellation into 68 cortical and 14 subcortical regions. A multivariate analysis of covariance (MANCOVA) was conducted on the prehypothesized ROIs. Our MANCOVA showed significant group differences in GMV (F24,158 = 1.611, p ≤ .05, ηp2 = 0.197), where the aggression group showed reduced GMVs relative to the nonaggressive group. Specifically, the aggression group showed reduced GMV relative to the nonaggressive group in the left lateral OFC (F1,183 = 4.542, p ≤ 0.05, ηp2 = 0.024), bilateral caudal ACC (F1,183 = 5.211-6.373, p's ≤ .05, ηp2 = 0.028-0.034), right rostral ACC (F1,183 = 5.535, p ≤ .05, ηp2 = 0.030), and bilateral caudate (F1,183 = 4.596-5.605, p's ≤ .05, ηp2 = 0.025-0.030) as well as trending significance in the right lateral OFC (F1,183 = 3.673, p = .057, ηp2 = 0.020), and left rostral ACC (F1,183 = 3.795, p = .053, ηp2 = .021). Several of our participants took psychiatric medications and were diagnosed with various comorbidities. However, our results survived after using medications and diagnoses as covariates. Our results provide insight regarding the structural brain biomarkers of real-time aggression in youth, which may aid in clinical applications across multiple diagnoses.

Clinical Impact Statement This study found five patterns of childhood adversity in youth entering a residential program. Because these were associated with different clinical outcomes, residential care programs should consider assessing a youth's pattern of childhood adversity during routine admission procedures to inform the youth's treatment. Objective: We explore patterns of childhood adversity (CA) in youth entering residential care. We also examine possible sex differences as well as the association between these patterns and key indicators of clinical functioning, including emotional problems, conduct problems, hyperactivity/inattention, prosocial behavior, peer problems, and trauma symptoms. Method: Data were obtained from archival records of 2,066 youth (M-age = 15.57, SD = 1.57) entering a family style residential program for the first time. The sample composition was: 65% boys, 45.8% White, 26.0% Black or African American, 12.5% Hispanic or Latino, 10.5% Multiracial, and 5.1% Other race. Inclusive latent class analysis was used to identify profiles of CA. Profile membership was used to examine sex differences and predict clinical functioning. Results: Five CA profiles were found: (1) Low Exposure, (2) Familial Dysfunction, (3) Neglect/Emotional Abuse, (4) High Exposure without Sexual Abuse, and (5) High Exposure with Sexual Abuse. Girls were more likely than boys to be in Neglect/Emotional Abuse and High Exposure with Sexual Abuse profiles. Each CA profile was associated with distinct clinical outcomes. Conclusions: This study highlights the importance of considering CA patterns when working with youth entering residential care. CA screening and classification during residential care admissions could better inform interventions for youth and their families and potentially improve the effectiveness of mental health services received. Future research should continue to study the connections between CA profiles and clinical outcomes.

Youth in residential programs have high rates of Posttraumatic Stress Disorder (PTSD) and suicidality. Although trauma symptoms and suicidality can both be related to peer relationship problems, there is little research on how social skills training on peer relations could help these youth. This study examined if progress made on peer relations training and sex moderated the association between trauma symptoms at intake and suicide ideation incidents while in the program. The sample included archival data on youth placed in a large residential program in the Midwest (N = 1118) ages 12–19 years old (M = 15.97 years, SD = 1.15), of which 62.2% were boys. Results indicated both peer relations training (b = −0.07, SE = 0.02, p = 0.001) and sex (b = −0.04, SE = 0.02, p = 0.032) moderated the relationship between trauma symptoms at intake and suicide ideation incidents in care. The benefits of peer relations training for youth presenting with trauma symptoms and suicide ideations are discussed along with recommendations for further research.