Therapeutic Engagement and Psychosocial Improvement Among Children in Residential Care: A Multisite Retrospective Cohort Study

Therapeutic Engagement and Psychosocial Improvement Among Children in Residential Care: A Multisite Retrospective Cohort Study

Syed Nauman Ismail *¹, Syeda Asma ², Omar Aziz ³, Rahid Ghori ³, Pamani Rasalingam ³

1. Mac Master University.
2. Cork University.
3. Toronto Metropolitan University.

*Correspondence to: Syed Nauman Ismail. Mac Master University.

Copyright

© 2026: Syed Nauman Ismail. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 28 July 2026

Published: 01 September 2026

DOI: https://doi.org/10.5281/zenodo.22268404

ABSTRACT

Therapeutic residential care integrates clinical, educational, relational, and recreational supports into daily living, yet the contribution of youths’ engagement with these supports remains uncertain. We conducted a retrospective cohort study of 150 children aged 6–17 years admitted to three therapeutic residential homes between January 2021 and December 2023, with outcomes collected through December 2025. Engagement was quantified using a study-specific Residential Therapeutic Engagement Index (RTEI; range 0–11). The primary outcome was improvement in at least two of five functional domains, assessed with a standardized chart-abstraction rubric by reviewers blinded to RTEI category.

Primary-outcome data were available for 142 children; 136 had complete covariate data. Overall, 79/142 (55.6%) met criteria for psychosocial improvement. Each 1-point increase in RTEI was associated with 24% higher adjusted odds of improvement (aOR 1.24, 95% CI 1.05–1.47; p=.011). In exploratory categorical analyses, improvement occurred in 44.2%, 52.5%, and 73.7% of children with low, moderate, and high engagement, respectively. Emotional dysregulation, trauma-related symptoms, behavioural incidents, school attendance, and crisis-service use improved, whereas anxiety symptoms, psychiatric hospitalization, and emergency behavioural assessments did not significantly change. Greater therapeutic engagement was associated with better multidomain functioning, although causal inference is limited by the observational design.

Keywords: residential care; therapeutic engagement; adverse childhood experiences; trauma-informed care; psychosocial outcomes.

Introduction

Children entering residential care frequently have histories of maltreatment, caregiver instability, repeated placement disruption, and substantial psychiatric and educational need. Cumulative adverse childhood experiences (ACEs) are associated with poorer mental, behavioural, and developmental outcomes across the life course (Hughes et al., 2017). Therapeutic residential care (TRC) has therefore evolved beyond supervision and accommodation toward models that integrate stable relationships, trauma-informed practice, education, family work, structured activity, and evidence-based psychological treatment into the living environment (Whittaker et al., 2016).

Evidence for residential interventions is nevertheless heterogeneous. Reviews suggest that youth can improve during residential treatment, but the literature is limited by variable program models, nonstandardized outcomes, and observational designs (Hair, 2005; Knorth et al., 2008; Lanier et al., 2020). More recent studies have documented reductions in trauma symptoms, dysregulation, and behavioural incidents within trauma-informed residential programs, while also showing that treatment response varies across domains and youth characteristics (Tyler et al., 2019; Hodgdon et al., 2023). One potentially modifiable factor is engagement. Earlier residential research found that treatment engagement was related to selected youth outcomes, but relatively little work has quantified engagement across the broader therapeutic milieu (Smith et al., 2008).

We examined whether greater participation in structured therapeutic programming was associated with clinically meaningful psychosocial improvement among children receiving residential care in Ontario. We hypothesized that higher therapeutic engagement would be associated with greater odds of multidomain improvement after adjustment for baseline clinical and adversity-related characteristics.

Methods

Design and participants

We conducted a multisite retrospective cohort study across three therapeutic residential homes in Ontario, Canada. Children admitted between January 1, 2021 and December 31, 2023 were eligible, and clinical outcomes were collected through December 31, 2025. Participants were followed for up to 24 months from residential admission using residential, clinical, educational, and healthcare records. Follow-up was not contingent on remaining in residential placement; residential placement duration and total study follow-up were therefore distinct. Children were eligible if they were aged 6–17 years at admission, resided in a participating home for at least six months, and had sufficient clinical and program documentation to assess therapeutic participation. Of 186 children screened, 36 were excluded: 18 had placements shorter than six months, 11 had insufficient documentation at screening, and 7 did not meet age or clinical eligibility criteria. The final cohort included 150 children (Site A, n=57; Site B, n=49; Site C, n=44).

Exposure

Therapeutic engagement was quantified using a study-specific Residential Therapeutic Engagement Index (RTEI). Weekly participation was scored across seven domains: individual counselling (0–2 points), group therapy (0–2), family intervention (0–2), educational support (0–1), recreation/physical activity (0–1), social-skills programming (0–2), and community activities (0–1), yielding a possible score of 0–11. Mean RTEI across the observation period was the primary exposure and was modeled continuously. For descriptive interpretation, post hoc categories were created after inspection of outcome separation: low (0–4), moderate (5–7), and high (8–11). Because the thresholds were selected after examining outcome patterns, categorical analyses were considered exploratory rather than confirmatory.

Outcomes and Covariates

The primary outcome was clinically meaningful psychosocial improvement, defined a priori as documented improvement from baseline in at least two of five domains: emotional regulation, behavioural functioning, school engagement, peer relationships, and activities of daily living. Improvement within each domain was determined using a standardized chart-abstraction rubric applied to multidisciplinary clinical, educational, and residential documentation. Reviewers assessing the primary outcome were blinded to RTEI category. Eight included participants lacked sufficient documentation across the prespecified functional domains, leaving 142 evaluable for the primary outcome. Baseline diagnostic characteristics represented documented clinical diagnoses, whereas longitudinal mental-health outcomes represented clinically significant symptoms at the relevant assessment; symptom prevalence could therefore exceed formal diagnosis prevalence. A cumulative adversity score counted eight prespecified ACEs (range 0–8). Secondary outcomes included emotional and trauma-related symptoms, behavioural events, educational functioning, and mental-health service use. Behavioural events were compared across two equal six-month windows (months 1–6 after admission versus the final six months of available residential follow-up). Mental-health service use was compared across equal 12-month windows (12 months before admission versus the final 12 months of available follow-up).

Statistical Analysis

Paired binary outcomes were compared using McNemar tests. Paired continuous measures were analyzed using paired-samples t tests or Wilcoxon signed-rank tests according to distribution. Unadjusted categorical comparisons used chi-square or Fisher exact tests as appropriate. Multivariable logistic regression estimated associations with psychosocial improvement. The primary model treated RTEI as a continuous variable and adjusted for age, sex, ACE score, trauma-related symptoms, ADHD, regular family support, and placement duration of at least 12 months. Of 142 children with primary-outcome data, 136 had complete information for all model covariates. Available-case analysis was used and outcomes were not imputed.

Placement duration was retained as a clinical covariate while recognizing that it may represent both a determinant and consequence of improvement. Sensitivity analyses examined the exploratory engagement categories, added residential site as a fixed effect, and excluded children with autism or severe neurodevelopmental impairment.

Results

Participant Characteristics

Mean age at admission was 13.1 years (SD 2.3); 88/150 (58.7%) were male. Mean residential placement duration was 17.0 months (SD 5.4), and 122 (81.3%) remained in placement for at least 12 months. The cohort had substantial clinical complexity: trauma-related symptoms/PTSD were documented in 40.0%, learning difficulties in 35.3%, oppositional defiant disorder in 30.7%, and ADHD in 30.0%. Mean cumulative ACE score was 4.23 (SD 1.93); caregiver instability (78.0%), previous foster placement (76.7%), and emotional neglect (67.3%) were most common. Engagement categories included 45 low (30.0%), 64 moderate (42.7%), and 41 high (27.3%) participants.

Primary Outcome

Overall, 79/142 (55.6%) evaluable children achieved clinically meaningful psychosocial improvement. In the adjusted complete-case model (n=136), each 1-point increase in RTEI was associated with 24% higher odds of improvement (aOR 1.24, 95% CI 1.05–1.47; p=.011). In exploratory categorical analyses, improvement occurred in 19/43 (44.2%) children with low engagement, 32/61 (52.5%) with moderate engagement, and 28/38 (73.7%) with high engagement. Compared with low engagement, high engagement was associated with greater adjusted odds of improvement (aOR 2.78, 95% CI 1.01–7.63; p=.047), whereas moderate engagement was not (aOR 1.12, 95% CI0.48–2.63; p=.789). Placement of at least 12 months (aOR 2.69, 95% CI 0.98–7.41; p=.056) and ACE burden (aOR 0.84 per ACE, 95% CI 0.69–1.02; p=.073) did not meet conventional statistical significance. Age, sex, ADHD, trauma-related symptoms, and regular family support were not independently associated with the primary outcome. Adding site as a fixed effect did not materially alter the high-versus-low estimate. After excluding 14 children with autism or severe neurodevelopmental impairment, 128 remained evaluable and the high-engagement association persisted (aOR 3.19, 95% CI 1.03–9.90; p=.044).

Secondary Outcomes

Change was heterogeneous across domains (Table 2). Emotional dysregulation decreased from 51.7% to 32.4% (p<.001) and trauma-related symptoms from 43.7% to 31.7% (p=.003), while anxiety was unchanged and depressive symptoms improved numerically without reaching p<.05. Behavioural incidents and aggressive episodes decreased, as did crisis interventions. School attendance above 90% improved from 45.1% to 59.2% (p<.001), and frequent disciplinary events decreased. Individual education plan use increased nonsignificantly, consistent with possible recognition of previously unmet educational needs rather than clinical worsening. Mental-health emergency department visits and crisis-service use decreased, whereas psychiatric hospitalization did not significantly change. Overall psychiatric medication use was stable (71.2% at baseline versus 69.2% at follow-up).

Table 1. Selected cohort characteristics (N=150)

Table 2. Selected longitudinal outcomes

Discussion

In this multisite cohort of children with substantial adversity and psychiatric complexity, greater engagement with the therapeutic residential milieu was associated with better multidomain psychosocial functioning. The continuous analysis is the most informative finding: each additional RTEI point was associated with 24% higher adjusted odds of clinically meaningful improvement. T