This study examined the relationship between gender, abuse history, and clinical change in a residential treatment program for youth with emotional and behavioral disturbance. Admission data and data collected after 1 year of treatment or at discharge were examined for 1,303 youth. Measures included the Suicide Probability Scale, Child Behavior Checklist, and the Diagnostic Interview Schedule for Children. Data also included medication count, demographic data, and history of sexual or physical abuse or both. At intake, girls scored significantly more pathologically than boys on 9 out of 12 measures. At intake, abused youth indicated more hostility, anxiety, and mood disorder symptoms as well as psychotropic medication usage than nonabused youth. Youth improved significantly on all outcome measures with treatment, although interaction effects indicate some differing treatment responses by abuse history or gender. After treatment, girls still scored significantly higher than boys on 6 of 8 outcome measures, and abused youth, especially youth experiencing both sexual and physical abuse, had significantly higher anxiety, affective, behavior, and eating disorder symptom counts and were on more psychotropic medications than nonabused youth. Although behaviorally focused treatment was associated with improvement on every measure, the most important implication of our study is that a singular treatment approach does not fit all youth completely as reflected by continuing treatment needs in our most troubled youth. Additional symptom-focused treatment and research attention must be given to girls and abused youth in residential care to maximize their therapeutic outcomes.