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"On any given night, as many as 2,000 children and teenagers are languishing in juvenile detention facilities across the country simply because they cannot access the mental health services they need."
That’s the assessment of a new report that details the growing problem of mentally ill children and youth who are committed to juvenile detention because there are no mental health services available for them.
"These inappropriate detentions are a regrettable symptom of a much larger problem, which is the lack of available, affordable, and appropriate mental health services and support systems for children with mental illness and their families," says U.S. Sen. Susan Collins (R-ME), who chaired a hearing of the Senate Governmental Affairs Committee. "When a child has a serious health problem like diabetes or a heart condition, the family turns to their doctor. When the family includes a child with a serious mental illness, it is often forced to go to the child welfare or juvenile justice system to secure treatment."
A crisis that demands attention
"Neither of these systems is equipped to care for a child with a serious mental illness, but in far too many cases, there is nowhere else for the family to turn. It is shocking that so many youth are jailed unnecessarily because they cannot obtain community mental health services. This is a crisis that demands the attention of Congress," she explains.
The report, prepared by the House Committee on Government Reform’s Democrat staff special investigations division, presented results from a survey of every juvenile detention facility in the United States to assess what happens to youth when community mental health services are not readily available. More than 500 juvenile detention administrators in 49 states responded, representing some 75% of all such facilities.
Among the findings:
• Two-thirds of juvenile detention facilities hold youth who are waiting for community mental health treatment. These facilities are located in 47 states. In 33 states, youth with mental illness are held in detention centers without any charges against them. And youth incarcerated unnecessarily while awaiting treatment have been as young as 7. Some 117 facilities reported holding children 10 and younger, and a majority of detention facilities reported holding youth younger than 13.
• Over a six-month period, nearly 15,000 incarcerated youth waited for community mental health services.
• Two-thirds of juvenile detention facilities, which hold youth waiting for community mental health services, report that some of these youth have attempted suicide or attacked others. But 25% of the facilities provide no or poor quality mental health services, and more than 50% report inadequate levels of training.
• Juvenile detention facilities spend an estimated $100 million each year to house youth who are waiting for community mental health services. That cost estimate does not include any of the additional expense in service provision and staff time associated with holding youth in urgent need of mental health services.
Committee analysts said the survey results likely underestimate the full scope of the problem and major improvements in community mental health services are urgently needed to prevent the unnecessary and inappropriate incarceration of children and youth in the United States.
A 19th century story
At the hearing, U.S. Rep. Henry Waxman, whose staff conducted the survey, said the report "recalls the 19th century, when reformer Dorothea Dix traveled from jail to jail gathering stories of individuals suffering from mental illness who were abandoned and ignored. Her work led to the creation of the nation’s first asylums. Since the mid-1800s, psychiatry and associated professions have learned to diagnose and treat complicated mental illnesses. Hospitalization is now recognized as a treatment of last resort. It is well understood that many children with mental illness can recover and lead productive lives.
"Yet even as scientific knowledge has advanced, our social policy has faltered," Mr. Waxman said. "We have seen the emptying of psychiatric institutions without the establishment of adequate community services. We have seen the starvation of public budgets that support the basic needs of millions of Americans with mental illness. . . . Congress must ensure that adequate mental health services are available to all who need them.
"We must reform a confusing and bewildering mental health care system so that it works for the benefit of children and their families. And we must insist upon accountability so that someone is held responsible each and every time a child is jailed to wait for mental health services," he continued.
National Alliance for the Mentally Ill (NAMI) Maine executive director Carol Carothers told the committee it is hard to imagine a worse place to house a child who requires health care treatment and services for mental illness.
"Surely, we would not dream of placing a child with another serious illness, like cancer for example, in a juvenile detention center to await a hospital bed or community-based treatment," she pointed out. "It is outrageous that we do this to children with mental illnesses, as young as 7 years old. This takes an enormous toll on the child and the family."
Corrections officers lack training
Ms. Carothers cautioned that in juvenile detention facilities, the symptoms of mental illness often are misinterpreted by inadequately trained staff as disobedience, defiance, or even threats and often well-meaning but untrained corrections staff respond to such behaviors with anger, discipline, or even force.
"When staff are allowed to resort too quickly to threats and force in the face of noncompliant adolescent behavior," she said, "minor incidents escalate and the risk of harm increases for both the child and the officer. . . . It is wrong to place children with mental illnesses that require treatment into juvenile detention centers where the symptoms of their illnesses significantly worsen and their long-term outcomes become much bleaker," she noted.
"These are environments almost guaranteed to exacerbate their mental illnesses. . . . Additionally, when a child is housed in a juvenile detention facility, parents experience a complete loss of involvement in their child’s life," Ms. Carothers explained. "The philosophy of many detention centers is to limit contact of youth confined to the facility with their families. Families lack the opportunity to stay closely connected to their child at a time when the child is vulnerable and most in need of their love and support."
She told the committee the nation is spending money in all the wrong places, and it will be important to appropriate funds to build home- and community-based mental health treatment and services for children with mental disorders.
Recommendations Ms. Carothers made include:
1. Passing the Keeping Families Together Act (S. 1704/H.R. 3243) that would provide grants to eligible states to develop a more comprehensive array of home- and community-based services so families would not have to surrender custody of a child to the state to access mental health services. It also would provide for better coordination among child-serving agencies.
2. Passing additional federal legislation to help improve access to essential community-based services for youth with mental illnesses and their families, including increased funding for the full array of mental health services needed by the youth.
3. Passing the Mentally Ill Offender Treatment and Crime Reduction Act (S. 1194/H.R. 2387) to provide funding for grants to states and communities to be used in a variety of ways to address the high percentage of youth and adults with mental illnesses locked up in jails and prisons. These would include jail diversion programs, community re-entry programs, and enhanced treatment for youth and adults with serious mental illnesses who come into contact with criminal justice systems.
4. Passing the Senator Paul Wellstone Mental Health Equitable Treatment Act (S. 486/H.R. 953) to end discriminatory caps on nearly all private health insurance plans for mental health benefits.
5. Passing the Family Opportunity Act (S. 622/H.R. 1811) to allow families with children with serious disabilities to buy into the Medicaid program on a sliding cost-sharing basis to provide insurance coverage for essential services.
Ms. Carothers tells State Health Watch that additional funding to make needed changes is the most important thing Congress could do to be responsive to the concern.
"It would make a big difference, especially given the fiscal crisis most states are facing," she continues. "Federal grants would help, although that’s not a long-term solution. Ultimately, we need an overhaul of the public mental health system and a revision in the way we look at children in corrections. But that’s a tall order. Mental illness is the only disease where you have to be so sick before you can get help."
Fixing the system
It’s necessary to fix the juvenile mental health system, according to Ms. Carothers, so the adult system also can be fixed. Many current policies and procedures, she says, are feeding the adult system with kids.
Despite the magnitude of the problem and of the needed repairs, Ms. Carothers stresses that she has some hope that change can be accomplished.
"Our issues are kind of on the public policy agenda," she explains. "Because the numbers are so high and the cost is so high, the country may begin to understand the folly of our policies because they’re feeling it in the pocketbook. If they understand the consequences of the policies, maybe they’ll change them."
Bazelon Center for Mental Health Law senior staff attorney Tammy Seltzer told the hearing that detention facility administrators say the children identified for the survey should not be in their facilities and would not be there if appropriate mental health services and supports were available in the community.
She said that while model programs still are rare, there are some effective alternatives to incarceration. For example, Wraparound Milwaukee works closely with parents to provide services tailored to the needs of each child so children can stay out of crisis and out of the juvenile justice system.
The program blends funding from the city’s child welfare and juvenile justice agencies and pools it with private and public insurance funds to pay for a coordinated service delivery system.
According to Ms. Seltzer, in its first five years, Wraparound Milwaukee reduced the average monthly cost of care per child from more than $5,000 to less than $3,300. And because the savings were reinvested in the program, program administrators have been able to nearly double the number of children served.
Even more importantly, the ability of the children involved to function at home, in school, and in the community has improved significantly, she continued, and the number returning to the juvenile justice system has been cut in half.
Programs that work
"Fortunately," Ms. Seltzer testified, "we know the principles that make programs like Wraparound Milwaukee successful in helping children avoid juvenile detention and succeed in their communities. Children and their families must have ready access to mental health services and supports, and this access must be based on kid time, not bankers’ hours. Services and supports must be designed to enable children to succeed at home and school, not just avoid detention.
"Child-serving agencies must be held accountable for serving children well and not rewarded for pushing them off the agency rolls and into the juvenile justice budget. In particular, schools must be responsible for educating and supporting all of their students, and communities must not allow schools to shirk their duties by suspending, expelling, and calling the police on students whose behavior could be effectively addressed using positive behavioral supports. In addition, states and the federal government need to do more to end insurance discrimination and to serve the uninsured," she told the committee.
Ms. Seltzer tells State Health Watch the problem is that parents can’t get the help they need when they need it — they can’t get the kind of help they need to keep their children at home.
"The system focuses on two types of children — at opposite ends of a continuum," she explains. "It looks at those who don’t need much help and at those who are in full-blown crisis. The system deals with these extremes, but doesn’t do a very good job in the middle. There’s no support to ensure that minor problems don’t escalate to a full-blown crisis. We’re pretty sure at this point that many kids will not need high-end treatment like hospitalization if there are enough supports in place."
Ms. Seltzer is careful not to blame only the mental health system, noting that the schools have a duty to identify and provide appropriate supports to children with mental health problems so they can learn and be successful.
"There’s not one state that meets the standards set by federal special education legislation," she adds. "Most schools are resisting applying scientifically proven steps like positive behavioral supports."
A solvable problem
Speaking emphatically, Ms. Seltzer declares the problem is "absolutely solvable. That’s why reading the congressional report is so frustrating, disappointing, and disheartening. Kids don’t need to end up in the juvenile justice system. It’s solvable at the school level, and it doesn’t cost all that much to create an environment in which children can learn and do well."
In some ways, she says, reforming the entire mental health system is more challenging than putting things that are proven to work in individual schools, but it also is doable, pointing to the Milwaukee project that she referenced in her testimony.
While Medicaid gives states great flexibility to address the needs of children with serious emotional disorders through waivers for home- and community-based services, according to Ms. Seltzer, few states have taken advantage of the opportunity.
Waivers for emotional needs
Although 49 states and the District of Columbia have such waivers in place to serve the mentally retarded and those with developmental disabilities, only four states have them for children with emotional problems. "States that have pursued the waivers find that they are very successful in terms of outcomes and at half the cost," Ms. Seltzer declares. She notes one problem is that the waivers can be challenging to obtain because of eligibility rules that require that children to be served need a high-end level of care and would otherwise have to be hospitalized.\
Issuing a plea for help
Is Congress listening to the pleas for help? Bazelon Center director of federal relations Laurel Stine tells State Health Watch the hearing raised the level of attention paid to the issue. "It raised the attention of other members of Congress, advocates, and the general public.
"We want to help continue to raise awareness that can lead to regulatory solutions to chip away at the problem," Ms. Stine stresses. "And we hope that Sen. Collins and Rep. Waxman will continue to exercise their leadership."
[Congressional information is available on-line at www.senate.gov and www.house.gov. Information about specific bills is available on-line at http://thomas.loc.gov/. Contact Ms. Carothers through NAMI at (703) 524-7600. Contact Ms. Seltzer and Ms. Stine at Bazelon at (202) 467-5730.]