by Michael Jonathan Grinfeld
Psychiatric Times February 2000 Vol. XVII Issue 2
If only we could have reached them sooner or found
this tape. If only we would have searched their room. If only we would
have asked the right questions.
Eric Harris, in a videotaped
prediction of his parents' reaction to the Columbine High School
shooting.
Their affliction is reflected in the way they act on the streets, in school and at home. It is reflected in the statistics: more than 2 million minors are arrested each year, and two-thirds of them suffer from some behavioral, mental, emotional or substance abuse problem. So why, instead of helping these children, are we putting them in jail? And, once they're in jail, why does the treatment seem more like punishment than compassionate care?
According to "Families on the Brink: The Impact of Ignoring Children With Serious Mental Illness," a report released last July by the National Alliance for the Mentally Ill (NAMI), 36% of respondents to a nationwide survey of families who have children with severe mental illnesses said that their children were in the juvenile justice system because of the unavailability of mental health care services. Nearly a quarter of the respondents said they were told that they would have to relinquish custody of their children to authorities in order for their children to receive treatment, while 17% said they actually did turn over their kids. Despite this sacrifice, half the respondents worried that their children would not get the care they needed and would most likely become physically aggressive or violent.
"The results of this survey…show without question the barriers these families face just to obtain basic and necessary medical treatment," Laurie M. Flynn, NAMI's executive director, said in a press statement. "The suffering that this report gives voice to deeply saddens and outrages me, not only because these are the voices of mothers and fathers who must try to comprehend why their loved one, their child, has a brain disorder, but because they find themselves all too often having to fight for every shred of medical attention…In the face of this struggle, they confront the unimaginable but all-too-real risks of family dissolution, financial bankruptcy, wrongful imprisonment of their child, and even the prospect of having to give up custody of their child just to get him or her treatment."
The reality that children exhibiting symptoms of serious mental illness should at some point come to the attention of the juvenile justice system is not all that surprising. According to the NAMI survey, caregivers reported that their children often exhibited "disturbing or maladaptive behaviors" within the past year, with "violence or physical aggression" one of the most prevalent behaviors (65%), second only to "mood swings" (83%).
During the 1990s, a societal tug of war raged, pitting against one another the adults responsible for educating, rearing and socializing children. On one side were those who were unwilling to accept what appeared to be excuses made on behalf of children who exhibited a growing penchant to commit violent acts. On the other side were family members, consumer advocates, mental health care practitioners and defense lawyers who urged compassionate care for even the most nefarious children.
Most states responded to the controversy by passing laws aimed at cracking down on juvenile crime. More than half the states enacted legislation that either made it easier to transfer juveniles to the adult system, enhanced sentencing options, or removed or modified confidentiality laws that once protected youthful offenders. In many instances, punishment and retribution-incarceration goals consistent with those applied to adult offenders-replaced rehabilitation, education and treatment.
For some caught in the crossfire, the endgame was death. As this issue of Psychiatric Times went to press, five inmates in Texas and Virginia prisons were scheduled to be executed during the first few months of this year for crimes they committed as juveniles. In all cases, they had a history of abuse and neglect and suffered from an untreated mental illness at the time of their arrest.
"We call it circling the drain," Melinda Bird, the managing attorney for the Southern California office of Protection & Advocacy Inc. (P & A), told PT. P & A is a quasi-public oversight agency that monitors treatment of the mentally ill and disabled. Bird described the vicious cycle that literally condemns children before they are given a decent chance, adding that most children with untreated behavioral symptoms will come to law enforcement's attention sooner or later. They usually deteriorate even further in youth authority facilities, at which point they are released and abandoned, destined to commit even more serious offenses, she noted.
Across the board, county mental health agencies, schools and the juvenile justice system adopt a "hot potato" approach, tossing children from system to system, said Bird. Last year, for instance, Metropolitan State Hospital, a suburban Los Angeles facility that houses 100 youngsters, turned young patients whose aggressive behavior was a symptom of their illness over to law enforcement.
"Many of the cases involve an untrained staff member who is injured in the process of trying to put a child in mechanical restraints," Bird said. "The staff members did a bad job. They either didn't de-escalate the behavior or didn't have some behavior plan in place, or they didn't follow safe techniques. It seems to us to be a growing phenomenon."
The irony, Bird explained, is that the lack of money is not what causes children to be ignored by nearly every social welfare system put in place to protect this vulnerable population. "It would actually be cheaper to provide services," she told PT. "The heartbreak is that you spend less money if you don't treat children punitively." Rather, she blames ongoing stigma against mental illness, and society's refusal to accept brain disorders as an "excuse" for unacceptable behavior.
"No system is comfortable with these kids," Bird said. In many instances, children who are legally entitled to special education opportunities and Medicaid are ignored until lawyers threaten litigation. P & A's clients often have to wait months for outpatient services, or they don't receive them at all.
One case Bird is handling in San Diego, for instance, involves a teen-age boy with Tourette's syndrome who was arrested for joyriding in his mother's car. Local agencies and education officials had failed to provide a school placement for more than a year and a half.
"We haven't won over community sentiment," agreed Christopher Thomas, M.D., a professor of psychiatry at the University of Texas Medical Branch in Galveston. A child and adolescent psychiatrist, he is also director of the Island Youth Programs, a pilot project started five years ago that was meant to end the ineffectual case management caused by agencies that fail to coordinate. He told MPT, "The negative reactions come from fear and it comes from a viewpoint that why should children who have hurt someone get services? When they do something wrong, they should have to face the consequences."
While it is an understandable reaction, said Thomas, it is a faulty one when considering the success his own program has achieved. In 1992, Galveston's population of 5,000 10- to 17-year-olds committed 12 homicides. Five years after implementing the Island Youth Programs, the number dropped by 80%. Overall crime dropped by nearly half.
What Thomas and others have done in Galveston is to create a collaboration between all of the adults responsible for children: city government, law enforcement, juvenile justice, public recreation, public schools, the University of Texas Medical Branch and local families concerned about youth violence. They designed an integrated prevention and intervention effort to identify and assist at-risk children.
"We don't want to come across that children should not be held accountable for their behaviors, but we need to recognize the burdens they suffer. We need to inform the public that regardless of what crimes have been committed, when a child suffers from mental illness, [the child] requires treatment and care," said Thomas. In addition, it is important for the community to recognize that a mental health care system that provides integrated services can get children back on the right track and reduce future offending.
Scott Henggeler, Ph.D., a clinical psychologist, is professor of psychiatry at the Medical University of South Carolina in Charleston and directs its family services research center. The "multisystemic therapy" program they have developed also works to provide a multifaceted intervention that has reduced recidivism and crime rates. Using a home-based model that works to improve parenting and caregiving skills, Henggeler said the cost effectiveness of his program is unmatched.
In 1998, the average cost of stabilizing a youngster at home and in the community was $4,500, a figure $22,000 less per year than that for managing a child through the juvenile justice system. Boot camp programs-now falling into disfavor as a failed experiment-posted an annual loss of $8,000 per child.
Once a child is institutionalized, however, it's not just the money that makes detention a poor option. Often, medical and psychological intervention is either nonexistent or below any reasonable standard. A two-part investigative report by the Los Angeles Times last December, for instance, chronicled the often abusive treatment received by the 7,563 young inmates who occupy the 15 facilities run by the California Youth Authority (CYA). Psychotropic medications were used for control, but mental health treatment was unavailable for many children in need.
Hans Steiner, M.D., a professor of psychiatry at Stanford University, has been working for years with the CYA, conducting joint research programs. Although he conceded that the abuses disclosed by the media often occur, he told PT the problem is far more complex. Depending on the group studied, the number of children exhibiting mental health morbidity can range from 30% to 90%. Each child, meanwhile, poses a unique social, psychological and biological conundrum, making one-size-fits-all programs difficult to manage.
Michael M. Faenza, president of the National Mental Health Association in Washington, D.C., told PT that the California model is too often repeated throughout the country. "There's a range of things that can happen in juvenile justice facilities, because there isn't adequate staffing or really professional supervision of mental health services," he said. "The bad things include the misuse of psychotropic medications, including overmedication for control, and the improper use of seclusion and restraint. What happens is that kids with mental disorders end up getting punished for exhibiting symptoms, instead of getting treatment."
One of the fallacies that obscures what happens to these children is the misperception that juvenile offenders automatically become predators. To the contrary, explained Faenza, most youths with mental or substance abuse problems do not become career criminals, but rather end up leading marginalized and unproductive lives burdened by their illnesses. "The biggest impact of the lack of treatment," Faenza said, "is that human beings suffer."
In discussing obstacles to meaningful reform, Faenza explained that politicians want to appear tough on crime. Although there are programs in various parts of the country that are doing a good job of coordinating services and that prove the effectiveness of a treatment-oriented approach, there will not be much public support for change until the political winds shift.
"The fact is there really are solutions to these problems. We really know a lot about how to prevent kids from entering the justice system, and we know a lot about how to provide treatment and supports to families," said Faenza. "We just need to cut through the political and public relations issues that surround these problems and bring the science to them."
Doing this will take the support of the professional community. "Psychiatric physicians have tremendous power because of the scientific and intellectual capital they bring to social policy," he said. "Psychiatry could have a major impact on child protective services, juvenile justice, criminal justice, public education, but it's not chosen to involve itself in any serious dialogue concerning these social systems."
Currently, several bills pending in the U.S. Congress would provide
additional funding to train personnel, coordinate services and improve
access to care, and its quality. The American Psychiatric Association
favors these bills and has actively supported their passage.