Cruel Convergence

For thousands of children with debilitating mental illnesses, the get-tough juvenile-justice culture of the 1990s could not have come at a worse time. The new punitive policies emerged in tandem with the slow breakdown of the public mental-health system, and the confluence has led to a pervasive criminalization of juvenile mental illness.

The excesses of the “super-predator”–era juvenile-justice policies are well-known, but just as damaging were the shift in focus and resources they signaled. Punishment came to replace rehabilitation as the core goal of the American juvenile-justice system at the same time that our mental-health system was sinking into a sustained crisis. The failure of community-based mental-health care to meet the needs of children in the wake of national deinstitutionalization served to push mentally ill kids into the juvenile-justice system -- in effect, to reinstitutionalize them, this time into a system woefully ill-equipped to help.

In the last 15 years, matters have grown worse, primarily because of the way states have responded to the shortage of mental-health services. Instead of addressing the problem directly, too many states embarked on a roller-coaster engagement with private, managed-care Medicaid providers who promised that cost cutting and streamlining could mitigate the need for more mental-health resources and services. State after state eventually discovered the perils of such arrangements. Sweetheart contracts gave for-profit HMOs few incentives for service quality. Savings were eaten up by enormous administrative costs and fat profit margins. Care was slashed and services denied, more acutely in mental health than anywhere else.

Meanwhile, the number of youths entering the juvenile-justice system increased substantially over the 1990s. The new get-tough laws played a large role in that, but some of the rise was related to the problems in mental-health treatment. The Texas Youth Commission, for instance, found a 27-percent increase in the number of kids with mental disorders entering the state juvenile-justice system from 1995 to 2001. “It's a hydraulic effect,” says George Davis, director of the University of New Mexico's Division of Child & Adolescent Psychiatry, who helped pioneer mental-health reforms in Albuquerque's juvenile-detention system. “This population exists no matter what, and if they're not in treatment facilities, they're in detention. When one goes down, the other goes up.”

Estimates vary regarding the proportion of detained youth suffering from mental disorders. Northwestern University Medical School's Linda Teplin and colleagues have studied mental-illness prevalence among detained youth in Chicago. In 2002, they reported that nearly 60 percent of male detainees and 67 percent of females suffered from at least one psychiatric disorder.

Moreover, there is increasingly robust evidence that the juvenile-justice system serves as a dumping ground for mentally ill children lacking health services. The National Alliance for the Mentally Ill (NAMI) commissioned a poll of families of children with mental illness in 1999 and found that more than a third of respondents reported placing their kids in the juvenile-justice system in order to access mental-health services. A series of investigations in 2002 and 2004 carried out by Congressman Henry Waxman's minority staff of the House Government Reform Committee addressed this issue. Their report, published last summer, analyzed responses from more than 500 juvenile-detention administrators representing 75 percent of all detention facilities in the country. It found that two-thirds of the facilities held children who were awaiting community mental-health treatment. In 33 states, facilities held mentally ill youth who had no charges against them.

At a Senate hearing highlighting the report, one witness, Carol Carothers, executive director of NAMI's Maine chapter, recounted stories of mentally ill youth in her state shunted into the juvenile-justice system. One 18-year-old whose mental illness had gone untreated for years eventually hanged himself in the state's “supermax” prison. Another youth, 13, had enjoyed treatment and counseling in a residential program until his mother, a member of a NAMI support group, moved north. “The plans to link him to new services fell apart,” Carothers testified, “and he ended up with nothing -- no psychiatrist, no caseworker, no medications, and no therapist. As one would expect, he fell apart and landed in juvenile detention, where he still is.” According to the mother, the child first began to cut himself and act violently while in detention.

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Addressing the crisis of mental illness in juvenile justice means grappling with the dysfunctions of two extremely complex and diverse systems. But several localities have shown how reform can happen.

As much as any other state, New Mexico epitomized the trends of the 1990s that had left mentally ill children stranded in the juvenile-justice system. A Republican administration initiated a litany of get-tough youth policies, including mandatory sentencing, state-run boot camps, and the construction of a $7.5 million maximum-security juvenile prison in Albuquerque. Meanwhile, the state's experience with managed care for mental health, implemented in 1997, was typically disastrous. The system's byzantine structure sucked 45 percent of all funding into administrative costs while services were slashed and reimbursement rates plummeted. Not surprisingly, the warehousing of juveniles with untreated mental-health needs in detention centers became an acute problem. An investigation by Waxman's team found that in 2001, one in seven youths in New Mexico's detention centers were there primarily due to the lack of available mental-health services.

In the midst of all this, one pioneering reformer spearheaded an overhaul of the largest detention system in the state, in Bernalillo County (encompassing Albuquerque). Tom Swisstack, formerly the mayor of a fast-growing Albuquerque suburb, took the reins of the detention center in 1998. With his intense drive, he commenced his reform campaign in 2000 with support from the Annie E. Casey Foundation's innovative juvenile-detention reform initiative. Replicating many features of the original Casey Foundation sites, the Bernalillo reforms focused on new, sophisticated screening procedures to place nondangerous offenders in home- and community-based alternatives to detention. During a June visit to the center's premises in dusty northwestern Albuquerque, I went step by step through the processes of booking, assessment, and individualized service, with Swisstack highlighting the myriad methods by which children get diverted into the two home-based supervision programs run by the center.

Adding to the basic Casey Foundation model, Swisstack applies an innovative focus on serving the mental-health needs of the children in the system. On top of intensive staff training and new therapeutic programs to provide a continuum of care, he has also negotiated agreements with the state's three Medicaid managed-care providers to reimburse counseling and medication services for kids with mental-health needs. This led to the construction in 2001 of a community mental-health clinic on the detention center's premises -- the only such clinic in the country. In addition to the clinic's case managers, psychologists, and psychiatrists, three full-time clinicians now treat the residential population in the detention center itself, and Swisstack is looking to hire more.

“I now have a clinical staff that is actually implementing programs in a proactive rather than reactive approach,” says a gratified Swisstack. Importantly, these benefits extend far beyond the detained youth: Albuquerque's clinic serves the mental-health needs of others in the community, too. During my visit, I met Tonya and her 10-year-old son, Charles (their names have been changed). Charles, whose father died when he was 3, suffered violent, uncontrollable outbursts at home and school. Two years ago, his school referred him to the mental-health clinic, where he was quickly diagnosed as bipolar. He now receives medication and meets weekly with a psychiatrist at the clinic for counseling; Medicaid covers both. Tonya called the treatment “a lifesaver,” and reflected on what might have happened if the clinic's services weren't available. “The juvenile jail's right next door,” she said, “and every week I drive in here and think, ‘If it wasn't for this place, he might be over there.'”

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Certain political conditions have helped Swisstack's efforts, and those of other reformers in the country. State and local fiscal strains have made officials much more amenable to cheaper alternatives to incarceration. Meanwhile, the first, disastrous cycle of state experiments with managed care has run its course and provoked closer public scrutiny, and many states are beginning to be much stricter about the requirements included in new contracts. Swisstack is now in negotiations with a newly contracted statewide managed-care provider to cover seven more mental-health-clinic sites across the state. As the University of New Mexico's George Davis explains, the prospects for such an agreement are better now because the company actually has strong contractual incentives to provide treatment. “The state has really wised up … [and] is going to watch them closely,” he says. “This time the contract at least makes some sense.”

For all the good such reforms do, however, this crisis is fundamentally an outgrowth of the broken public mental-health system itself. Neither detention reforms, nor other promising juvenile-justice innovations, nor smarter managed-care contracts are going to be enough to fix that.

A serious national commitment to providing community-based mental-health services and coordinated systems of care is needed -- and realizing that goal remains well beyond the capacity of juvenile-justice reformers alone.

Sam Rosenfeld is a Prospect web writer.

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