Citizen Staff Writer
Wild and warehoused
As state funds dry up, more and more mentally disturbed young people fail to get the help they desperately need.
Second of a two-day series
Stories by JOYESHA CHESNICK
What should be done with out-of-control children who have severe mental illnesses?
In Pima County, the answer is to lock them up in a detention facility where the psychiatric care they receive is minimal at best.
Nearly all the children in custody at the Pima County Juvenile Court Center have some sort of emotional or behavioral problem. One to 3 out of every 10 children have mental imbalances that affect their ability to function. They hear voices in their heads. They mutilate themselves. Unexpectedly, they erupt in violence.
Some children held in the court center belong in detention because they have committed crimes. But more often, they are locked up because there is no better place for them to go.
“There is no place in town that would take a number of these children, particularly the older, aggressive adolescent,” said Fred Chaffee, chief executive officer of Arizona’s Children Association, which runs the only residential treatment center left in Tucson.
“It comes down to resources and money. We can create a place that would do well with those youngsters, but it would not be cheap,” Chaffee said.
The problem of what to do with these troubled children is becoming more serious because so many programs have closed, said Donna Noriega, spokeswoman for the Supreme Court Administration for Arizona.
“It’s a state agency issue all the way around, for all kids. But it becomes more critical when kids are waiting in detention,” she said. “These are needy kids and high-cost kids. That’s sort of what it comes down to, who’s going to pay for this.”
The children who need these services comprise a small but significant population. Left untreated, a good number will commit more crimes. If the past is any guide, many will likely graduate to adult jails and prisons, sometimes for horrendous crimes.
There is no shortage of examples.
• A mentally ill Tucson man stabbed his mother to death in 1999, claiming he was instructed to do so by a television program. Faraz Ahmad, 24, told Judge Michael Brown in Pima County Superior Court that he had to do it “in order to fit in.”
The day before the slaying, Ahmad was evaluated at Kino Community Hospital but was sent back to a group home on the advice of his doctor. Brown referred to Ahmad as one of many mentally ill “time bombs” the state fails to assist.
“The system didn’t single you out,” he told Ahmad. “They don’t help anybody. The system is bankrupt.”
• On Christmas Eve 1983, a 19-year-old Tucson man shot and killed his father and wounded his mother. Doctors found Richard P. Dolny exhibited signs of “undifferentiated schizophrenia,” in which the sufferer might have delusions.
Seven years later, a Phoenix jury ordered the Arizona Department of Health Services and a psychiatric nurse employed by the state to pay more than $400,000 to Dolny’s family for not providing him proper care. Damages were actually set at more than $1 million, but jurors found the family was 60 percent at fault.
For now, there remain few alternatives to detention.
Of four residential treatment centers in Tucson a decade ago, only the Arizona’s Children Association facility survives – and it draws the line at children older than 14 or 15.
Companies such as the Intermountain Centers for Human Development offer a range of services, from group homes with 24-hour psychiatric services to apartments geared toward semi-independent living. But even then, there are not enough spaces available to meet the county’s need.
“There are options in this community, the question is, we remain full and always have a waiting list,” said David Giles, executive director of Intermountain. “There’s a tendency for most facilities like ours to have a waiting list.”
And they can be picky about whom they accept. Take the case of a 6-foot-2, 200-pound teen-ager who has a tendency to get agitated and throw tantrums.
“That’s OK when when you’re 2 or 3 years old, but threatening when you’re that size or age,” Chaffee said. “What you’re looking at is providing 24 hours a day, seven days a week of work with these kids.”
Complicating matters are the prohibitively expensive staffing needs: a psychiatrist to monitor medications and provide assessments; a social worker to work with the youngster and the family; a recreation therapist to help get through the day; a core group of counselors; at least two people to supervise at night and another four to supervise during the day; and then the whole notion of staffing a school.
“It gets to be very expensive, but it also gets to treat kids,” Chaffee said. “The treatment works.”
Mental-health-service providers say there’s been a shortage for years in funding for the human service system.
Arizona contracts with private companies to provide mental-health care to its residents, but does not cover the entire cost of providing that care, said David Miller, chief executive officer of the Arizona Council of Human Service Providers. The underfunding began long ago, he said, but the gap between what it costs and what they get paid has been getting wider in the past two years or so.
“The private agencies were subsidizing what the state system pays and the agencies questioned if they could continue to do that,” Miller said. “Residential treatment is expensive to operate, and several agencies were experiencing multimillion-dollar losses per year.”
The Arizona’s Children Association, for example, was forced to raise $100,000 a year for six years to meet costs on its residential treatment facility.
“We deficit-funded that program every year. Now the rates have gotten better, so we’re meeting our costs,” Chaffee said. “We get about $204 a day (per child), but the oldest kid we get here is 14 or 15. It’s not the big 16- or 17-year-old. If we took them, I know the cost would be closer to 240, 250 dollars a day.”
Unfortunately, the situation is not much better in the public sector.
Every year, the Pima County Juvenile Court Center overspends its $3.3 million annual budget for sending children who need services unavailable in detention for treatment, said Gabriela Rico, spokeswoman for the center.
“We’re trying to stretch out the dollars,” she said. “If we get a rash of kids coming in, maybe we’ll hold them in detention for a while before sending them off.
“Meanwhile, these kids, we’re just keeping them from chewing their arms off.”
Financial troubles with mental health care started 30 years ago with a national movement to remove people with mental illnesses from state-run institutions. The idea was that many patients did not need to be in an institution and could function independently, and more cost-effectively, in the community with proper help and support.
The problem was that the help and support were never what they needed to be.
“The state discharged the people but never put the services in the community,” said David Miller, chief executive officer of the Arizona Council of Human Service Providers. “That doesn’t mean there aren’t any services, but there aren’t enough.”
Again, it came down money.
“There was a basic misunderstanding of how much it was going to cost,” Miller said. “Everybody just wanted to close down the institutions and not reallocate the funds. Promises were made but never materialized.”
In Arizona, that led to a lawsuit. Filed by the Arizona Center for Law in the Public Interest in 1981, it resulted eight years later in a court order requiring the state to treat adults with serious mental illness – at an estimated cost of $350 million a year, well beyond what the state provided.
To comply with the ruling, Maricopa and some other counties began borrowing millions of dollars every year from the funding for children’s mental health care to shore up the adult system. Pima County did not.
The state Legislature finally ended that practice in July, at least verbally, Miller said.
In 1990, a Pima County parent sued the state when the managed-care system refused to provide mental health treatment recommended for his son. That suit was settled in March with what some experts call groundbreaking reform for the children’s mental health system.
It finally put into motion some community-based options based on the “wraparound” concept – the idea of wrapping a child in a blanket of support.
Wraparound concept involves family
From the moment she gave birth, Melissa Royal knew something was wrong with her son.
He was so intense.
When he nursed, he left wounds on her breasts. At age 2, he kicked her in the throat so hard he cracked her larynx. At age 3, he hit his elder sister in the head with a wooden board. And after that same sister ate one of his potato chips, he succeeding in killing her pet hamster – stabbing it with a screwdriver and then feeding it to the cat.
Yet Royal could not get the treatment she wanted for her boy until this August, a few months after she enrolled her son in Project MATCH, a behavioral health-care system putting into practice the “wraparound” approach to treating mental illness.
Today her son, now 6, is in a residential treatment center with his medications adjusted. He is doing much better.
“Had he stayed in the traditional system, he would never be in residential,” Royal said. “His case manager (at Project MATCH) fought and fought for it.”
Wraparound is an old concept that is getting new attention in Pima County and around the nation.
It means wrapping services around a family, using tools not traditionally thought of as a treatment resource – the library, the neighbor down the street, the school, the church.
Royal explains it like this: “It’s one person holding his arms around everybody and squeezing them in to work together. You get all these people together, whoever is involved with that child, and work out a treatment plan for the child.”
This is in contrast to the “traditional system,” as she calls it, where one therapist puts together the plan without input from anyone else, including parents.
“If you don’t sign it, you don’t get it,” Royal said.
Some mental health experts say wraparound is the wave of the future. Many see it as part of the solution to the problem of housing violent children with mental illnesses in detention.
“It works for a number of kids. It ought to, because it’s good treatment,” said Fred Chaffee, chief executive officer of Arizona’s Children Association. “There’s more and more talk about that.”
The wraparound approach stresses keeping a child in his home, close to his support system and roots, though in cases such as the Royal’s, an alternative placement might be necessary.
Neal Cash, executive director of the the Community Partnership of Southern Arizona, which administers publicly funded health care in this part of the state, said his agency is trying to use the wraparound concept to find ways of keeping kids out of more restrictive environments.
“We convened a community meeting to figure out what people wanted to do, and people wanted less restrictive,” he said. “The question now is, what’s available and is it enough?”
Royal said her son would most likely have ended up in custody after he turned 8, the age at which the Pima County Juvenile Court Center starts taking children, if it weren’t for the wraparound service the family is getting.
“He would have been arrested if he were old enough. He tried to cut his arm off at school, and he tried to stab the teachers,” she said.
Royal had several problems working with the “traditional” system.
The boy’s doctor, she said, completely disregarded her input and opinion. For example, she told the doctor that her son’s medication was making him more aggressive. The doctor didn’t listen and kept him on the drug for eight months before changing it.
The family’s caseworker, she said, told them he couldn’t find respite care for the boy for more than a two-year period. But when Royal called the facility she had in mind, the staff told her nobody had called on behalf of her son.
“The doctor tells you one thing, the caseworker does another. At one point, they dropped almost all my son’s services because we had a new caseworker, who wanted to be thrifty,” she said.
In another incident, Royal took her son to Palo Verde Hospital for acute care, and the doctor refused to admit him.
“This was after he had just tried to kill his sister,” Royal said. “The way the traditional system worked, they just wanted to sit and let him wait.”
In Project MATCH, she said, the people closest to the child make the decisions. And the whole family is taken care of.
Royal, who suffers from debilitating epilepsy, and her husband, Andre, who lost both of his legs to a rare blood disease, are treated to “family days” facilitated by Project MATCH because they don’t get out much. The program helped the family get a car fitted so Andre, the only driver in the family, could drive it.
“They involve everybody. They listened to us, what we wanted, what was best for (our son). We were the experts,” Royal said. “They work miracles.”
PHOTO CAPTION: Photo by GARY GAYNOR/Tucson Citizen
A girl hides under a blanket inside an intake interview room. She is being held in isolation while she is evaluated. The county spends $3.3 million a year to care for troubled children.