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Wrapping troubled teens in a blanket of support

Wednesday, July 18, 2001

By Steve Twedt, Post-Gazette Staff Writer

MILWAUKEE -- At the core of Milwaukee County's internationally acclaimed program that keeps mentally ill teens out of the juvenile justice system is:

Money.

Not how much, but how it's controlled and disbursed.

And this is the key. All the money -- for mental health services, juvenile justice, children and youth services, federal grants -- goes into one pot and then gets doled out as each case dictates.

Mario Fiore is one example of how intensive one-on-one care can pay off. After three years in an intensive program that Pressley Ridge Schools tailored for him, Fiore, who is autistic, took part in graduation ceremonies last month. (Robin Rombach, Post-Gazette)

"It's like these kids are in a special insurance plan," said Bruce Kamradt, director of the program, known as Wraparound Milwaukee.

By cutting through territorial barriers among programs and sources of money, Wraparound Milwaukee has found a way to deliver the right mixture of services for the children and families who need them.

Among other accomplishments, it has drastically cut the number of mentally ill and emotionally disturbed adolescents who are locked up, when what they really need is treatment.

Like Pennsylvania, Milwaukee relies on a network of private providers to run community-based group homes for mentally ill youths who've been judged delinquent.

In Pennsylvania, these homes, called Residential Treatment Facilities, can and do refuse to accept children they consider too aggressive, too troubled or too likely to run away.

In Milwaukee?

"Since we're the payers," said Kamradt, "if they refuse, they won't get business."

It's a serious form of leverage that juvenile officials in this region lack. Because residential facilities here get their funding from a variety of sources, there is no single agency that can threaten to deny them their money if they refuse to accept a certain child.

In the nearly seven years since a federal grant launched Wraparound Milwaukee, the program has shortened stays in detention, decreased the number of youngsters who are in residential facilities by more than half, cut how long they stay there -- and saved money in the process.


 
 
Last of four parts

Mario's Story: Designing a program for one

Community group making a connection to steer children from trouble with the law

Where are they now?


Part One:

Lack of options keeps mentally disturbed youth locked up

Part Two:

Juvenile justice and mental health: As two worlds collide, teen suffer

Part Three:

Juvenile justice faces growing crisis: What can we do about the girls?

Part Four:

Wrapping troubled teens in a blanket of support


About the series

A photo journal

   

 

Most importantly, children who complete the program reoffend at half the rate as before. Despite suffering from the whole range of mental illnesses, Wraparound Milwaukee children rarely have emergency psychiatric hospitalizations, thanks in large part to a crisis group home where they can go for up to two weeks.

Milwaukee "has successfully involved the major institutions that affect young people's lives," said David Doi, executive director of the Washington, D.C.-based Coalition for Juvenile Justice. "In many ways, they really are an all-purpose provider," able to find people and programs for almost any type of problem.

Doi is also impressed with the program's financial self-sufficiency. Although a five-year, $16 million federal grant started Wraparound Milwaukee, "they've figured out how to survive once the grant money ran out."

There are more than 600 youngsters in Wraparound Milwaukee, 400 of them ordered into the program by a juvenile court. Many of the thousands of youths who have gone through the program have histories of depression, self-mutilation and other destructive behavior. And yet, said Kamradt: "We've never had a serious injury," let alone a serious suicide attempt.

How do they do it?

Kamradt can point to some obvious reasons.

Wraparound officials have an array of more than 60 services they can tap into, based on an individualized plan that emphasizes a child's strengths. They also believe it is critical to involve the family, even if the term "family" must be broadened to include distant relatives or concerned neighbors.

Flexibility is also important, Kamradt said. If a teen is flunking every class except music, Wraparound Milwaukee will pay for music lessons to build on that strength. If he tends to get into trouble every afternoon before mom or dad is home from work, Wraparound will get him into an after-school program.

Then program officials follow up with whomever is working with the child. "We expect to see results and we expect to see a plan for how they are addressing that child's needs," said Kamradt. "We will move them if we don't see results."

Another essential element is Wraparound's 15-member mobile urgent treatment team, composed of psychologists and master's level social workers who are available at all hours. Last year, they responded to 1,500 calls.

Chris Morano, director of the team, said he recently intervened when a young woman had a psychotic episode and attacked her father, convinced he was some menacing historical figure.

The breakthrough, Morano said, came when he offered to share a bag of Doritos with her.

Another time, Morano had to physically restrain an angry and distraught 10-year-old boy who was running up and down the street throwing rocks at cars. While holding him, Morano started tickling him. "He calmed right down. Within 30 minutes, he was asking to do chores," Morano said.

He hastened to add, "I'm not recommending something called 'tickle therapy,' " and he doesn't believe that a bag of chips will solve every crisis. But, by having a trained counselor respond, rather than police, the team members are able to keep children out of the justice system, and help them avoid harming others or themselves.

"We're not in the habit of pulling kids out of a window, but we've done it."

Hiding the scars

In a manner of speaking, 17-year-old Marlo Wolters is one of those children Wraparound Milwaukee talked in from a ledge.

Bipolar disorder, more commonly known as manic depression, runs through Marlo's family. Her grandmother -- "a huge, huge part of my life," she said -- committed suicide when Marlo was 8. Her mother has been hospitalized for depression, and Marlo herself has attempted suicide twice. She has scars on her leg from one of those attempts. On prom night, she wore 125 bracelets to cover the slash marks on her wrists.

When she began cutting herself at age 10, it was "part of the way to cope," she said.

"The pain on the outside was not as bad as what I was feeling inside. When you cut yourself, you know it's there, and it's going to stop." She somehow thought the pain inside might go away, too. Instead, her emotions see-sawed from fits of depression to superheated energy. During one manic phase, Marlo said she went eight days without sleeping.

Marlo found herself in juvenile court in October 1999, after she was caught bringing marijuana to school.

In contrast to many juvenile systems around the nation, where emotionally disturbed children languish in detention, her total time in detention was less than two days, "and I slept the whole time."

From there, Wraparound quickly got her into a group home. When that didn't work, she was moved into a foster home run by Sandy Seiler, a social worker. When the scheduled three-month stay neared its end, Marlo said she wasn't ready to go home.

So Wraparound let her stay. And she has thrived.

Marlo has now been clean of drugs and alcohol for 18 months. Wraparound Milwaukee found her a psychiatrist with training in homeopathy, who put Marlo on a diet that has kept her mood stable without medications, even through a recent breakup with her boyfriend. She finished high school this spring while simultaneously taking 16 college credits at a local technical school. She intends to be an airplane mechanic.

Marlo has never spent another day in court or jail.

"If I would have kept going with the drugs, [going to jail] was bound to happen."

A troubled group

Almost every teen in Wraparound Milwaukee has at least two things in common -- each has a legitimate psychiatric diagnosis; and each has been ordered into the program by a court, even though only about 60 percent have been judged delinquent.

Program statistics show that nearly six out of 10 are clinically depressed, and that four of 10 have serious alcohol or drug problems. Half come from homes where parents have drug or alcohol problems, one-third come from families with a history of domestic abuse, one-fourth have at least one parent in jail and more than one in five have documented mental illness in their families.

The wraparound concept originated in Canada and has taken many forms in different communities. But most places -- including Pennsylvania -- don't come close to Milwaukee in how comprehensive and flexible their services are.

Consider Brian Durkin's experience.

Durkin's 16-year-old son, Michael, who has Asperger's syndrome, a rare form of autism, and other mental health diagnoses, applied to seven Western Pennsylvania residential treatment centers while he was in Shuman Juvenile Detention Center for aggravated assault last year. They all rejected him, before a judge decided to let him live with his father. Seven other applications to residential facilities were never even answered, Durkin said.

During the past five years, Durkin has had to deal with more than a dozen different agencies and institutions regarding his son: the Department of Public Welfare on medical assistance payments; the county's Children, Youth and Families agency; three residential treatment centers where Michael lived at one time or another; Western Psychiatric Institute and Clinic, and Pressley Ridge Schools, each of which ran programs Michael was in; Access Transportation, to get his son from Western Psych to Pressley Ridge each school day; five local hospitals where Michael received treatment; the county juvenile court probation office, which oversaw Michael's criminal charges; two county behavioral health clinics; and a Fayette County shelter.

Each of these agencies and institutions had its own administrators, its own rules, and its own budgets.

When someone did try to coordinate services, or propose some activity to get Michael more involved in the community, "there was always some reason why it was a problem," his father said.

Not enough flexibility

Pennsylvania does provide its own version of "wraparound" services. The services are designed to support youths in the transition from juvenile facilities back to their homes, usually by providing therapists or a period of time in residential treatment facilities.

But the program here is quite limited, said one national expert.

Consultant John VanDenBerg, who ran a wraparound program in Alaska in the 1980s as the state's director of mental health and until recently was based in Cranberry, said that in a true wraparound approach, "there is one core question: What does this child need to make it?

"We can answer that question with literally hundreds of different possibilities. In Pennsylvania when we ask that question, we can answer with one of four or five services.

"What if someone needs something dramatically different than those services? It's very common that kids with complex problems need something dramatically different. But we can't provide that in Pennsylvania because our money is locked up in these core services."

Pennsylvania also lacks one other key component of comprehensive services, experts said.

Those who work with juvenile offenders say the state desperately needs residential facilities that specialize in mental health treatment but can keep their residents locked up.

But the state's process for approving such facilities is daunting.

In order for a treatment facility to gain "secure status" where it can confine its residents, it would have to submit a program description to the Office of Mental Health and Substance Abuse in the state Department of Public Welfare; get a license from a county Children, Youth and Families agency to comply with regulations on secure facilities; then apply to the state Medical Assistance program to get reimbursement for the added costs.

To date, only one facility -- Cornell Companies' New Morgan Academy in Berks County -- has approached the state to obtain permission to operate a secure residential facility. Its application has been pending since the facility opened in October.

With all the services it provides, some wonder how Wraparound Milwaukee can save money. The program pays out, on average, $4,400 per child each month.

"That sounds like a lot, but these are $100,000 kids," Kamradt said, referring to how much it might have cost to care for them until they were adults. Typically, each child has been hospitalized for mental health or psychiatric care at least once.

The key to the low average cost, Kamradt said, has been reducing the number of teens in residential placement facilities, and shortening the stays of the ones who are there.

As just one example, he pointed to one of the first children ever referred to Wraparound Milwaukee, a 13-year-old African-American youth.

Vera O. Pina, a consultant assigned to handle the case, discovered the young man had been institutionalized in a private residential treatment center since he was 4, because of suspicions that his mother had beaten him. "This is a kid who hadn't done anything illegal at the time," Pina said.

But he did have mental health problems, including slight retardation. After he was put in the residential center, he sometimes defecated in the hallways, and, as he grew older, he became increasingly aggressive.

Although the parental abuse charge was never proven, Pina said, the facility would not let the parents visit him unless they agreed to undergo therapy themselves. They refused.

When Pina met the father, "he said, 'You've got to understand. In Mississippi (where the father grew up), the first thing they tell you is, 'Don't let them mess with your mind. They are going to shrink your brain.' "

So, year after year, the youngster remained in the institution.

Once Wraparound Milwaukee got involved, though, the teen was eventually reunited with his father after the father's brother agreed to take them both in.

One hurdle, Pina said, was overcoming an unexpected fear -- after growing up in a facility largely staffed with white professionals, the young black man was scared about moving into a predominantly black neighborhood.

"This agency had this kid for 10 years, and probably spent $500,000 on his care. Had that family had even one-tenth of that money..." Pina said. "That money did not need to be spent, and that kid did not have to go through the things he went through."

Residential care is still Wraparound Milwaukee's single largest expenditure each year, consuming 44 percent of the program's nearly $25 million budget in 2000. But as recently as 1997, residential care comprised 75 percent of the budget.

Crisis team director Morano granted there are some youths who can't be returned to the community, at least not immediately. "We have a core of about 130 kids, who are both aggressive and have mental health problems, who need residential care. But we still believe we can dwindle that number down."

Allegheny County juvenile courts, by contrast, have 450 to 475 youths placed in group homes, and another 70 youths in state facilities.

Said consultant VanDenBerg: "Even if we took half those kids and provided alternatives in the community, that would be incredible."


Post-Gazette Staff Writer Steve Twedt can be reached by telephone at (412) 263-1963 or by e-mail at stwedt@post-gazette.com



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