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Lack of options keeps mentally disturbed youth locked up

First of four parts

Sunday, July 15, 2001

By Steve Twedt, Post-Gazette Staff Writer

Every morning, hundreds of mentally ill and emotionally disturbed teen-agers wake up in juvenile detention centers and juvenile jails across the United States to spend another day locked up and isolated from the help they need.

Some suffer delusions, hearing voices that tell them to hurt themselves or others. Others dwell in the depths of depression, their young lives shut down emotionally because of abuse or an organic psychiatric disorder. Far too many of them try to kill themselves, cutting their wrists with any sharp edge they can find, or banging their heads violently against a wall.

Eight months after leaving Shuman Detention Center, Kevin Walker lived in motels for a time, panhandling for money from passersby. Kevin needed mental health treatment growing up but instead he has spent much of his teen-age years in detention. (Robin Rombach, Post-Gazette)

Some of these children are locked up because they're accused of serious criminal acts, such as assault or robbery. Others are there for charges as minor as trespassing or truancy. In either case, though, the offenses often can be traced to their mental problems.

Experts say most of these children need mental health services -- counseling, group therapy, perhaps medication -- in secure facilities where they are not mixed in with other young criminals. If they could get that, they say, many of them would not commit new crimes.

But virtually none of the young mentally ill people housed in the nation's juvenile detention centers get such services, and ever since states moved to shut down adolescent units in mental institutions several years ago, there are fewer and fewer places that will accept these sometimes violent children for treatment.

Juvenile justice "is where the children go when all the other systems fail -- the school system, the welfare system, the mental health system," said Tammy Seltzer of the Bazelon Center for Mental Health Law in Washington, D.C.


First of four parts

'I don't have the skills to be in the outside world'

U.S. detention centers becoming warehouses for mentally ill

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

Follow-up articles:

Troubled teen gets the help she needs -- in Florida -- July 17, 2001

Mental health plagues girl in juvenile lockup -- July 29, 2001

Teen with mental health problems to stay in maximum-security lockup -- July 31, 2001

State and local groups reach out to troubled juveniles -- Aug. 19, 2001

Officials seek ways to protect mentally ill teen-agers -- Oct. 1, 2001

How to keep mentally ill teens out of jail -- Oct. 11, 2001

Disturbed, violent teen-ager 'like a time bomb' -- Oct. 21, 2001

Juvenile lockups ill-equipped to care for young people considering suicide -- Dec. 9, 2001

Teen rejoins her mom after 18 months in juvenile system -- Dec. 14, 2001

Incarceration in Florida exacerbates problems for aggressive, mentally ill boy, 17 -- Feb. 4, 2002



"When this country de-institutionalized youth with mental health problems, they were quickly re-institutionalized in juvenile lockups," added Mary T. Previte, administrator of the Camden County Youth Center in New Jersey.

David Doi, executive director of the Coalition for Juvenile Justice in Washington, D.C., called mental health "the number one emergent issue as far as juvenile justice is concerned. We need better diagnosis and better treatment. I hope that we don't live in a society where the only way we have to treat mentally ill children is to arrest them and send them to jail."

But that is exactly what is happening in too many cases.

Once mentally ill children are put in juvenile detention, they often end up staying weeks or even months until some alternative placement, like a group home, can be found. Often that doesn't work either. They get kicked out of one program after another, each time making another swing through detention, until they end up in a maximum security facility.

"They become like reused adhesive tape," said one group home executive. "They really lose their ability to stick in any environment."

Two recent cases at Allegheny County's Shuman Juvenile Detention Center illustrate the problem.

Just last week, a 15-year-old boy diagnosed with schizo-affective disorder, bipolar disorder and depression with psychosis stood before Allegheny County Common Pleas Judge Cheryl Allen Craig after he had spent nearly two months at Shuman.

He had applied to several residential programs, Craig said, but "nobody would take him."

Yet his delinquency, an assault, was not serious enough to warrant sending him to a maximum security facility. Rather than keep him in detention indefinitely, Craig opted to send him home, after arranging support services to help him.

In January, a 16-year-old boy who has bipolar disorder and a history of substance abuse arrived at Shuman after he had "failed to adjust" at his eighth placement in two years. "Failure to adjust" is a juvenile justice term for a child who cannot follow the rules in a group home, foster family or some other program.

The boy had been found delinquent for burglary at age 14, and each "failure to adjust" was considered a probation violation that prompted another trip to detention.

This time, during his first week at Shuman, he got into a dispute with staff and refused to take his medications. Later that evening, the young man was rushed to the hospital because, as one staffer described it, he'd started eating his own hand. The teen was kept overnight to stabilize him, and then, as typically happens with emergency psychiatric admissions in the age of managed care, he was sent back to Shuman.

For these youngsters and others, "the only reason they are in juvenile justice is because the mental health system can't quite accommodate their needs," said Dr. Oscar Bukstein of the University of Pittsburgh, Shuman's chief psychiatrist.

"We've had them there three, four, five months. Where are they going to go?"

It's a question being asked repeatedly in detention centers across the United States.

"In an ideal world, they'd never get into the juvenile justice system and we'd have mental health services available for them," Doi said.

Unfortunately, because of cutbacks in government mental health programs for young people, and the difficulty of getting private insurance to cover such therapy, there is a huge gap between needs and services, he said.

"We end up basically warehousing these young children."

Experts from around the nation who were interviewed for these stories painted a disturbing picture of children who are barely able to cope with civilian life and are then thrown into locked facilities with hardened, street-wise teens. Not surprisingly, the mixture can be incendiary.

By "getting tough" on these mentally disturbed youths and locking them up, the juvenile corrections system may be a spawning ground for lifelong outcasts, a danger to themselves and those around them, experts say.

During a recent stay at Western Psychiatric Institute and Clinic, Kevin Walker met Becky Langer of Carnegie. This spring, the couple got engaged. (Robin Rombach, Post-Gazette)

Nowhere is that more apparent than on the front lines, where detention center employees each day face the challenge of keeping order with a growing mix of aggressive teens with mental problems.

Frightening stories

Examples of these difficulties showed up across the nation:

Anchorage, Alaska -- Despite being next door to a psychiatric institute, "we have a real difficult time getting children in there," said Barbara Henjum, superintendent at the 200-bed McLaughlin Youth Center in Anchorage. The psychiatric institute "won't take aggressive mental health children."

In January, a teen-age girl at McLaughlin suddenly became incoherent, and began banging her head against a wall. When she suffered a seizure, "we determined we needed to transport her [to the psychiatric hospital] so she could be stabilized," Henjum said.

"They said, 'Call us in the morning.'"

Convinced they could not keep the girl safe, Henjum's staff tried a different tactic. They took her to the local general hospital, where an emergency room physician made a referral to the psychiatric institute. With the referral, she could not legally be turned away.

Their plan worked, she said, but "it still took hours" while they tried to calm the distressed teen.

"There are children who we are just not trained to stabilize, evaluate or treat," Henjum said, "but they say, 'We don't want your children.'"

Idaho Falls, Idaho -- Three-B Detention Center Director Brian Walker had a 16-year-old youth in his facility for nearly a year because mental health centers in the region all said they could not safely care for the 6-foot-1-inch, 300-pound teen, who had committed a burglary.

That's a serious crime, Walker acknowledged, but the boy's only violent acts had been against himself. At Three-B, the young man was hospitalized three times in one week because he kept cutting himself or banging his head against a wall. "He'd rip his toenails out right in front of you."

For eight months, Walker unsuccessfully tried to find some place the young man could get treatment before a hospital finally took him.

"That's our frustration," said Walker. "Whenever we have a kid in crisis, you know they need the services, and you know they are available, but you can't get access to these services." Mental health facilities "can still disqualify anyone they want on the grounds that they can't safely detain them."

Painesville, Ohio -- After the local psychiatric hospital closed its adolescent unit in 1990, the Lake County Juvenile Detention Center noticed that more mental health children were being labeled "delinquent" and sent to detention. "We're seeing children with real psychotic symptomology," said Susan Kish, the center's director. Often, they end up staying in the center for the state-mandated maximum of 90 days.

In January, she said, the Lake County center sent a teen to a nearby psychiatric hospital after he tried to hang himself. His second night in the hospital, he cut himself, causing a wound that required seven stitches. On the third day, the hospital sent him back to detention.

"They said, 'He's a management problem.' "

While stories of mentally ill adults behind bars are widely known, awareness of the same phenomenon among children has only begun to emerge.

"They've committed a crime that has been exacerbated by their mental health problem, then we lock them up with a lot of children who are committing crimes for other reasons," said John VanDenBerg, a nationally-recognized expert on juvenile offenders and mental health who until recently was based in the North Hills. "It's really obvious what's going to happen. The kid's going to get worse, and commit more crimes, and it's going to be very expensive for society to deal with this."

A resident at the Danvill Center for Adolescent Females, the state's only maximum security lockup for teen girls, rests on an outdoor basketball court. The rise in mental health problems among girls is a growing concern. (Robin Rombach, Post-Gazette)

Rejected for treatment

In Pennsylvania, ground zero is Shuman Juvenile Detention Center in Lincoln-Lemington, whose 130 beds make it the state's largest detention center. For much of last year, it was over capacity.

The average stay at Shuman is 11 days, but children with mental health problems have stayed six months or longer because it's so hard to find mental health group facilities or foster homes to take them.

"I haven't seen a child with a mental health issue yet who's gotten any better at Shuman Center," said Allegheny County Common Pleas Judge Kim Berkeley Clark. "Most of the time they start to deteriorate. It's very, very frustrating."

And their numbers are growing. Since UPMC researcher Dr. Elizabeth Cauffman launched a screening program to check all new Shuman residents a year ago, more than 30 percent have shown signs of mental health problems, including some with thoughts of suicide and others who hear voices that aren't there. One girl at Shuman just a few months ago was convinced she'd been raised by wolves.

Judge Craig sees these children in her courtroom each week, and she doesn't always need a psychiatric report to recognize them. From her seat on the bench, she can see the scars and cuts of self-mutilation that cover their forearms.

When these youths stand before her, she knows the best option is long-term mental health treatment, but "it appears to me that the only option available to me is a youth development center," the juvenile equivalent of maximum security prison.

That's because Pennsylvania is among the states that have closed adolescent units at their state mental hospitals. In their place is a network of residential treatment facilities, which house smaller numbers of youths with mental illness.

But the treatment facilities aren't just smaller than state hospital units used to be. They also are privately owned, which means they can refuse applicants they don't want. Children in juvenile detention, not surprisingly, are the ones who wait the longest to get in a residential facility -- if they get in at all.

"They turn down aggressive children. And on the occasion they take one, they let you know they don't want two," said Craig. "I just have a difficult time reconciling business and profit with children's needs. It seems to me if there's a need, we have a responsibility to meet the need and it should not be a business venture."

For their part, operators at the residential facilities say state regulations adopted in recent years limit how much they can physically restrain an out-of-control child. After one hour, the restraints have to come off, regardless of whether the child has calmed down.

The children also can be isolated in their rooms for only one hour at a time, which may not be long enough.

Centers also are not allowed to sedate a child with medication unless a psychiatrist is present -- which means almost never, since most residential facilities don't have psychiatrists on site and staff cannot predict when a child will have a psychotic episode.

During the past decade, "we have moved away from institutionalization but, with the behaviors of the youth and the increase in regulations, we're almost moving the system back to a need for more institutional settings," said Jim Bendel, interim CEO for Adelphoi Village, which operates several residential treatment facilities in Western Pennsylvania.

But VanDenBerg, one of the pioneers of innovative approaches for troubled youths, criticized the private facilities' rejection of aggressive juvenile delinquents.

"People pay taxes and the state spends that money. I think we have to ask what we're buying if the facilities cannot take the very children they're designed to take."

Disturbing numbers

Determining how many of the estimated 32,000 children in detention on any given day have mental problems boils down to definitions.

If you include such recognized psychiatric disorders as misconduct disorder, or oppositional defiant disorder, nearly all youths in the juvenile justice system could qualify.

But even a narrower definition can yield startling results.

A first-of-its-kind mental health screening of all juveniles entering 10 major Pennsylvania detention centers in the past year showed that among the 6,330 cases reviewed, 45 to 50 percent of girls and 35 to 40 percent of boys exhibited serious mental health symptoms such as depression or thoughts of suicide.

Lead investigator Cauffman, who headed the research for the Juvenile Detention Centers Association of Pennsylvania, said she was particularly troubled by the number who said they'd considered suicide -- 33 percent of girls and 20 percent of boys.

Another measure of the extent of mental health problems is the percentage of juveniles who have prescriptions for psychiatric medications when they arrive at detention centers. At Shuman, that's more than 20 percent of the population. The center's monthly prescription bill exceeds $6,000.

While some children do well on the medications, others have serious trouble coping.

On a single day last October, three teens in different units at Shuman tried to kill themselves before 2 p.m.

One tied a shoelace around his neck. Another tried to hang himself with a bedsheet. Another banged her head against a wall and bit her arm, telling staff she wanted to die.

On a Friday last year in the spring, four teens attempted suicide at Shuman. One young man tried to flush his head down a toilet; a girl tried to choke herself with a crew sock; another young woman who had made several earlier suicide attempts started banging her head violently against a wall; and another girl started screaming that she wanted to kill herself.

"You have no idea how quickly they can do these things," said Terri DeFazio, who coordinates health services at Shuman and is often the one children seek in a crisis.

Suicidal thoughts

Once last year, a girl asked to see DeFazio after she'd cut her wrists and legs with a pencil eraser tip. When DeFazio got to her room, the girl was facing the wall, crying. As DeFazio went to comfort her, the girl tried to hide her face in her hands. When DeFazio pulled her hands away, she saw the girl had tied a wet crew sock around her neck, cutting off her air. Minutes later, it might have been too late.

In its history, Shuman Center has had only one completed suicide, in 1988, but that's only because the staff is ever alert to the possibility.

With the increasing number of unstable children, Shuman and the Western Psychiatric Institute and Clinic set up a quick-response team last year to handle suicide threats and other crises. That has helped, but it is still not uncommon for employees to respond to two to three suicide attempts in a week, putting enormous pressure on an overworked, overstressed staff.

Nor is Shuman alone.

Georgia's Department of Juvenile Justice, for example, recently reviewed 184 admissions to its Wrightsville Youth Development Campus between Oct. 31 and Jan. 30. Officials found that 25 percent had a previous mental health hospitalization, and 35 percent had been prescribed antidepressants. About one in five had a history of suicide attempts or threats.

At one point, a small detention center near Harrisburg had put 10 of their 11 residents on suicide watch for two weeks, requiring the center to find extra staff so each of the teens could have one-on-one coverage.

"Detention is not meant to provide children with treatment and therapy," said John Corr, supervisor of resident services at the Bucks County Detention Center in Doylestown in Eastern Pennsylvania. "It is only meant to hold them until an appropriate placement is found."

And the longer such troubled teens stay in juvenile lockups, the more likely they are to run afoul of the law when they re-enter the outside world.

"What we're doing," said Bucks County Administrator Don MacGregor, "is taking our mental health children and turning them into mental health criminals."

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

TOMORROW: On A Treadmill Of Tragedy

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