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US faces crisis in mental health care for juvenile offenders
World Report
US faces crisis in mental health care for juvenile offenders Budget shortfalls in many states have led to extreme cutbacks in services, resulting in a crisis for facilities that treat juvenile offenders with mental health problems. Norra MacReady investigates.
www.thelancet.com Vol 374 August 22, 2009
of people treated for some type of mental disorder grew from 19 million to 36 million, and treatment costs rose from US$35 billion to nearly $58 billion. This convergence of rising costs and falling funds is producing a crisis in the management of juvenile offenders who have mental health
“Correctional facilities are not the ideal places to provide the kind of services that these people need.” problems. In some jurisdictions, inadequately trained staff may keep young inmates on three or four psychotropic medications at once to control their behaviour or for unapproved uses such as insomnia. “Generally speaking, people with severe mental illness would do better in a mental health treatment setting”, says psychiatrist William Arroyo, medical director of Child, Youth, and Family Administration of the Los Angeles County Department of Mental Health. “Correctional facilities are not the ideal places to provide the kind of services that these people need.” When asked if the current problems are, at least in part, the result of California’s budget woes, he replies, “absolutely”. Actually, says Arroyo, funding for prison health care in California, including mental health care for juvenile offenders, is protected somewhat thanks to a receivership established in 2005 requiring the state to divert funds to bring the system up to a minimum standard. In other parts of the country, similar lawsuits have been settled on the condition that those jurisdictions also protect the health-care funding in their correctional facilities. The dire state of mental health care for young detainees in the Los Angeles County system was exposed last year
in an investigation of several youth camps by the Department of Justice. In a letter detailing their findings to the Los Angeles Board of Supervisors, the investigators described several instances of beatings, verbal and physical abuse, and excessive use of pepper spray by the staff on inmates, and also no attempt to discourage fights and violence among inmates themselves. Robert Taylor, chief probation officer for the county, pointed out that many of the observations were exaggerated or unsubstantiated, and that many of the problems that did exist have been corrected. In a follow-up investigation done recently, he noted, the Justice officials were “pretty pleased with what they saw”. Juvenile correction systems in Indiana, Maryland, Texas, and Ohio have also been the targets of federal investigations. Still, Taylor says, resources are tight, so the juveniles most in need of mental health services are sent to specially staffed facilities where they can receive appropriate care. Unfortunately, “we have more mentally ill kids in the system than we really have services to match those needs”.
Norra MacReady
For The New York Times article see http://www.nytimes. com/2009/08/10/us/10juvenile. html?_r=1&scp=5&sq=juvenile%2 0offenders&st=cse For the 2008 meta-analysis see J Am Acad Child Adolesc Psychiatry 2008; 47: 1010–19. DOI:10.1097/ CHI.0b013e31817eecf3
The printed journal includes an image merely for illustration AP/Matt Houston
The young man known as ASB had been severely abused since he was a toddler until he was adopted at age 4 years. But his adoptive parents ultimately severed their relationship with him after he complied with a hallucinatory command to cut a cat’s throat with a chainsaw. Remanded to the Mental Health Unit (MHU) of the Ohio River Valley Juvenile Correctional Facility in Franklin Furnace, OH, USA, ASB was diagnosed with bipolar disorder and attention deficit hyperactivity disorder. He had an IQ of 70, suggestive of mild mental retardation. During his confinement he exposed himself to others and left his faeces in a desk drawer. The staff at the MHU did not have the training to work with someone with his cognitive and intellectual limitations, and his chart contains no mention of any therapeutic interventions. There are roughly 60 000 young offenders in the American juvenile prison system, like ASB, who have at least one mental illness, according to a report in The New York Times on Aug 10. Overall, stated the authors of a 2008 meta-analysis published in the Journal of the American Academy of Child and Adolescent Psychiatry, adolescents in detention and correctional facilities are about ten times more likely to have psychosis than the general adolescent population. The system, which traditionally has been the option of last resort for hard-core cases like ASB, is now taxed to the limit as states cut their social services budgets to the bone to grapple with revenue shortfalls produced by the financial crisis. At the same time, an analysis by the Agency for Healthcare Research and Quality showed that mental illnesses were the costliest disorders to treat in the USA between 1996 and 2006. Over that decade, the number
601
US faces crisis in mental health care for juvenile offenders Budget shortfalls in many states have led to extreme cutbacks in services, resulting in a crisis for facilities that treat juvenile offenders with mental health problems. Norra MacReady investigates.
www.thelancet.com Vol 374 August 22, 2009
of people treated for some type of mental disorder grew from 19 million to 36 million, and treatment costs rose from US$35 billion to nearly $58 billion. This convergence of rising costs and falling funds is producing a crisis in the management of juvenile offenders who have mental health
“Correctional facilities are not the ideal places to provide the kind of services that these people need.” problems. In some jurisdictions, inadequately trained staff may keep young inmates on three or four psychotropic medications at once to control their behaviour or for unapproved uses such as insomnia. “Generally speaking, people with severe mental illness would do better in a mental health treatment setting”, says psychiatrist William Arroyo, medical director of Child, Youth, and Family Administration of the Los Angeles County Department of Mental Health. “Correctional facilities are not the ideal places to provide the kind of services that these people need.” When asked if the current problems are, at least in part, the result of California’s budget woes, he replies, “absolutely”. Actually, says Arroyo, funding for prison health care in California, including mental health care for juvenile offenders, is protected somewhat thanks to a receivership established in 2005 requiring the state to divert funds to bring the system up to a minimum standard. In other parts of the country, similar lawsuits have been settled on the condition that those jurisdictions also protect the health-care funding in their correctional facilities. The dire state of mental health care for young detainees in the Los Angeles County system was exposed last year
in an investigation of several youth camps by the Department of Justice. In a letter detailing their findings to the Los Angeles Board of Supervisors, the investigators described several instances of beatings, verbal and physical abuse, and excessive use of pepper spray by the staff on inmates, and also no attempt to discourage fights and violence among inmates themselves. Robert Taylor, chief probation officer for the county, pointed out that many of the observations were exaggerated or unsubstantiated, and that many of the problems that did exist have been corrected. In a follow-up investigation done recently, he noted, the Justice officials were “pretty pleased with what they saw”. Juvenile correction systems in Indiana, Maryland, Texas, and Ohio have also been the targets of federal investigations. Still, Taylor says, resources are tight, so the juveniles most in need of mental health services are sent to specially staffed facilities where they can receive appropriate care. Unfortunately, “we have more mentally ill kids in the system than we really have services to match those needs”.
Norra MacReady
For The New York Times article see http://www.nytimes. com/2009/08/10/us/10juvenile. html?_r=1&scp=5&sq=juvenile%2 0offenders&st=cse For the 2008 meta-analysis see J Am Acad Child Adolesc Psychiatry 2008; 47: 1010–19. DOI:10.1097/ CHI.0b013e31817eecf3
The printed journal includes an image merely for illustration AP/Matt Houston
The young man known as ASB had been severely abused since he was a toddler until he was adopted at age 4 years. But his adoptive parents ultimately severed their relationship with him after he complied with a hallucinatory command to cut a cat’s throat with a chainsaw. Remanded to the Mental Health Unit (MHU) of the Ohio River Valley Juvenile Correctional Facility in Franklin Furnace, OH, USA, ASB was diagnosed with bipolar disorder and attention deficit hyperactivity disorder. He had an IQ of 70, suggestive of mild mental retardation. During his confinement he exposed himself to others and left his faeces in a desk drawer. The staff at the MHU did not have the training to work with someone with his cognitive and intellectual limitations, and his chart contains no mention of any therapeutic interventions. There are roughly 60 000 young offenders in the American juvenile prison system, like ASB, who have at least one mental illness, according to a report in The New York Times on Aug 10. Overall, stated the authors of a 2008 meta-analysis published in the Journal of the American Academy of Child and Adolescent Psychiatry, adolescents in detention and correctional facilities are about ten times more likely to have psychosis than the general adolescent population. The system, which traditionally has been the option of last resort for hard-core cases like ASB, is now taxed to the limit as states cut their social services budgets to the bone to grapple with revenue shortfalls produced by the financial crisis. At the same time, an analysis by the Agency for Healthcare Research and Quality showed that mental illnesses were the costliest disorders to treat in the USA between 1996 and 2006. Over that decade, the number
601