Where the Sick Get Sicker: As the juvenile correctional centers empty, the mentally ill remain
Christopher, a slight 15-year-old boy with a long history of psychiatric illness, spent three months in a state juvenile correctional facility in upstate New York for pestering a girl and stealing a cell-phone. His mental health, always precarious, deteriorated further while he was incarcerated at the Highland Residential Center near Poughkeepsie, one of 22 state juvenile justice facilities that house nearly 1,000 boys and girls between the ages of 12 and 18. He punched walls with his fists and tried to strangle himself with his pajamas, his mother says. On one occasion, a staff member attempting to break up a fight slammed Christopher's head against a desk so hard that his face bled profusely. "I was in a pool of blood," he says. "It seemed like hell." More than half of the children admitted to the juvenile correctional centers run by the state Office of Children and Family Services (OCFS) suffer from mental illness, according to the agency's own statistics. Independent experts put the number even higher. Some 72 percent of males and 87 percent of females in secure facilities nationwide have at least one mental health disorder, according to The Office of Juvenile Justice and Delinquency Prevention, part of the U.S. Department of Justice. Children with serious mental illness may wind up in juvenile lock-ups, even if the charges against them are relatively minor, because there are so few alternatives for children who need psychiatric care, advocates say.
"They end up there because there are so few other other options," says Leslie Abbey, executive director of the Juvenile Justice Initiative, an alternative-to-incarceration program managed by the New York City Administration for Children's Services.
Psychiatric care for incarcerated youth in New York State is so deficient that the Civil Rights Division of the Department of Justice has threatened a lawsuit seeking a federal takeover of four juvenile facilities unless the state takes prompt action both to improve the quality of services and to transfer to more appropriate settings any children who need more intensive care than the facilities can provide. The Justice Department gave Governor David Paterson until October to respond to its finding that conditions in four prisons violated children's constitutional rights to protection from harm. Paterson's initial reply has not been made public, but it's clear the state is under enormous pressure to find a solution to the intractable problem of caring for children like Christopher.
The state's juvenile lock-ups house children convicted of serious crimes (in secure facilities) as well as those accused of less serious misbehavior (in limited-secure or non-secure facilities). Juvenile offenders, who make up about 20 percent of the population, are 14- and 15-year-olds accused of serious crimes such as murder, robbery and arson, as well as 13-year-olds accused of murder. They are tried and sentenced in adult courts. Juvenile delinquents, who make up 80 percent of the population, are children under the age of 16 who are charged with misbehavior ranging from graffiti and shoplifting to assault and third degree robbery, that is, taking property by force but without a weapon.
Juvenile delinquents are adjudicated by the city's Family Courts. Family Court judges may place juvenile delinquents in juvenile lock-ups run by OCFS or in residential centers run by nonprofit agencies such as Children's Village, Lincoln Hall and Graham Windham. Or, they may order them to take part in one of several alternative programs that often allow young people to remain living at home, in their own community.
Over the past decade, the city and state have cut in half the number of children under 16 years of age who are sent to juvenile correctional facilities, relying instead on a range of these "alternative-to-placement" programs that offer close supervision and guidance to juvenile delinquents. But these programs are generally only open to young people who have a parent or other responsible adult who is able to take an active role in their therapy and treatment. Christopher's mother, who acknowledges she once had a drug problem and has been hospitalized for psychiatric problems herself, visits him from time to time but is not a reliable source of support.
Inpatient psychiatric care is scarce: although Christopher was approved for admission to a community-based psychiatric facility soon after he was arrested, he had to wait months for a bed to become available. So Christopher wound up in a correctional center, even though children accused of similar misbehavior are often released or offered alternatives to placement.
"The biggest difference between the adult [criminal courts] and the children's [Family Court] system is that in the adult system, your sentence is contingent on the severity of your crime," says Tamara Steckler, attorney-in-charge of the juvenile rights practice of the Legal Aid Society. "In the juvenile system, it's contingent on the social supports you have."
Christopher says he had trouble following the rules at the Highland Residential Center, and was punished frequently for breaking them. "I didn't know how to make my bed the Highland way," Christopher recalled as he sat on his bed at the August Aichhorn Center for Residential Care, a psychiatric facility in Harlem where he was transferred in July. "They'd yell at me if my bed was wrinkled and now I'm late for breakfast, so I get another punishment, and then I'm late for school and I get in trouble again."
In the prison school, he says, another child hit him, and when he started to hit him back a staffer grabbed both boys and slammed them down on the floor to restrain them. As they fell, Christopher banged his head on the desk, causing a cut so deep he had to go to the emergency room at a nearby hospital for stitches. On another occasion, he says, he got into an argument over which channel to watch on television; again, a staffer restrained him by forcing him to the floor and bending his arm behind his back. When Christopher tried to squirm, his face rubbed against the carpet. "I got a rug burn on my face," he says.
Christopher has had mood swings and aggressive outbursts since he was a toddler, according to his mother, who lives in East Harlem. He was first sent to a residential facility in Westchester County for children with emotional problems when he was 9 years old. When he was 14, he was released from residential care and placed with a foster family in the Bronx. But he couldn't adjust to life outside an institution. "He was innocent. He didn't know how to cross the street," says his mother, adding that he was injured slightly when he was hit by a car. He also got into trouble with the law. He was arrested twice in the first three weeks after he moved in with the foster family, once for "harassment" of a girl, following her around, and a second time for stealing a cell phone, according to the Legal Aid Society, which represented him.
Christopher was approved for placement in a state in-patient psychiatric facility, called a Residential Treatment Facility (RTF), but, because there were no available beds, he was placed on a waiting list. In the meantime, he was sent to the mental health unit of a juvenile correctional center in mid-April, despite protests from his attorney, says Nancy Rosenbloom, director of the juvenile rights practice of the Legal Aid Society.
In mid-July, a space opened up at Aichhorn, an RTF on Manhattan's Upper West Side that houses 32 young people, and the only such facility in New York City. Christopher was finally transferred. Dr. Michael Pawel, executive director of Aichhorn, says Christopher still lashes out at people when he feels he's being picked on. But with three highly-trained staff members on duty for every eight residents, Aichhorn is equipped to calm Christopher and control his outbursts. "It takes a lot of time and it takes a lot of staff," says Pawel. OCFS, the state agency that runs the children's prisons, has long struggled to care for mentally ill residents sent to them by the courts. "We're basically a mental health system without mental health services," says an OCFS employee who asked not to be identified. "This is a system that re-traumatizes the children. The longer they stay with us, the more mental health problems they have."
The federal investigation, made public in August, found widespread abuse of children by staff in four of the state's juvenile facilities: Lansing Residential Center, Louis Gossett Jr. Residential Center (both near Ithaca), Tryon Residential Center and Tryon Girls Center (both northwest of Schenectady). The investigation found that staff members regularly used excessive force to restrain children, resulting in broken teeth, broken bones and concussions. In addition, the Justice Department found the facilities failed to provide adequate mental health care and treatment for seriously disturbed residents. For example, the staff was "at a loss" for how to address the problems of a girl who urinated and defecated on the floor of her room, refused medication, and stayed in her pajamas all day. She was isolated in a "cottage" without other girls for three months. A boy who had an upsetting phone call from his family hurt himself repeatedly by rubbing a scratch on his finger raw. The staff didn't know how to stop him, so they handcuffed him and took him to an emergency room.
Psychiatric evaluations were incomplete, and staff apparently failed to review children's previous medical records, the report found. Children were given powerful psychotropic medications without proper monitoring to see if they were effective or if they were causing side effects. One boy was taking six psychotropic medications, but federal investigators could find no rationale for the prescriptions. Even after he banged his head against the wall, there was no change in the prescriptions, the investigation found.
Unions representing the workers at the state prisons acknowledge that abuses by staff occur, but say they are the result of understaffing and poor training. Supervising aggressive, often violent youth is a stressful job. Staffers are frequently assaulted by young people in their care, the unions say. Staffers may overreact to children's outbursts because of their own trauma experienced on the job, says Jonathan Rosen, director of health and safety for the Public Employees Federation, the union that represents social workers, counselors, teachers and other professional staff at the OCFS facilities.
"Both the youth and the staff have been traumatized," says Rosen. "People who have been traumatized have an increased reaction to normal stimulus. It's a fight or flight response. So you have an increased startle effect among the staff combined with an increased startle effect of the youth. Wow! It's not geared toward de-escalating the situation."
The situation is exacerbated by what the unions describe as chronic understaffing. They say many staff members are forced to work 16-hour shifts. Vacancies are not filled because of a hiring freeze, the unions say, and turnover is high.
"People don't want to work there, and even when you do get people they don't stay," says Mark Davis, a youth aide (whose function is similar to a prison guard in an adult prison) at Brookwood Residential Center, a secure facility for boys near Albany. Davis, CSEA chair of the labor management committee for OCFS, says he is required to work 16-hour days at least three days a week. Although he says he loves the kids and the pay is good, with overtime, some aides make $80,000 to $90,000 a year, the hours are grueling. Up at 4:15 a.m., he leaves his home at 5:30 a.m. to arrive at work at 6:30 a.m.
When he works two shifts, he leaves at 10:30 p.m. and is home by midnight. "You don't really sleep, you keep looking at the clock knowing you have to get up in four hours."
Davis, who has worked in OCFS facilities for two decades, says he has seen a change in the kind of kids who have been incarcerated. "When I started, you were dealing with street thugs," he says. "It used to be 10 or 20 percent of the population had mental illness. Now it's 80 to 90 percent. You're dealing with kids who just don't understand directions. And the vast majority of people there just don't know how to deal with kids with mental health issues. You have a combustible mix of tired workers and mentally unstable kids."
Gladys Carrion, state commissioner of children and family services, has struggled to improve conditions in the juvenile correctional system in a time of severe budget restraints. Formerly a lawyer for Bronx Legal Services and executive director of a foster care agency for pregnant and parenting teens, Carrion was named commissioner of OCFS soon after Eliot Spitzer became governor in January 2007. She moved quickly to hire an experienced administrator as her deputy commissioner: Joyce Burrell, former president of the Council of Juvenile Correctional Administrators who had run juvenile justice systems in Washington, D.C. and Philadelphia. Carrion also hired Lois Shapiro, a psychologist from the state Office of Mental Health, to serve as the agency's director of behavioral health services, and nearly tripled the number of social workers and clinical psychologists on staff, increasing the number of mental health professionals from about 20 to nearly 60.
Carrion has also moved aggressively to close empty or nearly empty facilities and to reduce the size of those that remain, reflecting the fact that the number of children admitted to OCFS facilities declined from 1,938 in 2001 to 813 in 2008. She has also sought to transform the culture of the juvenile prisons from a correctional model of "custody and control" to one based on a therapeutic model that assumes juvenile delinquents and juvenile offenders need treatment rather than punishment.
Despite these moves, care for the mentally ill remains woefully inadequate, advocates say. For example, OCFS acknowledges there is not a single psychiatrist or psychiatric nurse on the staff of OCFS. Psychologists may offer psychotherapy, but only psychiatrists may prescribe and adjust the powerful psychotropic medications that some severely mentally ill children need.
OCFS has a contract with the state Office of Mental Health to provide "mobile mental health teams" of psychiatrists and other clinicians who prescribe medication and offer individual therapy to the severely ill children who are assigned to seven small, specialized, 10-bed "mental health units" within the OCFS facilities. However, these psychiatrists and clinicians are on the staff of nearby hospitals and are typically available to OCFS only four or five hours a week, OCFS sources say.
Psychiatric care is even more limited for the hundreds of children with mental health diagnoses who are not assigned to these seven mental health units. For example, a 2006 report by the state inspector general found that a consulting psychiatrist at the Gossett facility allocated just 90 minutes per week to manage 34 residents taking psychiatric medications.
All children entering OCFS facilities are evaluated for mental illness (as well as medical issues) at "reception centers" such as Pyramid in the Bronx, where Christopher spent two weeks. Once the evaluation is completed and a treatment plan is drawn up, a child is transferred to one of the state's juvenile justice facilities, most of which are in rural areas upstate. However, staff at the facilities often fail to follow treatment plans, sometimes because records are lost, says Rosenbloom of the Legal Aid Society.
There is also poor coordination between the professionals charged with treating children and the front-line workers who are with the children throughout the day. "There has been a huge issue with turnover of mental health staff at Lansing because they feel so unwanted by the line staff," says Mishi Faruqee, director of the Youth Justice Program at Children's Defense Fund-New York.
Children who are not assigned to mental health units receive little in the way of therapy, Rosenbloom says. Rather than individual psychotherapy by trained psychologists, children tend to receive group counseling offered by youth development aides (who typically have a high school diploma) or youth counselors (who have a bachelor's degree), she explains. These counselors have no specialized mental health training.
Carrion declined to be interviewed for this article, citing the sensitivity of negotiations with the Justice Department. However, other state officials acknowledge that OCFS has difficulty recruiting professional staff, particularly in facilities in rural areas. There is a national shortage of child psychiatrists and psychiatric nurses; finding professionals willing to work in remote areas of the state is particularly difficult, they say.
Carrion has sought to transform the culture of OCFS by adopting a therapeutic design called "The Sanctuary Model,"which is used by some psychiatric facilities and congregate care foster care agencies. She contracted with the Andrus Children's Center in Yonkers, New York, to train staff members and the young people in their care. The Sanctuary methods, which recognize that trauma is often at the root of a child's bad behavior, work to de-escalate conflicts, says Dr. Joseph Benemati of Andrus.
Some of the juvenile correctional centers have embraced the new training: The Annsville Residential Center in Taberg, New York, received a prize from the Juvenile Justice Trainers Association in October 2008 for its success in training staff. Benemati, who says the training may take up to three years, says staff morale has improved and violence has decreased at Annsville.
But at other facilities, including the troubled Tryon center cited by the Department of Justice investigation, training has been less successful. In some cases, advocates say, the staff are simply resistant to change. In other cases, the staffers say they are open to change but don't have the resources to carry out the reforms effectively. For example, if a child becomes agitated when asked to leave his room and go to school, "the Sanctuary model says leave the kid behind with one or two staffers to see him through the crisis," says Davis, the youth aide at Brookwood. But, he says, there aren't enough adults on duty to stay behind with one child and still supervise the rest of the group. "If you took any facility and staffed it appropriately, Sanctuary would work," he says.
On the night shift in so called "limited secure" facilities, a youth development aide may be alone supervising nine to 12 residents; two aides might supervise 18 to 20 residents, according to Mary Rubilotta, deputy director for contract administration for the CSEA, the union representing the youth aides. (As a comparison, an in-patient psychiatric facility like Aichhorn has three staffers for eight residents.)
Advocates for juvenile justice reform say better training and smaller facilities will help ameliorate some of the dangerous conditions. Faruqee, of the Children's Defense Fund, says there have already been improvements. For example, while some facilities report a large number of "restraints" each month, others report almost none.
Annie Salsich, director of the Center for Youth Justice at the Vera Institute of Justice, is optimistic that a governor's task force appointed in September 2008 will make useful recommendations in its report, scheduled for release by the end of 2009. She and others point to the improvement in the conditions of confinement in the Missouri juvenile justice system, which is held up as a national model for reform. In Missouri, juveniles are housed in small, cottage-like dormitories, rather than large facilities. The Task Force on Transforming New York's Juvenile Justice System will report on both the conditions in the prison and on alternatives to placement.
Sylvia Rowlands, a clinical psychologist who worked for many years at the Youth Leadership Academy, a juvenile lock-up for girls in South Kortright, New York, north of the Catskills, cautions that reformers face an uphill battle, in part because the skills kids need to get along in prison run counter to the skills they need to get along in a community.
"The problem is what folks are being asked to do is impossible," says Rowlands, who is now director of Blue Sky, an alternative-to-placement program in New York City. "In prison, you throw a bunch of kids who have anti-social behavior together. To create a positive peer culture [in that setting] is an impossible job.
"Most of the folks on the ground are not trained psychologists, they are not trained social workers. The folks who do the day-to-day care do not have advanced degrees, they have high schools diplomas."
Much of the counseling revolves around group therapy to get kids to better conform to the institution's rules, rather than individual therapy designed to help them overcome trauma, and the skills they develop don't translate into more sociable behavior when they leave, she says.
"It's hard to do work on how to live better in the community when the community is three hundred miles away," she says.
Rowlands left her OCFS career in 2003 to work with New York Foundling on creating Blue Sky, one of the few alternative-to-placement programs in the city that treats children with mental illness. The Blue Sky model is designed to work with children as well as their families, and it is unusual in that it also works with parents and caregivers who have mental illness themselves. Together with the city's Administration for Children's Services, Rowlands has applied for a $1.3 million grant from the Robin Hood Foundation to expand the program, which now serves 130 children in the Bronx and Manhattan. Their goal is to serve children in all five boroughs. About 60 children in Brooklyn and Queens are rejected from alternative-to-placement programs each year solely because of mental illness, so a larger Blue Sky program could have an immediate impact on their lives and reduce the number of children with mental illness living in the upstate OCFS centers.
"The answer is keeping kids connected to their families," Rowlands says. "Do everything up front before you place them."