Decentralization impacts youths needing mental health services _lowres

Photo provided by Sarah Carr/The Hechinger Report -- Elizabeth Marcell, executive director of intervention services at ReNEW Schools, works with a student in the charter network's therapeutic program.

One New Orleans 15-year-old with explosive disorder felt abandoned after the only therapist she trusted left town.

A 14-year-old diagnosed with bipolar disorder and schizophrenia, who became suicidal and threatened others, had to travel 300 miles to get admitted to a hospital.

A 6-year-old with attention-deficit hyperactivity disorder was told he couldn’t come back to his public school until his mother found mental-health care services for him.

In recent years, New Orleans has become a case study in how children and families are affected by rapid decentralization of public education and mental-health systems.

In theory, the city’s families should have more options than ever when it comes to schools and mental-health providers. But decentralization has wrought some unintended consequences, particularly for children with the most severe needs — needs that aren’t always met by private operators.

The problem is particularly urgent in New Orleans, where more schoolchildren suffer from mental-health issues than in other parts of the country.

A 2010 report by the Children’s Health Fund and Columbia University’s Mailman School of Public Health found that children displaced by Hurricane Katrina were 41/2 times more likely to have symptoms of a serious emotional disturbance than a group of demographically comparable children in a national survey.

Moreover, surveys of public schoolchildren in the city have found that between 40 percent and 60 percent qualify for trauma counseling, said Doug Walker, the clinical director at Mercy Family Center, which provides extensive mental-health services for New Orleans children.

In New Orleans, decentralization of public services has affected children with mental-health needs in several ways.

First, Gov. Bobby Jindal has privatized or closed several hospitals, leading to an acute shortage of beds for children who require overnight stays for mental-health crises. But at the same time, the state has widened the pool of low-income children who are eligible for community-based mental-health care, as well as the number of private operators eligible to serve them. The result is a landscape where quality varies tremendously and turnover for operators and staff can be high.

Meanwhile, the independently operated charter schools that have opened since Katrina have no central office to rely on for social and counseling services. Because they are judged almost solely on test scores, some schools have neglected mental health and counseling.

“Decentralization does allow for more innovation,” said Paulette Carter, president of the Children’s Bureau of New Orleans, which works to make mental-health services accessible to families and schools. “Now it’s just a matter of how to get that done.”

No vacancy

The gaps in service are worst for children with severe needs who routinely require hospital care.

Janice Willis has had to bring her nephew, a 14-year-old diagnosed with bipolar disorder and schizophrenia, to the hospital more times than she can recall. He acts out in ways dangerous to himself and others, including “tearing things up,” threatening people and walking out of school.

But they “don’t keep him long enough to evaluate him,? Willis said. Doctors might give her nephew a shot to calm him down and then release him after a day of observation.

“If he’s just there for one day, he will come back exactly the way he was,” she said.

Doctors have sent the teenager to out-of-town hospitals — in Monroe and Shreveport — twice because of a shortage of beds for youths in the New Orleans region. The out-of-town hospitals, at least, kept her nephew for several days, Willis said.

There are actually more hospital beds in the New Orleans area for children and teens experiencing mental-health crises than there were before Katrina. Before the storm, there were 76 beds. That dropped to 55 by 2009 but rose to 83 in 2013.

However, the number where children can stay longer than one to three days has dropped precipitously. Local hospitals that admit children and adolescents experiencing mental-health crises try to stabilize them with medications — to stop psychotic episodes, for instance — and then usually release them.

“There are no (public) residential or therapeutic group homes left in the city,” Carter said.

The New Orleans Adolescent Hospital had some long-term beds available before it closed in 2009; Hope Haven, a social-service organization run by Catholic Charities, shut down its residential psychiatric facility for children in 2008.

Partly as a result of these closures, New Orleans youths often are sent to Shreveport, Monroe or Alexandria for hospitalization. This can be particularly traumatic for low-income families that can’t afford to travel.

In one case, a suicidal first-grader wound up in Shreveport because there were no beds in New Orleans, according to a social worker. The child was transported by ambulance, but the mother didn’t have a car and couldn’t visit her son.

Joe Smith, the chef at Cafe Reconcile, which trains youths for the restaurant industry, said his daughter was sent to a hospital in Alexandria two years ago because there was no room in local hospitals.

His daughter suffered from post-traumatic stress disorder that led her, at different times, to act out and retreat from her peers in panic. Some days, she snuck a knife into school out of fear. Other days, she tapped her feet incessantly in class.

Although the distance made visits difficult, the Alexandria hospital held Smith’s daughter, a preteen at the time, for several days. That gave doctors time to diagnose her with explosive disorder, which made it easier to find appropriate mental-health services once she returned to New Orleans, Smith said.

He believes the scarcity and complexity of mental-health services for adolescents contribute directly to New Orleans’ high rate of gun violence.

“If a kid slips through the cracks, once that kid gets out on the street … there are people there who know how to use his mental illness for their own purposes,” he said. “ ‘He got an anger issue? We can use him as an enforcer. He wild and crazy? That means people will be scared of him.’ ”

“When one of them hurts or kills somebody, it’s too late.”

Navigating a maze

There are plenty of mental-health providers in New Orleans for children who aren’t in crisis, but they can be difficult to find and assess. For instance, two years ago, the state stopped providing some mental-health services directly — eliminating a state-funded program for children up to 5 years old. Instead, virtually any private provider can now get reimbursed through Medicaid for child and adolescent therapy.

That has opened up new treatment opportunities — particularly for children with less severe issues. They often were shut out entirely under the old model in which grants and state government provided most of the funding.

“Access to services has increased,” said Doug Walker, of Mercy Family Center, noting that most children on Medicaid qualify for up to 24 therapy sessions.

But there are still complications — including some new ones.

Not all psychiatrists and psychologists will take Medicaid clients; others cap how many they’ll treat. Carter said she recently tried to locate a psychiatrist for a child and couldn’t find a single opening in the city for young Medicaid clients.

The state “wants us to run everything on Medicaid dollars alone,” she said. At the same time, it’s become harder for psychologists to get reimbursed for certain services, particularly diagnostics and testing.

“They’ve whittled us down to where we are not able to do testing,” Walker said. “We’re sending kids to psychiatrists without fully knowing what the deal is.”

In a recent case, Walker and his colleagues wanted to perform IQ and other tests to see if a child was mentally retarded, but they couldn’t get authorization. They were told testing should be handled by the school. Many schools, in turn, defer to community-based mental-health professionals for diagnoses.

Meanwhile, the fee-based model has long led some community-based operators to sacrifice quality for quantity.

“If they don’t see the kids, they don’t get paid. It can lead to overbooking because you know some clients are not going to show.” Overbooking, and the routine stress of the job, lead to high attrition.

Variations in quality

Some mental-health providers are “great” while others are “hiring anybody,” said Shayne Latter, the director of student services at Communities in Schools, which provides social work and other family support services to the schools. “It’s almost like anybody can open up” a mental-health provider.

Overwhelmed families often struggle to distinguish between the great and the shoddy providers, turning to school counselors or anyone else they can find for advice.

“If they don’t get a referral from someone they trust, they are kind of lost,” said Penny Conner, a social worker at Lafayette Academy Charter School.

The Metropolitan Human Services District, a government agency that coordinates services related to mental health, has tried to assist with referrals and to fill any voids in care, said Michael Smith, the director of child and youth services.

“We are trying to act as a single point of entry” into the system, said Smith. Any family can call his agency and get help finding treatment, he said. “The key is getting the child to the right level of care.”

While his agency has simplified the process for many families, Smith said the next step is to determine which private providers offer the best care. “We don’t have a barometer on how effective we’ve been with all the services that are out there,” he said.

Even with help, stressed-out families can find it hard to find the right treatment.

Willis said her nephew sees a psychiatrist just once a month. She’d like to put him in group therapy so the teenager could talk to other kids facing similar challenges. She’s not sure whether those programs exist, or how to find them.

Smith’s daughter sees a psychiatrist once a month, primarily to get prescriptions for her medication. The 15-year-old had been seeing a therapist more often, but the woman moved away.

“That can be devastating when you put your trust in that person and they up and leave,” Smith said. “Now she feels abandoned. … She needs to be seeing a therapist on a more regular basis.”

Tragically, many youths don’t get comprehensive mental-health services until they enter the foster care or juvenile justice systems, Smith said. His daughter recently wound up in Juvenile Court for trying to crash the computer system at her school. The silver lining is that she now seems to be eligible for more help.

“Free mental-health services are few and far between if you aren’t in the court system,” Smith said.

Bouncing around

In the schools, too, families often encounter uneven quality in mental-health services — and an uneven willingness to work with challenging students.

Prior to Katrina, “we can argue whether (the Orleans Parish School Board) did a good job, but at least it had a central office responsible for the mental health of children,” Carter said. Now “some charters put a lot of resources into emotional health. Some don’t put any resources into that area.”

In 2007, administrators told Willis that her nephew could not return to Murray Henderson Elementary School on the West Bank until she got him diagnosed and treated for his strange behaviors. The child, 7 at the time, would bark like a dog, crawl on the floor and curse at his principal.

Willis agreed to withdraw her nephew. After he was forced out of a second school, she found a spot for him at SciTech Academy. Initially, the school suspended the child frequently, but over time he connected with one of his teachers in a therapeutic program that the school’s charter operator, ReNEW Schools, started for children with severe emotional disorders.

In recent years, the Recovery School District, which operates most of the city’s public schools, has tightened up admissions and expulsions processes across its schools, partly in an effort to make it harder for schools to force challenging students to withdraw. But some schools still stumble.

In October, administrators at Encore Academy asked Anisha Gallin to keep her 6-year-old son, diagnosed with attention-deficit hyperactivity disorder, at home, the mother said. The child had been suspended several times for dramatic mood swings, getting physical with staff and classmates, and running around uncontrollably.

In a letter, the school counselor said the student would be “restricted from coming to school until a proper evaluation can be done and documentation can be given to the school with detail about outside mental-health services being provided for him.”

After a month, Gallin found a psychiatrist for her son, and he returned to school. But staff continued to suspend him for unruly behavior, and Gallin has since pulled the child out of school.

“I feel they just don’t want to deal with him,” she said.

Terri Smith, the school’s principal and CEO, said she could not discuss the case in detail. But she said that asking a child with a possible mental-health disorder to stay away from school is not standard practice at Encore. “We pride ourselves in putting a lot of time and energy with families who are having a difficult time,” she said.

No bans for disabilities

It’s a violation of federal special-education laws for schools to ban children due to their disabilities. If a child is suspected of having a disability, including an emotional or behavioral disorder such as ADHD, the school must evaluate the child and put him on an individual education plan. Smith said she believes the school had a plan in place for Gallin’s son.

Some charters, like ReNEW, use their autonomy to devote extra resources to mental health. At other charters, the focus on academics has led them to pressure even Communities in Schools workers to stray from their mission of providing social support such as counseling and coordinating homeless services.

Sara Massey, president of the organization, said they sometimes have to remind schools that “we don’t do lunchroom duty, we don’t do testing, we don’t do homework duty.”

Meanwhile, efforts to create special programs like ReNEW’s — or even entire schools for children with severe mental or behavioral health needs — have been divisive.

“It gives people excuses not to accept kids,? said Margaret Lang, the former director of intervention services for the RSD. “They can say, ‘Oh, they do that over there.’ It’s keeping us a segregated community.”

But parents like Smith, whose children have been shuffled from school to school, say they’d welcome a specialized program that would keep them from dealing with a confusing system of school and mental-health services.

Smith and Willis said they have considered sending their children to Texas or Mississippi, where they have been told there are public schools devoted to children with mental illness and more extensive residential services.

“If I could afford it, I would probably relocate my family,” Smith said. “In this city, we need to stop with this state of denial that we don’t need more mental-health services.”

Lens staff writer Jessica Williams contributed to this report. This story was produced by The Hechinger Report, a nonprofit, nonpartisan education-news outlet affiliated with Teachers College, Columbia University.