Magazine article The American Prospect

Cruel Convergence: The Era of Get-Tough Juvenile Justice Is Also the Era of Managed Care, and Children with Mental-Health Needs Are Caught in the Crossfire

Magazine article The American Prospect

Cruel Convergence: The Era of Get-Tough Juvenile Justice Is Also the Era of Managed Care, and Children with Mental-Health Needs Are Caught in the Crossfire

Article excerpt

FOR THOUSANDS OF CHILDREN with debilitating mental illnesses, the get-tough juvenile-justice culture of the 1990s could not have come at a worse time. The new punitive policies emerged in tandem with the slow breakdown of the public mental-health system, and the confluence has led to a pervasive criminalization of juvenile mental illness.

The excesses of the "super-predator"--era juvenile-justice policies are well-known, but just as damaging were the shift in focus and resources they signaled. Punishment came to replace rehabilitation as the core goal of the American juvenile-justice system at the same time that our mental-health system was sinking into a sustained crisis. The failure of community-based mental-health care to meet the needs of children in the wake of national deinstitutionalization served to push mentally ill kids into the juvenile-justice system--in effect, to reinstitutionalize them, this time into a system woefully ill-equipped to help.

In the last 15 years, matters have grown worse, primarily because of the way states have responded to the shortage of mental-health services. Instead of addressing the problem directly, too many states embarked on a roller-coaster engagement with private, managed-care Medicaid providers who promised that cost cutting and streamlining could mitigate the need for more mental-health resources and services. State after state eventually discovered the perils of such arrangements. Sweetheart contracts gave for-profit HMOs few incentives for service quality. Savings were eaten up by enormous administrative costs and fat profit margins. Care was slashed and services denied, more acutely in mental health than anywhere else.

Meanwhile, the number of youths entering the juvenile-justice system increased substantially over the 1990s. The new get-tough laws played a large role in that, but some of the rise was related to the problems in mental-health treatment. The Texas Youth Commission, for instance, found a 27-percent increase in the number of kids with mental disorders entering the state juvenile-justice system from 1995 to 2001. "It's a hydraulic effects," says George Davis, director of the University of New Mexico's Division of Child & Adolescent Psychiatry, who helped pioneer mental-health reforms in Albuquerque's juvenile-detention system. "This population exists no matter what, and if they're not in treatment facilities, they're in detention. When one goes down, the other goes up."

Estimates vary regarding the proportion of detained youth suffering from mental disorders. Northwestern University Medical School's Linda Teplin and colleagues have studied mental-illness prevalence among detained youth in Chicago. In 2002, they reported that nearly 60 percent of male detainees and 67 percent of females suffered from at least one psychiatric disorder.

Moreover, there is increasingly robust evidence that the juvenile-justice system serves as a dumping ground for mentally ill children lacking health services. The National Alliance for the Mentally Ill (NAMI) commissioned a poll of families of children with mental illness in 1999 and found that more than a third of respondents reported placing their kids in the juvenile-justice system in order to access mental-health services. A series of investigations in 2002 and 2004 carried out by Congressman Henry Waxman's minority staff of the House Government Reform Committee addressed this issue. Their report, published last summer, analyzed responses from more than 500 juvenile-detention administrators representing 75 percent of all detention facilities in the country. It found that two-thirds of the facilities held children who were awaiting community mental-health treatment. In 33 states, facilities held mentally ill youth who had no charges against them.

At a Senate hearing highlighting the report, one witness, Carol Carothers, executive director Of NAMI's Maine chapter, recounted stories of mentally ill youth in her state shunted into the juvenile-justice system. …

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