A Criminal Development 

Montana is treating its mentally ill kids like criminals. Can the system be fixed before more children fall through the cracks?

What do you see when you look into the eyes of 11-year-old Tyler Prouty, past the freckled cheeks and guileless smile? Look hard, beyond the neat clothes, the nice home in the hills overlooking Missoula, the two loving parents. Do you see the face of tomorrow’s violent criminal?

Spend an afternoon with Tyler and you may never notice anything but what many people have seen: a well-mannered young gentleman who is articulate, sweet, funny and intelligent. A boy who asks his mother’s permission to get up from the table for a glass of water, then offers to bring one for their guests. A boy who likes to play Nintendo, Game Boy, and surf the Internet—“Like any pre-teen,” he says, in the vernacular of the teachers, counselors, and doctors he speaks to most often.

Ask Tyler what he wants to do when he grows up, and he says he wants to do what his mother, Heather Morris, and her partner, John Masterson, do: work with computers. That’s Tyler on a good day. You don’t want to see him on a bad day.

Of those, Heather has seen more than she cares to remember. Like the time Tyler was 2 years old and got kicked out of daycare because he constantly harassed the other children. Or the repeated times in the fifth grade when Tyler ran away from school and Heather had to leave work and pick him up in the principal’s office.

By age 9, Tyler was suicidal. The most inconsequential event can trigger an extreme outburst of anger and violent behavior that seemed to well up from nowhere. “Going psycho,” is how he puts it, in a quiet, almost disinterested voice, as though he were discussing a computer hard drive prone to crashing, instead of a mental state that routinely leaves him slamming himself against the walls of a padded booth at school so that he doesn’t hurt himself or others.

With Tyler scheduled to begin middle school last September, Heather and John feared the worst. So they drained their savings, borrowed some money and scraped together $8,000 to send Tyler to an outdoor education camp in southern Idaho for children with behavioral problems. For three weeks last summer, Tyler lived in the wilderness with other children, sometimes hiking seven miles a day, building his own shelter, living off rice and lentils and relieving himself in cat holes he dug himself. By the end of the trip, Heather and John were optimistic and proud. Tyler had worked well alongside other children instead of fighting with them.

A week later, Tyler entered Washington Middle School in Missoula. Within three weeks he was kicked out for trashing a classroom and assaulting his teacher. He has since received about a dozen criminal citations, and in January he was arrested for the first time.

“His probation officer sort of gave him an ultimatum,” says Masterson. “The next ticket and we’re going before a judge.”

Strike one.

Tyler had been seeing a psychologist and a neurologist for several years, but last November his name finally came up on a waiting list to see a pediatric psychiatrist. (Like most communities across the country, Missoula has a severe shortage of pediatric psychiatrists.) It was then that he was first diagnosed with a condition known as Intermittent Explosive Disorder (IED).

“Whatever is wrong with Tyler is somewhere in the borderland between what would be considered neurology and psychiatry,” says Dr. Ethan Russo, a Missoula neurologist who has been treating Tyler for the last two years, with limited success. “We think there’s some biochemical trigger in the brain, but practically speaking, we haven’t figured out how to deal with it at this time.”

IED is not cutting edge or “fringe” psychiatry, but a clinically acceptable diagnosis. But when Heather submitted the bill for Tyler’s psychiatric visits to her insurance company, Blue Cross of Montana, her claim was denied. She was told that while Blue Cross covers some impulse disorders, IED is not one of them. Oddly, Blue Cross agreed to pay for the medications prescribed for Tyler’s condition, while not acknowledging the condition itself, or paying for the doctor who diagnosed it.

“What we’ve got is a situation where medical visits and diagnoses are being dictated by an unregulated industry, the insurance companies, rather than having medical decisions made by physicians and medical consumers,” says Dr. Russo. “How is this condition any less valid than someone who has a heart condition? Any distinction is arbitrary.”

Since Heather makes too much money to qualify for Medicaid but not enough to afford the $180 weekly visits to the psychiatrist, there is no system in place to cover the cost of Tyler’s psychiatric care.

More accurately, there is no mental health system in place to pay for Tyler’s psychiatric care. As Heather soon discovered when she began calling different groups around town in search of other treatment options, there is another way—albeit an unpleasant one.

“I was told that sometimes you can use the criminal justice system to your advantage,” says Heather. “If you can get a judge to order treatment, then the state has to pay for it.”

“That sounds like a pretty gruesome gamble,” says John.

Juveniles in Crisis

Tyler’s situation is hardly unique in Montana. Most mental health experts agree that nationwide a growing number of mentally ill children suffer needlessly because their emotional and behavioral needs are not being met by the very institutions and systems designed to care for them.

In a report released in January, U.S. Surgeon General David Satcher writes that the United States is facing “a public crisis in mental health for children and adolescents,” with one in 10 children suffering from a mental illness severe enough to cause some level of impairment. Yet in any given year, Satcher estimates that fewer than one in five of these children will ever be diagnosed or receive treatment.

The situation isn’t much better in Montana. According to Larry Noonan, chief executive officer of AWARE, Inc., a private, nonprofit organization that runs more than two dozen group homes throughout Montana, including four in Missoula, only about 40 percent of the children in Montana that should be eligible for mental health case management are being served.

As a result, many of these children—some as young as 8 years old—are being diverted into a criminal justice system that looks upon them more as criminals than patients and is largely untrained and ill-equipped to recognize, treat or manage mental illness.

“Unfortunately, kid [mental health] services still takes a back seat to adult services in Montana,” says Noonan. “As a state we’re really conflicted over this: Do we treat these kids or do we punish these kids? Right now it falls on the side of ‘Let’s punish them.’”

The numbers, both in Montana and nationally, confirm that assessment. According to the Coalition for Juvenile Justice, between 50 and 75 percent of all incarcerated youth have “diagnosable” mental health disorders, but most juvenile detention centers are not equipped to deal with those disorders.

The Coalition also found that 36 percent of parents of adjudicated children say that their children are in the criminal justice system because local mental health services could not help their child—or were not available to them.

Shanna Bulik knows firsthand how mentally ill children end up in the correctional system. As administrator of the Cascade County Regional Youth Service Center in Great Falls, she estimates that at least 60 to 65 percent of the juvenile offenders in her charge suffer from some form of mental illness. For many of them, the correctional system was the only way their families could obtain mental health treatment and the costly medications that their children require.

“I see it every day,” says Bulik. “Parents are relinquishing custody to the state, giving up their rights or having their kids arrested so they can get those points against their record and the judge can order those [mental health] assessments. It’s really sad. The criminal justice system isn’t made to house these kids.”

That Montana’s criminal justice system has become the primary port of entry for accessing mental health care in Montana—both for juveniles and adults—is irrefutable. In September the Montana Advocacy Program (MAP) released the results of its survey of Montana prisons and jails and concluded that more people with mental illness are housed in Montana’s correctional facilities than in the Montana State Hospital.

At least 40 percent of the jails surveyed reported that they detain people with serious mental illnesses on minimal or no criminal charges as a way to protect the person, the family or the community. In many cases, the county jail serves as the last—or only—community resource available to deal with a person in acute mental crisis.

The survey also revealed that most corrections personnel are ill-prepared, untrained and thus uncomfortable in managing people with mental illness, receiving on average less than two hours of training in recognizing and managing people with mental illness.

“People with SMI [serious mental illness] are almost invariably treated like criminals by being handcuffed to belly chains, shackled with leg irons and transported like, and often with, criminals,” the report reads.

While the survey doesn’t address the prevalence of juvenile mental illness in the correctional system, an advocate with MAP says that the problem is at least as bad, if not worse, in juvenile detention centers.

Why are more mentally ill people ending up in jail at a younger and younger age? The reasons are numerous, experts say, from the historic trend toward de-institutionalization in the 1980s to the “get tough on juvenile crime” legislation of the 1990s, fueled by a lingering public misconception that juvenile crime is on the rise. In fact, just the opposite is true.

Rethinking the Criminal Mind

Dan Morgan doesn’t sound like most juvenile probation officers. When asked about the causes of juvenile crime, he avoids the predictable diatribe about fractured home lives, gratuitous violence on television or the nation’s declining moral values. Instead, you hear terms like neuro-EEG biofeedback, SPECT analysis and hemispheric imbalances.

“What we’re talking about here is something incredibly new to the concept of criminology,” says Morgan. “In the past criminology has been based on conscious decision-making, cause-and-effect relationships, having no empathy for victims. We still see that, but sometimes it’s because the kid’s brain isn’t capable of making those connections yet.”

As one of only four juvenile probation officers in Missoula County Youth Court, Morgan routinely handles 75 or more active cases at any given time. (The national standard for juvenile probation officers is no more than 35.) When asked how many of those children suffer from some form of mental disability, Morgan says without hesitation, “Nearly all of them.”

“I’ve been at this a long time,” says Morgan, who has worked in juvenile justice in Missoula County since 1976. “And for the first time in the last few years I’m starting to get an understanding of why it is, in many ways, we’re very ineffective at working with these kids. We may not have had the whole picture.”

Completing that picture, explains Morgan, requires applying some of the latest scientific tools for understanding how a healthy brain functions, and perhaps more importantly, how a child’s brain differs from that of an adult.

Morgan says that when he sees children as young as 8 years old entering the formal court system, they likely all have neurological disturbances. So to apply the same standards for rational decision-making as is used for adults makes no sense.

“We’re dealing with a system that assumes that kids think like us and can understand the consequences and realities of their behavior, when, in fact, in many cases they can’t,” says Morgan. “It’s akin to having a paraplegic being told to get up and walk six hours a day in school. He can’t. Pretty soon, the stress builds up, he starts screaming and then someone calls the cops and has him arrested for disorderly conduct.”

What’s more, recent changes in Montana’s juvenile justice laws are shepherding more and more children into the criminal justice system right at the very age—pre- to early-teens—when even the healthiest children enter their most active period of aberrant behavior.

Montana’s “Youth Court Act,” which took effect in October 1999, imposed the “three strike and you’re out” standard on juvenile offenders. Reflecting a national trend in the 1990s toward getting tough on juvenile crime, the law was meant to counter what controversial criminologist John DiIulio dubbed the “rising tide of juvenile super-predators.” Images like the shooting at Columbine High School only anchored that perception in the public psyche.

“Grandmas in Twodot, Montana walk down the street thinking every kid in the community is walking around with a TEK-9 pistol under his arm,” says Morgan. “That’s their fear, and that’s what they talk to their legislators about.”

But the statistics don’t bear out such hyperbolic assessments. In fact, between 1993 and 1999 the number of homicides committed in the United States by juveniles dropped 68 percent, with youth crime now at its lowest level since the 1960s.

Morgan puts it another way: Remove every person under the age of 18 from the face of the earth and you’d reduce crime by only 7 percent.

Meanwhile, one consequence of the “three strikes and you’re out” law has been that for many children with neurological or cognitive disorders, their first chance at a clinical diagnosis comes only after they’re behind in the count. For many of them, by the time a diagnosis has been made, says Morgan, “the doors are closing behind them.”

As the MAP survey confirms, most of Montana’s jails, including the Missoula County Detention Center, have no psychologist or mental health professional on staff to perform mental health evaluations, nor consistent procedures for screening inmates for mental illness.

“It’s hard enough to get insurance to pay for mental health benefits for adults, much less for kids,” says Morgan. “So it becomes incredibly difficult to get these kind of evaluations and assessments paid for [in jail]. And there’s almost nothing for treatment.”

Morgan emphasizes that the situation in Missoula is better than in many places in Montana, and cites Judge John Larson’s Drug Court as the kind of innovative approach to juvenile treatment instead of punishment that should be expanded. Still, he admits that with the current caseload in Youth Court, there is only so much time he and his colleagues can devote to each child.

“We’re overwhelmed,” says Morgan. “Even if I took a hundred kids and stacked ’em up in the hallway and marched them in here, in a 40-hour week I would have less than a half-hour with each kid. That’s the reality we have.”

New Horizons, New Solutions

In the Cascade County youth detention facility, Bulik has come up with some creative solutions. Last year she hired a licensed clinical professional counselor (LCPC) who performs mental health assessments on every youth who come through the facility, even those who are not incarcerated. The counselor meets with them on a daily basis and is on-call 24 hours a day, seven days a week. She even visits the families at home to provide therapy and crisis intervention at a reduced or no cost.

The results have been impressive. According to Bulik, since the LCPC came on-board last year, the detention center has had no suicide attempts or major disturbances. Probation officers are already reporting some improvements, and Bulik says that parents, judges and mental health workers appear to be working together to try to keep law enforcement out of the child’s picture.

In Missoula, children like Tyler are finding some answers in the schools. Tyler is now enrolled in a Special Education program at Meadow Hill Middle School called New Horizons Day Treatment Center. The model program, which serves 12 middle school children with severe emotional and behavioral problems, is the only one in the state that has mental health staff in the classroom at all times.

“We’re kind of the last stop in the public schools,” says Dr. Ric Hepburn, Tyler’s Special Ed teacher. “If they don’t make it here, then they’re looking at some kind of hospitalization or homebound situation.”

The classroom, an entirely self-contained unit for sixth through eighth graders, provides intensive, individualized education that blends academic instruction with behavioral adjustment. Like Tyler, many of these children already have probation officers and “strikes” against them.

New Horizons handles some of the most extreme behavior for children this age. “If you can think of it, it’s probably occurred in this classroom,” says Hepburn. Still, the goal of the program is to eventually return these children to the academic mainstream and avoid institutionalization, criminal or otherwise.

“I’ve worked in other states where some of these students wouldn’t be in the schools. They would be institutionalized,” says Hepburn. “This is the farthest I’ve seen a school district go with kids in terms of extremes of behavior. It’s a unique challenge.”

Under ideal circumstances, New Horizons would have less children in each classroom. While it’s a truism that holds for all classrooms, it’s especially true for New Horizons, where Hepburn admits, “Some days it’s little more than crowd control.”

More importantly, the program provides some degree of relief for parents like Heather and John who cannot afford other psychiatric care for Tyler, though everyone admits that much more needs to be done for these children.

“We’re not an auto body shop. We don’t just fix them and throw them back out there,” says Hepburn. “We’re a spot along the continuum. There are kids who may need more help than a classroom can provide.”

“This program is wonderful,” agrees Morris. “I just wish there were more of them.”

Pay Now or Pay Later

By the end of the 1990s, the number of adults and juveniles behind bars in the United States exceeded 2 million. In Montana, corrections now constitutes the fastest growing sector of the state budget, while the mental health budget is facing a $20 million shortfall for the 2000-01 biennium.

The Montana Department of Corrections is aware of the problem, and some mental health experts express optimism that its new director, Bill Slaughter, who took over last month, will continue to be a strong advocate for the rights of the mentally ill.

Ironically, while some experts say that Montana now offers more juvenile mental health services than before, there is still considerable fragmentation in services, little consistency from region to region and no one administrator who oversees and coordinates all juvenile mental health services in the state.

Legally, the courts have ruled that a prison inmate’s constitutional right to medical care includes mental health care. Unfortunately, by the time many adolescents with mental illness enter the correctional system, their hope for a meaningful recovery and a productive life has slipped out of reach.

“These kids are getting formal criminal records down here that aren’t going to go away when they turn 18,” says Morgan. “They’re going to be active from age 18 to 28. So, what chance do they have?”

“Nobody wants to pay for these services, but the way I see it, it’s either now or later,” says Morris. “Because the way the system works, Tyler is going in that direction. And there’s nothing we can do to stop it.”

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