How to Treat Mentally Ill Children

When Metropolitan State Hospital in Norwalk opened a children’s ward this summer for the first time in two decades, officials pledged that the state’s last fling at hospitalizing mentally disabled children would be different.

They promised short stays, more contacts with the outside world and treatment that stressed returning children home whenever possible. Five months after its opening, the operators of the hospital say those plans are on track, if incomplete.

But many patients rights advocates say that long planning and plenty of good intentions have not been enough. They see much that suggests the painful and troubled past: children who seldom leave their locked units; children who are drugged excessively; children strapped to beds with leather restraints.

Those complaints touch a facility that is the last of its type. With the shuttering of Camarillo State Hospital in June and the planned closure in January of the children’s unit at Napa State Hospital, Metropolitan soon will be California’s last state mental hospital for children and teenagers.

This will probably only increase the scrutiny of the facility, which has 83 residents and is projected to reach its capacity of 120 by year’s end. The opening of the hospital has also reinvigorated a wider debate on the need for mental hospitals for the young.

Many private mental health advocates argue that more children should be sent back to parents, to foster families and to group homes. Those families would then be bolstered with a smorgasbord of visiting psychotherapists, tutors, speech pathologists, social workers and others.

That entire menu of care still would cost less than the $100,000 or more per year it costs to hospitalize such a youngster. It also would propel many more children back to life in the mainstream, the advocates say.

“What we are saying is there is no reason to put any child in Metropolitan or any state mental hospital,” said Melinda Bird, managing attorney in the Los Angeles office of Protection and Advocacy Inc., a public interest group that represents mental patients.

The government officials responsible for the mental hospital say they too want to move children back into the community. But they believe there will always be a need for hospitals to care for volatile children who have exhausted every other alternative.

They say only locked doors can assure treatment for teenagers with all manner of mental and emotional disabilities--children who throw fits, start fires, slash themselves, abuse others and repeatedly run away.

For 61 years, Camarillo was the alternative of choice for many of these children. But when it was closed by Gov. Pete Wilson’s budget cuts, state and county officials were left to find alternatives.

They managed to shift about half of the mentally retarded and emotionally disturbed patients to homes and less restrictive programs. But that left 70 juveniles who were sent to the Norwalk hospital in the first two weeks of June.

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Many of the Camarillo children were leaving virtually the only home they had known. Although many staff members followed their patients south, the sense of dislocation was exaggerated by the physical contrasts. The old hospital was set in a bucolic, semirural setting with views of the mountains from beneath shady weeping willows. The new facility abuts tract homes and a defunct oil refinery.

One day last week, several children at Metropolitan said in interviews that they missed Camarillo’s wide open spaces, its pool and bowling alley and its small menagerie of pets--including a horse.

“There, we had more nature--the mountains and rabbits and squirrels,” said a teenage girl. “Here, it’s hot and smoggy.”

A couple of children, however, said they were happy to be closer to their families in Los Angeles County.

The children reiterated the complaints of several advocates, who said that a discipline system had left many of them with too few “points” to earn outside field trips.

“At Camarillo, we just went on outings,” said one pigtailed 14-year-old girl, who said she had not been off the grounds in five months. “Here you have to do lots of paperwork and reach a [behavioral] level before you can get out.”

Administrators at the hospital conceded that they had limited outings as they sought to learn about their clientele. But on Friday, Michael Ichinaga, assistant chief of the program, addressed an assembly of all the hospital’s juveniles.

“We have been looking at the [discipline] system, and we agree with you--it’s a little too strict,” said Ichinaga. As children cheered, Ichinaga then described how he expects to begin a new point system next week that will free many more children to leave their units.

Lawyers for the children applauded that change, but said other concerns remain--particularly over what they believe is the excessive use of so-called five-point restraints.

The devices are named for the leather belts used to strap patients by their wrists, ankles and waists to beds in seclusion rooms. The devices are to be used only as a last resort, when other tactics are not enough to prevent children from hurting themselves or others.

Five-point restraints were used 194 times in the month of August, an average of more than six times a day, according to hospital administrators. Their use decreased slightly in September, to 149 reported instances. Figures were not available for October or for the Camarillo years.

Two children’s attorneys said they were “horrified” by a restraint they witnessed when visiting the 20-bed unit for adolescent boys last month. There, they saw one seemingly placid teenager strapped down.

“He didn’t seem severe or agitated at all. We were just talking to him calmly as he was strapped to the bed. It was bizarre,” said Nancy Shea, senior attorney for the public interest law firm Mental Health Advocacy Services.

“Earlier in the day, he had escalated and tried to break a window. Things got out of hand,” Shea said, adding that she believed the boy was restrained for more than an hour because “frankly at that point, I think it was just easier to put him in restraints rather than deal with him.”

Program Director Cynthia Woodruff said the boy had told the staff that he felt out of control and wanted to be restrained. He hadn’t told anyone--except Shea--that he was ready to be released, Woodruff said.

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Woodruff said she has used the incident to emphasize that patients who have calmed down need to be released immediately.

Perhaps the most serious conflict in the short history of the juvenile program came as midnight approached one night in mid-August. It was then that a 16-year-old boy with a history of assaults burst out of a lounge and began hitting the head of a psychiatric technician with a Ping-Pong paddle.

The staff member’s head was severely cut. Other patients erupted in a mini-riot, which ended when the instigator was placed in restraints and another boy, who was threatening to slash his wrist, was pepper-sprayed by hospital police, according to a staff report.

One hospital employee and a patients rights advocate called the use of the spray “inexcusable” and said other techniques must be used to defuse tensions more quickly. A use-of-force committee was formed to review the situation.

Such assaults have taken a toll on the staff, placing several either off duty or in desk jobs because of injuries suffered on the job.

The best defense against such attacks is a good offense--creating “meaningful activities for kids,” said one employee who asked to be anonymous. Or as attorney Shea said: “There is a saying in this work: ‘If you don’t keep the kids busy, they will keep you busy.’ ”

Woodruff said programs are already underway to keep children engaged and out of trouble, such as one in which older students tutor younger ones in the hospital’s on-grounds school. Even critics say the school is teaching students much more than its predecessor at Camarillo did.

Other jobs will soon be created to pay children for gardening and cleaning the hospital’s large fleet of vehicles, and a video arcade and game room are under construction.

For now, patients spend most of their days in a low-slung constellation of green buildings with linoleum-floored hallways, fluorescent lights and small, enclosed concrete patios. Their time on the hospital’s expansive grassy grounds has been strictly controlled--in part, to limit their contact with 800 adult patients.

Just weeks before the children arrived at the hospital, 180 mentally ill criminals were transferred there from Patton State Hospital. The inmates are held in a compound encircled by razor wire. The opening of the penal unit inspired protests and picketing by neighbors in the surrounding neighborhood.

Scant public attention has greeted the arrival of the children. But the small community of attorneys and mental health advocates for children has been preoccupied with the subject.

The debate intensified last month when a former employee of the state Office of Patients Rights, who had been briefly stationed at the Norwalk hospital, wrote a scathing critique of conditions there.

The advocate, Ted Chabasinski, was himself placed in a mental hospital as a child. He said he was sickened by conditions at Metropolitan, which he says offers its patients only “drugs and despair.” Chabasinski left his job at the state agency and has pledged to lead a campaign to close the children’s unit.

Other critics say that Woodruff and much of her staff are making a serious effort to provide the best hospital program they can and that they have seen improvements.

But they worry that more reforms could be thwarted by a few workers who seem preoccupied with exerting their authority over patients.

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On one point government officials and mental health advocates agreed: Real, life-altering alternatives for children and teenagers require more than just one hospital, no matter how smoothly it functions.

John Hatakeyama, who heads children’s programs for the Los Angeles County Department of Mental Health, supports the Metropolitan program.

He is pleased that Los Angeles County children are now much more accessible for family visits than they were at Camarillo. And he pledged that the hospital will be only one facet of a much wider menu of mental health programs.

But he said he is distressed that many children who are spinning out of control have to wait years to get the treatment they need, and only receive it by posing a clear danger to themselves or others.

Hatakeyama believes that some severely disturbed children need to be placed in locked foster homes, and he is pushing for the state to move forward in licensing such facilities, which have previously been illegal because of civil rights concerns.

Only by locking the foster home doors can caretakers assure that children do not run away from therapy, schooling and other services, Hatakeyama and others say. He believes that California should not have to ship its children to other states--as it now does--to find such a program.

“I visited 26 kids we now have in Utah and they said they know their rights in California, where they can walk out of any placement, any time,” Hatakeyama said. “They complained about the restrictiveness there, being in locked homes. But several of them said they would probably have been dead if they had not landed there.”

Many mental health advocates disagree. They say institutionalization, by its very nature, cannot teach young people to thrive in the world.

They look to places such as San Jose and the state of North Carolina, where children with mental problems are treated with so-called “wrap-around” services. The programs try to keep children in family and foster homes and bring professional help to their doors.

“We know how to provide services in noninstitutional places, and we know it works,” said Jim Preis, executive director of Mental Health Advocacy Services. “We just have incredible bureaucratic resistance at all levels of government.

“People are talking the talk, they just aren’t walking the walk.”