Hundreds of Los Angeles County children housed in group homes or locked in psychiatric facilities should be removed and cared for by either their parents or foster families, according to children's advocates, who are fighting to make the change a reality.
An ongoing court struggle between four public interest law firms and the government could result in a stark change in policy in a county where the most disturbed youths typically have been institutionalized.
If the firms succeed, scores of households would effectively be converted into micro-treatment centers, with caretakers bolstered by a phalanx of child mentors, behavioral aides, tutors and psychotherapists.
Lawyers and social workers pushing for the change say that home care has proved far more effective for most disturbed children and that many parents are prepared to try it. Federal Medicaid (known as Medi-Cal in California) is available to pay for support services. But state and local officials have not created a bureaucracy to allow parents and others to institute home-grown mental health care.
The state and county concede that they have been slow to enact such a program, which is required under federal Medicaid laws. The government officials said they support the concept of home care but worry about attempts to send home the most disturbed children, whose violence, despondency and impetuousness they believe require more structured living conditions.
The dispute raises the question: How disturbed must a child or teenager be before he can't be helped at home?
The answer has tremendous significance, and not just for the families of hundreds of children in the county who suffer from anxiety, depression, bipolar disorder, conduct disorder and other serious psychological problems. Home treatment could affect the neighborhoods to which children might return. If successful, it could reduce the ranks in juvenile halls and camps, where youths with untreated psychological problems are vastly overrepresented.
Lawyers with Protection and Advocacy Inc. and three other public interest law firms say home treatment will help stem the flow of youths, many of them disturbed foster children, into jails, drug rehabilitation programs and hospitals. They point to the success of Alaska and other states, where large numbers of children with a wide variety of psychological problems have been sent home.
"The system in Los Angeles County has been set up to finance slots in institutions, not to tailor programs to a particular child," said Robert F. Cole, an independent expert who is nationally recognized for his work with disturbed children.
"We should start with the idea that children do better in homes and with families," added Cole, who has analyzed the care provided at MacLaren Children's Center in El Monte--the county's lone shelter for abused and neglected youngsters.
Government mental health officials in Sacramento and Los Angeles say that, in principle, they agree. They concede that home care is required under federal Medicaid laws.
But they are concerned that some children--even some who have demanded home care through a lawsuit--are so violent, self-destructive and unmanageable that parents and foster families could not handle them.
Less Money for Home Care
John Hatakeyama, who oversees children's services for the county Department of Mental Health, asked: "If we know the situation is just going to blow up, why subject the kid and the community to that, when we are feeling pretty confident that the plan to send them home is not going to work?"
The bulk of the minors who fall under the county's oversight are foster children, whose mental health treatment has been left to government in lieu of dysfunctional or absentee parents.
The current claims for home care are rooted in the arcane funding mechanisms used by both the public mental health and child welfare systems. In essence, money has been more readily available to care for difficult children in mental hospitals, the county children's shelter or group homes than in family or foster homes.
But since the late 1960s, Medicaid has required that states and counties offer low-income individuals under age 21 who suffer psychological disorders free, comprehensive mental health care under a program called Early and Periodic Screening, Diagnosis and Treatment. Yet California and many other states never enacted regulations allowing the public to access the money, perhaps fearing it would open the floodgates to exaggerated and bogus claims.
California has attempted to excuse the absence of the program by saying the state offered equivalent care, just not in children's homes. But after the filing of the lawsuit last spring, a state official conceded that California's children are entitled to in-home behavioral aides if their families demonstrate a medical and financial need.
The state pledged to develop a procedure by this month to allow parents and others to apply for the aides and, possibly, other individualized services.
With those important concessions made, attention has shifted in recent weeks to which children can benefit from receiving mental health services in homes.
Three teenagers recommended for admission to Metropolitan State Hospital in Norwalk were among the first to apply. Through their attorneys, the three have asked to be treated at home. The county has demurred, saying they are too dangerous to themselves and others.
In what has effectively become a test case for the home-based treatment approach, an administrative law judge this week will continue protracted hearings about how the teenagers should be treated. The judge is expected to rule next month whether Jim N., Andrew O. and Angela C. can be treated more successfully in homes, not institutions.
No Easy Test Cases
Advocates pushing for home care did not pick easy test cases.
Andrew O. (who, like all children in this story, is identified by his court-designated pseudonym) is 15 years old, but has suffered enough serious physical and sexual abuse for a lifetime. Since age 8 he has been placed in 15 schools, group homes and mental hospitals. He has taken nearly that many different medications, none of which prevented two suicide attempts.
Andrew sometimes lashes out--screaming, throwing things or hitting other kids or staff members. But at home he shows affection toward his mother and an interest in music and the guitar--attributes that psychologist Thomas J. Willis, who reviewed the case for the plaintiffs, hopes to build on through home care.
"He has been abused in these institutions, and the conditions have been horrible," said Andrew's father, Frank. "There have been unqualified people working with him. He is safer at home than in these institutions."
Even if the judge decides that Andrew would do better in a home, he still must decide which home.
The boy's parents have had their own problems. His father has been deeply depressed. Willis, who wrote the 93-page plan for Andrew, suggested that his parents should not continue as his caretakers until they complete intensive therapy, as individuals and together, to stabilize their home.
In the meantime, Willis recommended that the boy be placed in a foster home with no more than one other youth. The caretakers there would be given special, intensive training. They would be bolstered by a behavioral aide or youth "mentor" up to 16 hours a day, with a therapist on call 24 hours a day, Willis proposed in his report to the court.
The mentors would be critical in helping not only Andrew but other children who might obtain home-based mental health care, proponents said.
Mentors Seek to Be Friends
Confinement and negative reinforcement have failed to help these children, the advocates insist. So mentors would typically first try to establish themselves as "a helper, a friend or a buddy"--as Willis recommended for Andrew O.
These aides would be paid $15 to $20 an hour, plus benefits, and would typically have college degrees. They would go everywhere with their clients, even trailing them to school and sitting in the classroom, if necessary.
Andrew's lawyer, Melinda Bird, said she hopes the boy can be paired with a musician, who might help bring out his interests in that area. A psychotherapist would review his progress at least weekly and another supervisor would be available daily, under Willis' proposal for the boy.
Such intensive care would not come cheap. Andrew's plan initially would cost more than $100,000 a year, even more than hospitalization at the Norwalk mental hospital, which the county has recommended.
But cost alone is not to be a factor in the court's determination, unless it can be shown that equally effective care is available at a lower price. Studies in Alaska and other locations have shown that home-based programs eventually cost less, in part because children served in homes are less likely to have to return to mental hospitals, probation camps or other expensive settings.
Los Angeles County's mental health experts worry, however, that well-meaning attempts to send some children home can backfire.
"It's not a reality for some of these kids, if you know they are going to hurt themselves or someone else," said JoEllen Perkins, who manages children's cases for the county Department of Mental Health. "If you put one of them out there, you might be setting it up so someone gets hurt. It's not going to help the child's treatment to end up in the Twin Towers [jail]."
But representatives for Andrew and Angela C. said those dangers already exist, since both the teenagers' families have refused to admit them to Metropolitan State Hospital during the dispute over their care. Both have returned home without nearly the supervision that they need, the advocates said.
"You can't just say there is a risk and write off a kid and put them in these institutions that have failed many times before," said Marilyn Holle, another of the attorneys representing the teenagers. "We need to try something new."