Mental health issues common among youth at Sununu Center

New Hampshire was rocked this May when a federal investigative group reported a child with emotional disabilities suffered a fractured shoulder due to illegal physical restraint at the Sununu Youth Detention Center.

Yet the issues surrounding children with behavioral health disabilities and the juvenile justice system have long been a struggle in the Granite State.

A May report the Disability Rights Center on the incident notes former medical director of the state’s Juvenile Justice Services Eric Vance said in 2008 that an estimated 60 to 70 percent of the boys and 70 to 90 percent of the girls at the Sununu Center have been physically and/or sexually abused and are dealing with post-traumatic stress disorder.

A decade later, those numbers are relatively unchanged, despite legislative efforts to reduce the number of children committed to the center. A Department of Health and Human Services report on the adequacy of New Hampshire’s child welfare system released in August reported that 67 percent of all youth eligible for release from the Sununu Center have an identified disability, with “emotional disability” as the most prominent type.

The report also found New Hampshire lacks adequate services to treat these children. In a system that prioritizes the “least restrictive, most appropriate” type of treatment first – even if that’s not appropriate for a child – these children often have to “fail up” in order to get the services they need, the report found.

The state is working toward a more integrated system that would coordinate care across multiple agencies, but it will be some time before it gets there. In the meantime, many children are unable to access the care they need until they interact with the juvenile justice system, advocates say.

“I think behavioral health and juvenile justice collide more often than they should,” said Michelle Wangerin, the Youth Law Project director for New Hampshire Legal Assistance. “Using it (the juvenile justice system) as the primary service model for the mental and behavioral health system is hugely problematic.”

One of the biggest challenges is the juvenile probation system often handles minors who would be better served in other systems, DHHS found.

Michael Skibbie, policy director for the Disability Rights Center in New Hampshire, said the conduct of children with behavioral disabilities frequently lands them in court.

“I don’t think there’s much to dispute that in New Hampshire a lot of kids are placed at the Sununu Center not because of the severity of their crime, but because we’re unable to find an appropriate setting for them,” he said.

Wangerin, who focuses on issues such as juvenile justice and the school-to-prison pipeline, said the most glaring gap is the lack of good, non-residential community services.

“We want to prevent them from needing residential placement unless they need it,” she said. “There’s all kinds of research identifying that they do better when remaining in family placements.”

When children who don’t need residential placement get put into a place like the Sununu Center, the move disrupts family bonds, Wangerin said, and removes them from their community, like school and sports teams. It can also expose them to a negative peer group, she said, which can worsen their behavior.

Unlike traditional residential settings, where weekend visits home or to clinicians may be possible, children at the Sununu Center are unable to leave, Wangerin said. Children are unable to start adjusting to life back at home, and “the intensive family work doesn’t happen,” she said.

JoAnne Malloy, a research associate professor at the University of New Hampshire’s Institute on Disability, said the Sununu Center is no place for children with behavior conditions.

“People say they’ve redesigned it, but those kids are still locked up,” she said. “There are children and youth there who are truly dangerous. ... Once there, you have a record. Some treatment can be good, but you’re not learning how to be in school or how to deal with stress.”

The child’s mental health system faces many of the same challenges as the adult system.

A 2017 report from the Human Services Research Institute found one of the biggest problems to be a shortage of child psychiatrists and clinicians trained in evidence-based, trauma-informed treatment models.

“Professionals who move into New Hampshire from out of state can experience challenges obtaining licensure (and) demonstrating that the state requirements have been met,” the report reads.

Use of evidence-based practices is also sporadic in community mental health centers, the report found.

Because those services are so rare, there’s a heavier reliance on inpatient care for children, similar to the adult system, the report says. And when residential services are viewed as permanent living situations, the rate of turnover for beds in the system is reduced. If parents are unaware of local, community-based treatment options, they often seek care out of state.

For people who work within the system, one of the biggest problems is communication.

“There are all these systems that serve the child,” said Ellyn Schreiber, director of the children’s intervention program at Riverbend Community Mental Health, “and they have to be able to talk to each other.”

Schreiber said a child typically has more people involved in their care than adults, like parents and school employees; and if communication is bad, a child can fall through the cracks.

Becky Whitley, the children’s behavioral health policy coordinator for New Futures, said the state is working towards building a wraparound style of care, where community-based teams chosen by the family offer support by developing and monitoring a plan of care that addresses family needs. The Legislature directed the state to develop such a system in 2016, building on years of work by advocates, state agencies, school districts and providers.

Efforts to do so are hampered when players in the system operate in silos, Whitley said. The system is underfunded, and fragmented, leaving children and families unable to access supports early, when treatment is most effective. “We’re clearly not there yet,” she said.

Part of the state’s initiative includes a program called FAST Forward, which serves children with severe emotional disturbances by providing peer support, respite care, transportation and other services.

The program’s focus is to identify and build on the family strengths by using the wraparound approach. For children to access FAST Forward, they need to be Medicaid eligible; ages six to young adults transitioning out of school, foster care, or state placements, and at risk of multi-agency involvement, including out of home placement in a residential treatment facility, psychiatric hospital, or juvenile justice facility, according to the New Hampshire Children’s Behavior health Collaborative website.

The state noted three other places with successfully implemented similar systems in its August report: New Jersey, Milwaukee County in Wisconsin and Indiana.

New Jersey services 12,000 children annually through its wraparound approach and retains the responsibility of developing the provider network, contracting, rate setting, and payment. It’s funded through a combination of Medicaid and state dollars.

Families access services through a contracted systems administrator, who assesses the needs and eligibility for services, authorizes services, and provides care coordination. Complex cases are referred to care management organizations, who provide care management to youth with both moderate and high needs through a comprehensive Medicaid waiver.

Through its program, New Jersey has reduced the utilization of residential treatment/group home beds from 2,000 to 1,000, the report says.

Milwaukee Wraparound contracts with six community agencies for over 100 care coordinators who facilitate planning teams and implement wraparound approaches. They serve about 1,700 see children weekly, provide crisis intervention services, and coordinate with child welfare and juvenile justice based on identified roles.

About $52 million in funding is pooled across several state and county agencies for the program, including Medicaid dollars. The state’s report notes Milwaukee’s system has reduced the number of children who need to access residential treatment facilities and has shortened their stays.

Indiana Choices serves up to 700 children each year through its contract with Indiana Department of Child Services. Choices assumes the risk for the level of care for a youth and if the youth needs more intensive intervention, like a residential placement.

They pay for all community-based and placement services. Choices is paid a capitated per member per month rate for managing the cases. Children in the Choices program spend up to 45 fewer days in residential settings than other Child Services youth, according to the report.

If operated correctly, a system that relies on community supports would keep children out of institutions like the Sununu Center, Whitley said.

“It’s a big building,” she said, “and there’s sort of an institutional bias to fill an empty building. … If you truly have a robust system of care, you don’t need institutions like this.”

(Material from the Associated Press was used in this report. Caitlin Andrews can be reached at 369-3309, candrews@cmonitor.com or on Twitter at @ActualCAndrews.)