The Costs of Caring

The kids are waiting and the agencies that help them are changing

It's ironic, deplorable, maybe even diabolical. In recent weeks, we've watched as some of our troubled teens become fodder for crime headlines, gaining their 15 minutes of fame in daring robberies and brutal killings. We follow reports about killer kids with fear and disgust and, yes, with a degree of morbid fascination: How much worse can it get? Will it endanger me or my loved ones?

Yet most of us know next to nothing about the systems our state has put together to rescue children, to heal families, to protect the vulnerable and to rehabilitate the kids who have already strayed past the bounds of law and order, and of decency.

While we read the news reports and sigh, major changes in Tennessee's treatment of its children are under way or in the planning stage, virtually invisible to the general public but reshaping and sometimes disrupting the child-care bureaucracy.

Tennessee Tragic

It's Dickensian, yet it's the stuff of modern American tragedy: There are now more than 10,000 children in the custody of the state of Tennessee--4,000 more than there were just a few years ago. According to a 1994 report from Attorney General Janet Reno, Tennessee has the most children in state custody, per capita, of any state in the union.

What's worse, many of our kids sit for months in group homes and shelters before receiving the help they need to get out of state custody one day, or at least go on to recapture some semblance of a normal childhood.

"The number of children in the system is threatening to bring the system down," says Susan Kovac, a Department of Human Services lawyer who represents children that are placed in state custody. "The ability of the state to deal with children in custody is limited by a lack of resources and a change over the last decade in the types of children the state is being asked to raise."

Judge Charles Sexton, who handles juvenile matters in Sevier County, agrees. "We have too many children and nowhere to put them; they're waiting in line forever for appropriate services."

This week in the 24-county region of central and northern East Tennessee, some 167 children are awaiting a residential placement of some sort, according to Roselee Siegler, the director of the assessment and care coordination team for Knox County. These children are already in state custody, having received some sort of evaluation or treatment, but have no place to go to get the next appropriate step in their treatment.

The biggest shortage is in regular foster homes, therapeutic foster homes, and group homes for the least needy children, Siegler says.

The System That Will Change

Children who are in so much trouble that they need state intervention have historically been handled by one of one of four departments of the state bureaucracy, depending on how the child comes to the state's attention.

The Department of Human Services is the agency with which most people are familiar; it takes custody of children with a gamut of problems. Babies and young children most often come to DHS, usually because of abuse or neglect. They receive a medical assessment, and perhaps a battery of psychological tests if emotional or developmental problems are suspected. Then they move on fairly quickly to a foster home, perhaps after a brief stay at a children's shelter such as the local Catholic Services' Columbus Home here in Knoxville.

It's a different story for older kids and teens. These children may be runaways; they may have been deemed unruly or truant by a juvenile judge. Or maybe, as in Naomi's case (see sidebar), the parent or guardian has exhausted her insurance and can't afford the mental health program the child desperately needs.

Truants who refuse to go to school are often placed in the custody of the Department of Education, usually at its residential facility in Nashville, the Tennessee Preparatory School.

Teens with emotional problems or mental impairment may come into the custody of the Department of Mental Health and Mental Retardation. But children that run afoul of the law often find themselves in the custody of the Department of Youth Development, which uses such correctional facilities as Mountain View in Jefferson County.

There'll Be a Short Wait

Once teens come into state custody, they most likely go onto a waiting list for mental-health services. The number of available slots is so limited and the list so long that a four- to five-month wait in a youth shelter is now the rule rather than the exception. (Naomi is lucky. She has family members who persistently fought the system to get her the help she needed. Because of her grandmother's dogged efforts, a bed at Peninsula was more or less waiting for her when her seemingly inevitable crisis occurred, and she went straight from juvenile hall to a treatment facility. Most kids don't get that kind of service.)

And whether it's to Columbus Home or the Youth Emergency Shelter in Morristown or some other "holding tank," the state pays a board rate for each child in custody while the wait for a placement slot drags on.

Of course, it's not inevitable that a troubled child will wind up a ward of the state. Many early-intervention and preventive programs exist, administered by communities who strive to help an at-risk child before state custody becomes a reality. These include Home Ties, a family preservation program run by DHS; the Regional Intervention Program; and Basic, a school-based program for children with emotional and behavioral disorders. There are also juvenile-court intervention programs. But it's often up to the family to seek these programs out, through local health departments, say, or the school's guidance counselors, or simply by calling the Department of Human Services.

Even for families who can overcome the denial of the fact that their child is in jeopardy (too often coupled with the perhaps shameful feeling that they've somehow failed) and seek out services, preventive and intervention programs are obviously no panacea. The best of intentions and the most capably applied resources can scarcely undo in a few weeks or months problems that have often taken years to evolve and surface.

Dumping on the State

But why is the state responsible for so many children, and why now?

"My sense is that a lot of parents are just dumping these kids," Kovac says flatly. "We see adopted kids who get to be 14 and they're not cute little babies anymore, so the adoptive parents say, 'I'm not doing this anymore.' That's rare, but it happens.

"We see parents who obviously have different priorities," she continues. "Mom's got a new boyfriend, or Dad doesn't want to spend any more money, or the parent is just fed up.

"Yes, it's harder to raise teenagers than it used to be, and being a teenager is harder than it used to be. But the notion that as a parent you have the option of just turning your child over to the state--there's a lot more of that than there was 20 years ago."

Another key player in this scenario is the juvenile court judge, many of whom are less and less reluctant to turn truant or unruly kids over to the state.

"The demographics show that [the] children in state custody, instead of being primarily neglected and abused children who are growing up in foster care, are more and more coming in as unruly or delinquent teenagers," Kovac notes.

As a result, there's no shortage of people in state government who then turn around and blame the courts for the influx of kids in custody. It's an attitude that enrages many judges, who would point out that they don't put a child into state custody unless it's the absolute last resort; and that when they do so, it's because they've exercised their responsibility in determining that a child meets the legal guidelines to be in custody.

Sexton says that Tennessee's Children's Plan, put in place during the administration of former governor Ned McWherter, actually required judges to send children into custody.

"When the Children's Plan was devised, it was called on to work miracles," Sexton says. "Many kids we would have dealt with locally are now sent through the state system. And it has nowhere near enough resources--not enough money or service providers."

Wanted: A Culprit

Can we blame the government for being ineffective, uncaring, and hopelessly scattered when it comes to providing state services to kids in trouble? It would be satisfying to find a bad guy in all this, particularly in government, but it's not as though the governor's office is clueless or uncaring.

Five years old, the Children's Plan was intended to make the children's services delivery system more family-oriented and more community-based, to stem the flow of children coming into state custody, and to get the state's act together in deciding which kid needed exactly what kind of help and how much.

The plan gave birth to community health agencies known as assessment care and coordination teams (ACCTs), which took over from the usual departments (DHS, DYD, etc.) the task of coming up with what's known as a plan of care for each child. The local ACCTs would decide, for example, how serious a child's mental or behavioral problems were, and thus which facility (Camelot, Peninsula, or Lakeshore, for example) would best meet the child's needs; monitor the child's progress; and ultimately decide where the child would go--back home or up for adoption--once the services had been rendered.

Implementation of the Children's Plan has been haphazard at best, with expectations often clashing with performance. Sexton says the McWherter administration assumed that it could get bargain-priced services because service providers like psychologists and treatment programs would cut their rates by 60 to 70 percent in order to get a steady stream of the state's guaranteed business.

"It didn't happen. The providers weren't willing to cut rates," Sexton says. As a result, the available services have too frequently not met the level of need.

"Sometimes we give too little to kids, and sometimes too much--say, more intensive intervention than is needed, perhaps because very often there's not another place for them to be," says Charlotte Bryson, former director for Child and Adolescent Services for the Department of Mental Health and now executive director of the nonprofit organization Tennessee Voices for Children, which was founded by Tipper Gore in 1990. "Tennessee was beginning to develop a system of care so that we'd have a whole continuum [of services], to try to right-size the system for everybody. But it was a fragile system, and it's not been developed thoroughly throughout the state."

Reviews of the ACCTs have been mixed. Some complain that lack of cooperation, if not downright hostility, between the teams and the various departments that used to handle the caseloads rendered delivery of services nearly impossible. Some charge that monitoring of the care plans has been inadequate. Still, the Tennessee Commission on Children and Youth's 1994 evaluation of the Children's Plan recommended, among other things, that support for the ACCTs continue, with the proviso that the turf conflicts end and collaborative training take place.

Sundquist's Sequel

Now it's 1996, and we have a new administration and a new plan of action. On the same snowy January weekend that Naomi was cooling her heels in juvenile hall, Governor Sundquist signed his own executive order, approving the consolidation of all of Tennessee's children's services into one big department. How that will take place, what improvements (if any) will be wrought, where priorities will be placed, and how funding will shake out is all spelled out in an 80-page bill the governor has prepared for the Legislature.

For the time being, the Department of Health has become a sort of holding tank for the folding-in of programs and services, as the state studies ways to eliminate duplication of services and to streamline efforts. Children's advocates and other observers are cautiously optimistic.

"You have children who have been in DYD custody and children who have been in DHS custody competing for the same services, and one or the other gets it, depending on whose caseworker could move faster," says Kovac of the way services are currently administered. "There's no question that pulling together all the different services to children and having them actually coordinated is a good thing. If you don't address any of the other problems, that alone surely will help. "

The consolidation plan, overseen at the present time by Nancy Minke of the governor's office, is now wending its way through the legislative process, and it's hoped that a cohesive structure will be in place by July--the beginning of the new fiscal year.

"The program itself is still in the works," says Minke, "but, in general, the governor's focusing on community prevention initiatives in the particular areas of teen pregnancy, school dropout, substance abuse, and crime."

Sexton was one of several East Tennessee juvenile judges who called Minke before them in Morristown last November. Seated in the jury box, the judges listened to Minke, then aired their own gripes and complaints, giving her what Sexton calls "hard-core, eye-opening scenarios."

"The juvenile judges are very much in favor of a unified system," Sexton says. "No one is kicking about that. They're kicking about how to implement it." The juvenile judges and all the other players will be studying the Sundquist legislation closely to see how priorities will be set in the jostling for state funds.

"There's no question about it. We need to be preventing more and treating less," Sexton says. "But the new plan won't be a cure-all. None of us has a magic wand."

Says Linda O'Neal of the Tennessee Commission on Children and Youth: "It's important that the system focus on providing services at the most family-focused and community-based level possible. And certainly, whenever possible, we need to be involved in early intervention. I think it's always a fear and a danger that early-intervention programs will suffer. We've seen some success with those programs in recent years, and there's increased awareness of their value and importance, and we just have to be vigilant and not let that happen."

Which doesn't banish the fear that the number of slots for kids in need will shrink further. It's a balancing act, one being contemplated at a time when there are already more children in the system than can be handled adequately. Furthermore, these children are often caught between spiraling medical costs and a political climate that fosters an intensifying abhorrence of the government doing anything for its people--even its children.

If prevention becomes the priority, will slots for kids already in the system decrease--at a time when there's already a shortage?

"What we need to be doing is increasing those services throughout the state, so I'm concerned we might lose ground if we don't do it appropriately and coordinate the system," says Bryson. "The yardstick for that is if we can have a system in which children get what they need and only what they need from the state--if we can create a system that can provide services more efficiently for families and services for children when they need them, and that they're out of the system when they don't need them."

Some hope the Sundquist administration will learn from other states' mistakes.

"Other states are showing that their consolidations of children's services have not been the cure-all they hoped it would be," says Bryson. "So other states have learned the hard way that if you don't build in some real good safeguards, what tends to happen is that children with mental-health needs lose out and don't get the resources they had before."

"One of the problems in the system historically has been to look for a silver bullet--one-service answers," says O'Neal. "And many times what we need is a case-management process that brings together a range of services that might be needed--psychotherapy, intensive counseling, parenting classes, or working one-on-one with the families to help develop some behavior modification plans.... It's whatever it takes in an individual case, and that's part of the challenge. There are no cookie-cutter answers."

ACCT director Siegler agrees. "Each one of us has a role in preventing or intervening in problems. Parents have a legal and moral obligation to the children. And the community needs to support young families.

"It doesn't have to be professional support. We must take ownership of the problems in our own community."


A Year in the Life of Naomi

The True Story of a Teen, Her Grandmother, and the Agencies Around Them

(Names have been changed for confidentiality.)

January, 1995: Naomi, my 12-year-old granddaughter, is coming to live with me. She was less than a year old when her parents divorced, and since then she's been cared for by either my sisters or me. She and her mother have never really bonded, and she has never seen her father. Martha, my daughter, will retain legal custody, since she can cover Naomi under her health insurance. I can put food on the table--I work in a professional office--but I can't afford everything.

February, 1995: Naomi's hormones must be kicking in. She's always been emotional and somewhat defiant, but her mother was never like this. Today, for example, I let her go to movies with her friends. When I picked her up she wanted to go over to her friend's house. I had to say no, and she started screaming at me, right there in the parking lot. For two hours she was hysterical. It's just getting worse and worse. I called Martha and told her I thought Naomi needed some counseling, and Martha said okay, her insurance had provisions for that.

March, 1995: Naomi is seeing a counselor once a week. She's so unhappy; she just wants to sleep all the time. The counselor says she believes Naomi is deeply depressed, and might benefit from antidepressant medication.

May, 1995: Naomi's medication seems to be working; it's taken away a lot of her unhappiness, and she's much more upbeat. But her behavior is getting out of control. She's becoming more and more defiant, staying out late, and not telling me where she's going. I'm afraid she may even be experimenting with drugs.

July, 1995: We've had a very bad incident. Naomi slapped me, and said she wanted to kill me. It's very frightening, but I'm also afraid Naomi is going to harm herself. With the help of her counselor, we got her into St. Mary's CAPs unit, an in-patient treatment program. They're trying different sorts of medications on her, which I don't like. I know they're truly trying to help Naomi, and their hands are tied, too; they only have a week, fifteen days maybe, to try to figure out what to do with this girl. I'm just afraid shoving in all these different medications like this can do more harm than good.

August, 1995: Naomi's insurance has capped out. Martha talked with the people at St. Mary's, and under the circumstances we were able to get TennCare's Blue Cross program to pick up payment. That means she can stay another week, but then that's it.

September, 1995: School has started back. Naomi's still seeing her counselor, but she's becoming more and more uncooperative in her sessions. She's also starting to stay out at night, and I don't know where she is, she won't call me. Her counselor has put us in touch with a Department of Human Services program called Home Ties. They'll send a counselor out every day for the next 30 days to work with me and Naomi.

Her counselor also recommended we get a second opinion from a psychiatrist, which we did. His opinion was pretty scary. He recommended total in-patient care for Naomi, like at Camelot or Peninsula. He said, "She's not an accident waiting to happen; it's happening already." Naomi's counselor called Camelot and Peninsula, but neither one would accept TennCare's Blue Cross coverage. So here we sit. We have nobody to help her, because she doesn't have the right insurance. Naomi's counselor is keeping the wheels going, but we're fast running out of options.

The Home Ties counselor came one night for the appointment. Naomi never showed up. At this point, the counselors told me, we had no other option but to go through the legal system. It's the one thing I've fought and dreaded. We had to go to juvenile court and file a petition on Naomi as being "out of control" and "a runaway." We called the police, and they did go and find her, and I think it shook her up a little bit.

At the end of Home Ties' 30-day program, I asked for 15 more days; sometimes they'll do that, and I thought the counselor was actually starting to make some headway with Naomi. He tried very hard. But they couldn't extend the program. So now our 30 days with them are up.

November, 1995: One of the juvenile court supervisors told me we should try to get Naomi into Helen Ross McNabb or the Lighthouse [a day program for emotionally troubled children]--anything, wherever they will take her.

We went down to Peninsula with all of Naomi's records and went through the precertification process. All that red tape, it seems like it took hours. And then the receptionist there came out and said, "I'm sorry, TennCare-Blue Shield says Naomi isn't violent enough; they won't allow her to be admitted." She met all of Peninsula's criteria, but Blue Shield decides she's not "violent enough"? Everyone is telling us to get this girl into a treatment program, yet no one will take her.

I'm at my wit's end. I'm afraid I'll end up in Peninsula before Naomi does. If she commits a crime, the state will take her and treat her. In other words, if she had done harm to me, she'd be there right now. In desperation I called one of the other counselors I've dealt with along the way. He said, unbelievably, "Well, just lock her out of the house, let her walk the streets, then if she commits a crime, we'll see what we can do." That's the way the system works? I want help for this girl before she becomes tomorrow's headlines, and I'm told no way?

January, 1996: Naomi stayed out all night again last night. I called Martha; Martha called the school. Surprisingly, there she was, in math class. Since we already had a petition filed on her at juvenile court, the police went and picked her up, took her out of class, and she went directly to juvenile hall. Three days later, as a ward of the state, she went straight to Peninsula Village.

I never wanted this. Naomi's counselor told me from the beginning, though: if all else fails, the state will have to take her. I tried in every way I could to avoid this, but here we are.

I saw Naomi two weeks later for the first time since she left. We talked for about three minutes. She looked scared and nervous. She asked me when she can get out. I don't know what to tell her, and neither does anyone else. It really all depends on Naomi now.

© 1996 MetroPulse. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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