Journalism Fellowships in Child and Family Policy

Condition Critical
Mental health care for children has reached a crisis point, with parents who can't afford expensive treatments and public services ill-equipped to lend a hand.

By Jonathan Martin
Reprinted with permission of The Spokesman-Review

Sept. 29, 2002 - The thump, thump, thump of Brian Murray's boots resound through the house.

It's well past 1 a.m. The 13-year-old climbs the narrow basement stairs, his mind racing from Dixie Chicks lyrics to insults endured at school. Anxiety boils. He whirls around at the top of the stairs, heads down, then up again.

The thumps keep his mother and stepfather awake. Their bedroom door is open so they can hear Brian coming. In severely manic moments, he's threatened to stab his 9-year-old sister. They've found two steak knives under his bed.

For years, Brigitte Murray has watched Brian's moods veer wildly. He sleeps 12 to 14 hours a night for two or three nights, storing dangerous energy. He is moody and irritable. Then Brian's mood spins to mania, and his basement light burns several nights in a row. He speaks in a rush. He feels invincible. He threatens.

Between the swings, the Murrays wait for three weeks or more, fearing the next mysterious misfires in the almond-shaped node deep in Brian's brain that regulates his moods.

This is the future of the Spokane family: Bipolar disorder doesn't go away. And Brian's experience, researchers say, is becoming the future for more and more American children.

The U.S. Surgeon General in 2000 called children's mental health "a national crisis." The federal Substance Abuse and Mental Health Services Administration estimates that one in five children have a diagnosable mental or behavioral illness.

Like Brian, many of those kids will suffer for a lack of money for treatment, will be given a hail of drugs, and will be at higher risk of dropping out of school or attempting suicide.

Inadequate treatment leaves taxpayers with huge bills.

Juvenile jails, including Spokane County's, face rising overtime tabs to monitor suicidal children. Mental illness causes one of every eight emergency hospitalizations for children in Washington, boosting state Medicaid costs. School districts are being forced to provide mental health care through special education programs.

It's impossible to document a surge in mental illness among children. Only in the past 15 years has genetic and brain-imaging research shown that kids get depression, bipolar disorder and schizophrenia. Troubled kids usually were said to be hyperactive.

But teen suicide rates have tripled since the 1960s - one every two hours, six minutes - to become the nation's third-leading cause of child deaths. It is second among teens in Washington and Idaho.

Confusion surrounds these kids' care. Psychiatrists, reluctant to slap a label on a developing brain, switch diagnoses and rely heavily on medications. Most drugs - whose side effects include obesity, facial twitches, even boyhood lactation - aren't approved by the government for children.

Overwhelmed public mental health clinics coordinate poorly with special education teachers or child welfare workers, in part because of federal rules against agencies pooling their resources. That prevents kids from getting the best care, researchers say.

States have cut funding, giving priority to caring for chronically ill adults. Washington's public mental health system estimates that 6.7 percent of school-aged kids will need help, a figure psychiatrists say is very low.

Parents of seriously ill kids routinely turn to the public system after exhausting their insurance coverage.

Idaho's mental health system, although expanding because of a class-action lawsuit, has even fewer options.

Brigitte and Brian Murray's lives have turned on his moods. The family relies on public clinics, which only diagnosed Brian after several violent episodes, then leaned heavily on a variety of pills.

But the pills only go so far. Back at the Murrays' house, Brian's boots drum the stairs late into the night. Brigitte, facing a 5 a.m. shift as a nursing home aide, yells down the stairs, "For God's sake, go to bed, Brian!"

He swears back. "I can't, Mom."

Signs of illness

Brigitte fell for a man in a uniform. He was her ticket out of a Spokane childhood that ended in foster care.

She carries the scars of a child of alcoholics - one through her right eyebrow, cut when she was thrown through a car window at age 10. Her stepfather was drunk behind the wheel.

The Air Force airman, Wayne Murray, fathered two boys, Brian and Dustin. It took Brigitte a while to realize her husband had bipolar disorder.

Genetics research links bipolar disorder to fewer than 20 genes. The odds of a child having the disorder are 20 times higher if a parent has it. Dustin, three years older than Brian, didn't get it; researchers don't know why.

But bipolar disorder, like other mental illnesses, can also grow out of a chaotic upbringing or trauma.

One day in 1991, after the couple's marriage dissolved, Brigitte dropped Brian and Dustin, then 3 and 5, off at Wayne's house in Bend, Ore., for a brief visit. Wayne fled, violating Brigitte's custody rights.

Two years later, her private detective found father and sons in a Portland apartment. Wayne pleaded guilty in Spokane to custodial interference.

Brian's mental health records suggest he was physically abused during the time away. Wayne says that's wrong - he was a good father.

Wayne spent most of 1999 and 2000 in an Oregon boot camp for selling marijuana. He blames his disorder for the troubles.

"I worry about Brian getting into criminal trouble, too," said Wayne, 37. "I tell him, 'Don't wind up where I was, you don't want to see the inside of bars.' "

For years, psychiatry attributed misbehavior in kids to a distant "refrigerator mother." Therapists dealing with such children often looked first for signs of abuse or neglect.

But expanding genetics research has prompted therapists to increasingly ask a different question: Has anyone in your family been mentally ill? As it turns out, almost three-quarters of kids in Child Protective Services care have a mental health disorder.

"Mental illness is not a switch that turns on when a child is 13," said Michael Manz, chief child psychiatrist at Sacred Heart Medical Center's Psychiatric Center for Children and Adolescents. "If you go back and look with a fine-tooth comb, you'll see the behaviors early."

Manz began seeing Brian three years after the boy returned to Brigitte. Brian was stashing food under his bed, and his angry outbursts forced Dustin and their younger sister, Christina, to flee until he calmed down. Rex, Brigitte's new husband and father of Christina, also left, to avoid pummeling Brian in anger.

Brian's bipolar disorder erupted violently three years ago, during his fifth-grade year. He was charged with assault for slugging his mother in the stomach in front of a police officer and yelling that he wanted to be like his father, "a drug-dealing, kid-beating, prison guy." Brian apologized. The charge was dismissed.

Later that year, Brian attacked his mother with a screwdriver taped to a board. "I hate you," he screamed, swinging the board. "I'm going to kill you."

Dustin sat on him until police arrived. Brigitte pleaded with officers: Don't press charges. Take him to Sacred Heart.

Manz had already seen Brian five times at Sacred Heart's 24-bed child psychiatry center, and the ward's school for kids on their way to hospitalization. The average stay costs $10,000; Medicaid pays less than half.

Before the screwdriver attack, Manz thought Brian's violence was caused by attention deficit hyperactive disorder, defiance and post-traumatic stress disorder from Brian's years with his father.

This time, however, Brian was euphoric, claiming he was going to find a girl to have sex with. The euphoria, bragging, mood swings and rapid speech suggested bipolar disorder, in addition to attention deficit hyperactivity disorder, or ADHD.

"My fear is, he'd think he was Superman during a manic episode, and he'd jump out the window," Manz said.

Early onset bipolar disorder hits about 770,000 of the nation's 26 million children. More common diagnoses are depression (up to one in eight adolescents) or anxiety (one in 10), the National Mental Health Association estimates.

Childhood-onset bipolar disorder has been hotly debated in psychiatric journals since researchers argued in the early 1990s that it could afflict kids more seriously than adults, and that it is often misdiagnosed as ADHD. Manz has diagnosed it less than 10 times in the past five years.

But Brian, he told Brigitte, was legitimate. The illness dramatically raises the likelihood of suicide, although many sufferers - from astronaut Buzz Aldrin to singer Tom Waits - have managed their illness.

"It's a devastating diagnosis," Manz said. "A kid is going to be disabled his entire life."

But hearing Manz's firm diagnosis gave Brigitte an odd sense of relief. "That explains what he's been doing all this time," she said.

She didn't tell the neighbors, or even her family. "It's a closet issue," she said. "If you have a mental illness, you're crazy, you're dangerous. It's not like a developmental disability, like retardation. If he had cancer, everyone would be sympathetic. People assume I'm a bad mother."

'Absolute scandal'

The diagnosis shifted Brian's treatment, to strongly emphasize regular medications.

Manz and other psychiatrists began prescribing a dozen different medications in rotation. Brigitte tried to make sure Brian got regular sleep and avoided stress. She began using strict rules to reinforce good behavior.

Therapy is secondary. "You are not going to solve bipolar disorder" with therapy, Manz said, although "he may be better adjusted, he may think better of himself.

"It would be great if we could afford" both therapy and behavior management, he said, "but there just isn't the money" in the public mental health system.

The $500 million per year Washington system, funded by federal and state Medicaid money, is fractured into 14 regional support networks (RSNs), similar in concept to school districts. The intent is to tailor care to community needs.

But the system is so decentralized that it often fails to coordinate with schools and state child-welfare agencies, which also provide mental health care, the Legislature's in-house auditor wrote in a 2002 report.

The auditors found it "impossible" to determine the effectiveness of the state children's mental health system. The Department of Social and Health Services has since tried to improve coordination and data collection.

Sharp criticism also comes from Washington's trade group of public mental health clinics.

The decentralized mental health system siphons off 20 percent of precious dollars for administration, the Washington Community Mental Health Council wrote in a 2000 report.

That group - using conservative estimates of the number of mentally ill adults, elders and kids - calculated that an additional $285 million should be spent per year. Legislators considered it a pie-in-the-sky figure. Facing huge deficits, they instead cut the state mental health budget by $3.85 million this year.

Resulting low salaries at Spokane Mental Health have prompted rapid turnover -- Brian Murray has had five therapists in two years. The agency has cut intensive case management programs for the most mentally ill kids and reduced staff travel to elementary schools. "We just don't have the array of services for families we did," said Lou Sowers, head of Spokane Mental Health's services for children.

The cuts frustrate Roy Harrington, who retired as head of the DSHS Eastern Washington child welfare division two years ago to become a child advocate.

Because half the state's Medicaid population is kids, Harrington reasons that half the mental health budget should be spent on them. Instead, the state spends less than 10 percent of the mental health budget on kids.

"I think it's an absolute scandal, the way the state ignores these kids' eeds," he said. "We can think of it as pay now, or pay later, for jail cells or hospitals."

'Full of meds'

A large clock looms above the patient couch in Robert McIntyre's office. Brian Murray strode into the child psychiatrist's office sporting a new camouflage headband and a wide-eyed look that foretold an impending manic swing.

Since being discharged from Sacred Heart and Manz's care, Brian has seen McIntyre about once every three months, for a 30-minute conversation. McIntyre was one of two child psychiatrists at Spokane Mental Health who oversee 1,100 kids receiving care through the Spokane RSN.

The doctor was alarmed by Brian's sleeping habits last winter: 10 hours total over three days, then, after a crash, 14 hours a day for three days. "When he's up, he's talk talk talk," Brigitte told him. "He's here, he's there, he's up the stairs, down the stairs."

She described his depressive moods like Snow White's dwarves: "mopey, whiny, angry, bitchy, sleepy."

Brian takes four psychotropic medications three times a day: Depakote and Tenex, to stabilize moods; Dexedrine, for ADHD; and Risperdal, to treat delusions or hallucinations. McIntyre was concerned about Brian's high dose of Tenex, and ordered a blood draw to check for potentially toxic buildup of Depakote.

Use of medications to treat depression, mood swings, anxiety, hyperactivity or psychosis in kids exploded in the past decade, corresponding with the expansion of available drugs and managed care in psychiatry. A Columbia University study in 2001 found just 11 percent of kids who were prescribed a psychotropic drug also got psychotherapy during a single office visit. A leading researcher on the topic, Julie Magno Zito of the University of Maryland Pharmacy Department, estimates that one in 10 kids between ages 5 and 14 is on psychotropic drugs, including Ritalin.

Alarming side effects can occur. Drugs like Risperdal may cause adolescent boys to lactate, and adults taking moderate doses of anti-psychotic drugs were 2-1/2 times more likely to die of sudden cardiac arrest (most drug studies don't look at the effects on kids). Zyprexa - one of 18 medications Brian has taken since second grade - caused his waist size to temporarily double, to 40.

Some medications cause involuntary ticks in up to a third of long-term users. But, psychiatrists say, the medications can prevent suicide, violence, incarceration.

Doctors spend too little time with patients to always make the best decisions, Zito said. "We shouldn't rush to judgment," said Zito. "You can't afford to be pro-drug or anti-drug, because we don't have enough information. What concerns me is we have this steep rise in usage."

In McIntyre's office, the clock was ticking and the doctor had little advice for Brigitte. He hoped to cut back on some drugs, but didn't because of Brian's behavior.

"I'm full of meds," said Brian, cheerfully.

"You're right, Brian," McIntyre said.

'Off the charts' stress

Brian's bad year in fifth grade set the Murray family on edge.

Dustin, a broad-shouldered 15-year-old, has become a surrogate father. Brian yelled at his mother one day last winter when he was told he couldn't have a glass of Nestle Quik before dinner. Dustin slammed a fist on the kitchen counter. "I'm sick of this!" Christina retreated to her bedroom.

Brigitte's plan to become a special education teacher ended last year, a few credits short of a degree from Eastern Washington University, when emergency trips to Brian's school made a student-teaching practicum impossible. She now works as a nursing home aide for $7.75 per hour.

The stress of raising bipolar children "is off the charts," said Dr. Mary Fristad, a professor of psychology at Ohio State University. Her studies have found unusually high rates of divorce, bankruptcy and stress-related illness.

Fathers often cope by drinking, and mothers wrestle with guilt, afraid to take their volatile child into social settings, she said. Siblings feel resentful and mortified. "It's not your fault, but it's your problem," Fristad tells parents in her training groups. "If you don't deal with it, the rest of your life will be hell."

Brigitte asked for additional help from Gene Hunter, a state social worker in the Family Reconciliation program that helps families with unruly teens. She needed an occasional break from Brian's swings, what Manz called "time for an undisturbed bubble bath. Those are the things that make a child last at home," he said.

Taxpayers have a financial incentive to keep kids at home: A mentally ill kid living at home, getting outpatient treatment, costs $15 a day; foster care, $50. A hard-to-get spot in a long-term juvenile mental health center: $339 and up.

But Hunter had no money available for respite care, unless Brigitte wanted to sign away parenting rights and put Brian in a foster home. Brigitte, the former foster kid, protested.

"Everyone's option is to put him in a home, put him in an institution. What does that do when he's 18 or 20 years old? He's not a dog. You don't just get rid of him. I want him here, but I need help."

An arrest at school

Hoping that a bigger house would ease tensions, Brigitte and Rex last year left their two-bedroom rental, getting a sweet deal on a former crack house in North Spokane. Brian had done $2,800 in damage to the rental house wiring, floors and walls. In the new house, they built separate basement bedrooms for the boys.

Within a few months, Brian began to sneak out at night and steal cigarettes. When confronted, he punched holes in walls.

"I'm tired. I thought we'd get here, and I'd be OK," said Rex, a salty ex-Marine 17 years older than Brigitte.

By last November, Brian's manic swings had become more menacing.

"I'm going to stab you to death when you sleep," Brian yelled at Rex, then at Brigitte.

He would apologize. "You feel all weird inside, because you know you're going up the escalator," said Brian, in a thoughtful moment. "Once you go up the escalator, it's hard to go back down."

Problems arose at school, too. Brian's behavior and diagnosis qualified him for a new program at Bancroft School for troubled elementary and middle-schoolers. The school has at least three staffers for every 10 kids and two small seclusion rooms.

Last December, Brian earned a timeout for throwing a folder. The school's behaviorist approach means bad behavior is immediately confronted. The school also has authority to give him Risperdal as needed - but the bottle was empty that day.

After 10 requests to calm down, Brian went to the seclusion room, a 5-by-6-foot closet with carpeted walls and a deadbolt. Teacher Michael Keith, watching through the room's small window, feared Brian would try suicide when he saw the boy take off his Seahawks jersey.

Keith summoned a response team of four teachers and assistants. Then, when Brian kicked and punched, police were called. Brian was booked for fourth-degree assault.

Brigitte felt Brian would have calmed down if left alone. "Do you understand that going in with five or six people will trigger violence?" she asked during a parent-teacher conference a week after the arrest.

The teacher, Libby Hertz, said Brian is "naive and pure of heart," but taunts from other students set him off. The school had to hold him accountable or he'd learn violence was appropriate, she told Brigitte.

Brigitte nodded and sighed. "It's not a reflex, it's not like hitting on a funny bone. He can control his behavior," she told Hertz. "He just doesn't see things in shades, in black and white and gray. He goes right to purple."

A stern warning

Wrapped in a puffy down coat, Brian shuffled into the public defender's office for a January meeting about his criminal charge.

Fearing an outburst, Brigitte sedated Brian with extra Risperdal. He stared catatonically as he waited for attorney Michael Elston.

Elston's warning cut through the fog: If you get arrested once more, you're going to jail. Brian hates the taunt of "jailbird" he hears at school.

The next two months were surprisingly calm. Brian got just two five-minute timeouts at school, earning the right to learn snowboarding at Mount Spokane.

The criminal charge was dropped after a psychologist found Brian incompetent to stand trial. But the boy's fear lingers.

One Thursday in March, Brian's class gathered for a group therapy session. The students were asked what they would do if their father drank too much. A small girl said: Hide the booze and hide yourself.

Brian said no.

"It could get you killed," he blurted.

The group fell silent, as if a pause button had been hit.

"You'd die. Dead. Die. Look at the jail cells. Look at how full they are," Brian said, almost shouting. "You don't want to go there."