State care, minus the institution - Portland (OR) Oregonian

Oregon changes how -- and where -- it treats mentally ill kids, favoring home over a facility

SUZANNE PARDINGTON

At age 7, Zachary Hogan took his first psychiatric medication and spent his first of many nights away from his family in residential care.

Now 14, he's living at home, learning to cope with his mental illness in everyday life and working toward another first: attending regular public high school.

That goal would have seemed impossible two years ago, before a radical shift in the way Oregon pays for and allocates mental health services for 37,500 low-income children.

Following a nationwide trend, the state now aims to treat its most severely disturbed children primarily in their homes and communities instead of institutions. The change is part of a larger push from the state mental health, education, social service and juvenile crime authorities to work together to provide "wraparound" services to children.

The state's new mantra is every child should be "at home, in school and out of trouble."

The mental health system based its changes on evidence that children do better over the long run if they receive coordinated services and support in their regular environment. Their school attendance and performance improves. They are less likely to be arrested and spend time in juvenile detention. And they have fewer emotional and behavioral problems. That's according to the federal Substance Abuse and Mental Health Services Administration.

Keeping those children at home requires a web of care and support that typically costs about $3,000 to $5,000 a month in Multnomah County, less than the $8,500 a month for residential care. But the price of community-based care varies widely depending on each child's needs, and Bill Bouska, manager of the state's Child and Adolescent Mental Health Services, expects the new system to cost about the same overall as the old one.

For Zachary, that means a battery of therapists and trainers from the Albertina Kerr Centers drives to his family's mobile home in Welches several times a week to work with him, his mother and twin sister. If there's ever an issue the family can't handle alone, they can call a 24-hour crisis line.

"They've enveloped us as a family," Pam Hogan, Zachary's mother, said. "They're not just treating Zachary, they're treating the family."

Zachary can tell the difference, too.

"It's the first place that has really committed to helping me and hasn't given up," he said. "They are there through thick and thin."

Less time in facilities

Under the old system, Oregon contracted with residential psychiatric care providers and paid them directly for each child served.

There was often no alternative to residential care for children needing intense services, and there was only a limited system of monitoring cases locally to determine whether the placement was really needed, how long the child should stay or what happened after the child left.

Now the money is routed through one of nine mental health organizations, which manage each child's case and determine the best services for the child. With a team of local people monitoring treatment, more children are avoiding residential care or staying there no longer than necessary.

Since the change took effect in 2005, the average length of a child's stay in residential psychiatric facilities in Multnomah County has gone from 205 days to 115 days. Statewide, it decreased from 175 to 136 days.

Judge Nan Waller, chief family law judge in Multnomah County, said residential care still has a place. "It is needed sometimes, to stabilize. But I think everyone would agree that's not where we want to put our highest priority for kids. We want to keep them in as normalized a situation as possible."

"They just want to be regular kids," she added. "For some kids what I really see is that we are providing them with some hope."

Struggle since birth

Zachary and his twin sister, Zoe, were born about three months prematurely, each weighing about 21/2 pounds. Doctors thought they would die, and life has been a battle for Zachary ever since.

Pam Hogan's first indication that something wasn't right with Zachary was at age 4, when he would claw himself and pull his hair out if he didn't get his way. No one seemed to have any answers.

He was kicked out of his first preschool in Hawaii, where the family lived at the time, because the staff had to spend too much time chasing him. In his second preschool, he urinated on everything and everyone around him during nap time, prompting his first full psychological evaluation.

Over the years, he has been diagnosed with depression, anxiety, attention deficit/hyperactivity disorder and oppositional defiant disorder, according to Hogan. She said he also has post-traumatic stress disorder caused by how his father treated him.

When Zachary first went into residential care at age 7 in Hawaii, "it was like he was swallowed up by darkness," his mother said. "It was horrible. When I did see him, he was so miserable."

Hogan moved Zachary and Zoe to the Portland area from Hawaii five years ago to make a fresh start.

The family lives on Hogan's financial aid from Eastern Oregon University, where she plans to take online classes in the fall, and federal disability benefits for the children. Zoe, who attends Sandy High, has a mild form of cerebral palsy in her legs and has received special education services.

When Zachary was upset, he sometimes became violent, hurt himself and threatened or attacked others. His mother often had to place him in a physical hold to keep him safe. When she couldn't handle him at home, he stayed in residential care, sometimes for months at a time.

Zachary, who is intellectually bright, made major behavioral strides after Oregon created its system to keep children like him out of institutional settings whenever possible.

He attends Kerr's day treatment program in east Portland. When he gets too worked up, he can take a break in respite care at a residential facility for a few days, instead of a month or longer.

Pam Hogan now feels that she has a larger role in decisions about her son's care and enough support from Kerr to keep him at home.

"It's really working," she said. "The people who knew us in Hawaii would be shocked to see him now."

A paid role model

One morning at the beginning of July, Zachary built a shed outside the family's mobile home in Welches with Ian Mouser, who teaches music at Kerr's day treatment program and spends several hours a week with Zachary.

The lanky 28-year-old with shaggy hair is Zachary's skills trainer. Playing the role of a mentor and older brother, he shows Zachary positive ways to deal with his emotions and interact socially.

He helps provide stability for Zachary in other ways, too. When he heard that the family would be kicked out of the mobile home park if they didn't paint and fix up their home, he arranged for Home Depot volunteers to do it for free.

Without help, "we would have lost our home," Hogan said. Kerr is "the first to understand that part of the process is everyone feeling safe and secure and that we'll be there for a while."

That morning, Mouser and Zachary sat cross-legged in the shade to read the shed directions.

"What do you think is the likelihood of our building this the first time perfect?" Mouser asked.

"Not very likely," Zachary replied.

Mouser showed him how to measure and saw the wood into 3-foot pieces. That was just the first step in a complicated project, and Zachary soon grew annoyed with the slow progress.

"This is frustrating and boring," he said, before retreating inside the mobile home to complain to his mother. He sat on the floor, laid his head on his knee and rubbed his cat.

Mouser and Hogan spoke quietly to him, trying to calm him. Zachary soon curled up on a futon next to his mother with his back to Mouser and announced he wanted to take a nap.

What's key is what didn't happen, his mother said later. Zachary didn't fly into a rage. He didn't try to hurt himself or his mom. She didn't have to put him into a hold to keep him safe. She hasn't had to do that for about two years, since his last stay in residential care. She now gives him hugs instead.

"Something as simple as saying 'no' could set off a domino-type event that before might have ended up in some kind of crisis situation," Hogan said. "Now we're able to talk about feelings and reasons why."

Zachary hopes to attend Sandy High School in about a year. His mother said he's smart enough to do well there. But the social and behavioral expectations of a large public high school pose a major challenge for him. For now, he's still working on managing his fear and anger.

"I just want him to get along in the world," his mom said.

Suzanne Pardington: 503-294-5927; spardington@news.oregonian.com