Decide to pay attention in 2008 - Prince George (CANADA) Citizen

Opinion) Monday, 31 December 2007, 00:01 PST
Paul Willcocks, Special to the Citizen

VICTORIA -- I've been writing similar columns this time of year for a while now, always urging readers to make the same resolution.

Decide to pay attention for the next 12 months. To the people closest to you, but also to the way life works for people in your town and across the world. (

We're not good at paying attention. We suddenly notice people have changed -- children have grown up, parents have grown old, lovers have grown apart. We wonder, when did that happen?

Of course it happened every day, right in front of us. But we weren't paying attention.

We miss a lot. You grow close to people when you share experiences with them, travel through life together.

But if you don't notice where their lives are taking them, the little bumps and joys, you're left behind. Soon you're somewhere else all together.

And the smallest things you missed put you there. A hesitation when you ask how things are. A laugh. A brief sad look. The kind of things you don't notice, unless you're paying attention.

It's not just about the people right around you, though. I believe that when people see that something is wrong -- an injustice, cruelty, waste, foolishness -- they want to right it. If they can't, they expect those responsible to fix it, with that responsibility often falling to governments.

I have to believe that. There's not much point in writing this kind of column unless you believe that people will consider the information and analysis and -- at least sometimes -- do something with it. Just chronicling our troubles isn't enough.

I also believe it's true. It takes us a while for us to figure out there is really a problem, and then longer to decide what to do. Longer still to judge who should do it.

But we don't like to see people left behind, or children in care shortchanged, or businesses struggling with pointless government regulations and paperwork.

Eventually, we deal with the problems.

But only if we notice -- if we're paying attention.

Here in Victoria, we've suddenly noticed big problems on our streets. Drunken louts at bar closing time. A lot of homeless people, including many dealing with serious mental illness, damaging drug addictions or both.

They didn't just appear one day, a group of 50 hanging around the needle exchange, panhandlers on the corners, heaps of belongings and cold-looking people outside Streetlink, the main shelter.

But we didn't notice when the first people released from mental hospitals in the 1970s, with the promise of support in the community, started showing up on the streets. The support wasn't there; they could make their way without it; so they fell.

We didn't notice when the small group of older alcohol addicts were joined by more and more people haunted by cocaine, their limbs twitching, sores on neck and arms and faces.

Because we didn't notice, governments thought we didn't care.

If we'd been paying attention, it would never have got so bad. Instead, this all got so much worse that we now face a giant problem.

So I'm amending the resolution that I hope you'll adopt. It's still to pay attention. And really, it's best to start close to home. With the people you live with each day, the world you inhabit - the way the breeze feels on your face or the sky looks like at dusk on a middling spring day.

But when it comes to the bigger world, maybe this year we could all resolve to focus. To pick something that seems wrong, and make it better.

Maybe it troubles you that children in care are pushed out into the world the day they turn 19, with no real support or guidance. (Except for the efforts of some extraordinary foster parents.) Or you don't think people with mental illnesses should be dumped on the streets.

Pick something, and resolve to make it better by the end of the year. Demand action of politicians. Give some money. Give some time. Hold yourself accountable.


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Study indicates drug addicts' brains may be wired for relapse - Southwest Florida News Press

By Jean P. Fisher
McClatchy News Service

Drug or alcohol abusers who relapse, even after long periods of abstinence, are often reviled as too weak or undisciplined to straighten themselves out. But a University of North Carolina-Chapel Hill psychologist has found evidence that suggests, in fact, that addicts' brains may be wired in a way that makes them more prone to give in to temptation.

The research, published in the December issue of the Journal of Neuroscience, provides further evidence that addiction is a disease, not a character flaw, says Charlotte Boettiger, an assistant professor of psychology at UNC-Chapel Hill and lead author of the paper.

"It wasn't that long ago that we believed schizophrenia was caused by bad mothers and depression wasn't a disease," Boettiger said. "Addiction is maybe just a couple of decades behind."

What they did: Boettiger and colleagues peeked inside the brain to see how brain function might be different in a substance abuser. The study, conducted while Boettiger was at the University of California at San Francisco, used imaging technology to take pictures of sober alcoholics' and nonalcoholics' brains as they chose between immediate and delayed rewards. Alcoholics chose the quick payoff almost three times more often.

What they found: Scans showed that the most impulsive subjects — most but not all of whom had a history of alcoholism — had reduced activity in an area of the brain that helps assess rewards and increased activity in other sections of the brain associated with judgment and decision-making. The differences suggest that some addicts may have impaired ability to think through a decision, Boettiger said. Blood tests implicated a variant gene.

What it means: More study is needed, but Boettiger said the findings suggest new treatment approaches for addiction. Drugs for early-onset Alzheimer's disease and Parkinson's disease target the same regions of the brain, so those medicines may also be useful for alcohol or drug addiction.

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Bucking Privacy Concerns - Wall Street Journal

Staff Trained to Spot
Students in Distress;
Campus Suicides Drop

By ELIZABETH BERNSTEIN

ITHACA, N.Y. -- For 19 years as a custodian at Cornell University, Sue Welch has been taking out the garbage and mopping the floors of residence halls. Recently, she added a new responsibility: trying to prevent student suicide.

Ms. Welch noticed during a recent semester that she was repeatedly having to clean up after a particular student's apparent bouts of nausea, and told her supervisor she feared the young woman had an eating disorder. The supervisor told the residence-hall director, who encouraged the student to go to the university health center. Counselors there arranged for her to get treatment for bulimia nervosa. Ms. Welch credits the training sessions that she and other custodians attended on how to spot students with mental-health problems.

"These kids are looking to us to provide care," she says. "But they don't see administrators every day, they see me."


Ms. Welch's dual role puts Cornell at the center of a debate over the privacy rights of American college students. After years in which many colleges have said privacy rules prevent them from interceding with troubled students, Cornell is taking the opposite tack.

Its "alert team" of administrators, campus police and counselors meets weekly to compare notes on signs of student emotional problems. People across campus, from librarians to handymen, are trained to recognize potentially dangerous behavior. And starting this year, Cornell is taking advantage of a rarely used legal exception to student-privacy rights: It is assuming students are dependents of their parents, allowing the school to inform parents of concerns without students' permission.

The Virginia Tech massacre earlier this year, in which a student with a known history of troubling behavior shot and killed 32 people, set off alarms about whether schools were overemphasizing the privacy of students at the expense of their health and safety. Watching over students and keeping parents in the loop may seem like obvious approaches, but many schools decline to share information about their students either internally or externally. Schools say they fervently guard students' privacy because a federal law requires them to, and because they are afraid of getting sued. They also say college students are adults who need to be supported in their growing independence.

Many schools refuse to release information without a student's written permission, and most rarely invoke exceptions allowed in the law, known as the Family Educational Rights and Privacy Act, or Ferpa. Some colleges have paid out settlements when families sued for wrongful death of students and alleged that officials should have raised flags. But other schools have won their cases. A jury last year decided that Allegheny College, in Meadville, Pa., was justified in not alerting the parents of Chuck Mahoney to his distress before his suicide, despite warning signs and discussions among officials worried he might pose a danger to himself or others.

Ferpa allows privacy to be breached if a student is under 21 and has a drug or alcohol violation, or if there is a health or safety emergency. The law only protects educational records, and doesn't generally apply to observations about student behavior. Schools are allowed to share information with parents if students are their financial dependents, as Cornell is now doing. This fall, Cornell used the new policy to inform parents that a student living in a residence hall was no longer enrolled in classes; the university says the parents were grateful for the call and took the student home.


"When parents send their sons and daughters off to college, there's an expectation -- and I think it's understandable -- that there will be people looking out for them," says Timothy Marchell, an associate director of health services at Cornell who holds an unusual additional title, director of mental-health initiatives.

In the last six years since Cornell took it first new steps in 2002, the school has had five student suicides, it says. In the previous six years, there were 11.

Dr. Marchell, 47 years old, is a Cornell alumnus who grew up in Ithaca, the son of a guidance counselor and a nurse-teacher in the local school district. He has been at the center of Cornell's recent collaborative mental-health approach. Until a few years ago, Cornell interpreted privacy law as narrowly as other schools. Even counselors and medical doctors in the health center were reluctant to share information.

But Cornell was battling a reputation as an intense school with a high suicide rate. The university was named the most stressful of 15 top schools in a 2000 book that surveyed students. Adding to its reputation was the campus's physical isolation in the rolling hills of central New York state, and its unusual local geography. Over the years, some students and others took their lives by flinging themselves off one of Ithaca's steep gorges. Stressed-out students have sometimes joked about wanting to "gorge out." Cornell administrators say the reputation is unfounded, and that the school averages one to two suicides a year, consistent with the national average for colleges. Still, they believed that some suicides might be preventable.

Dr. Marchell, who volunteered at a local suicide hotline when he was a Cornell senior, had gone on to earn a master's degree in public health and a doctorate in psychology. In 1998, Cornell hired him with a mandate: Tackle the school's problems with student drinking.

The flash point was a campus tradition called Slope Day. On the last day of classes each May, students would converge on a steep lawn in the middle of campus to drink themselves silly. Decades ago, the university itself supplied beer trucks and barbecues. That stopped when the legal drinking age was raised to 21 in the mid-1980s, but thousands of students started toting their own alcohol to the slope. Ambulances lined up at the edge, and students suffering alcohol poisoning or injuries from fights filled the health center and the local emergency room.

Dr. Marchell urged changes such as arranging appearances by well-known bands to make regulating alcohol more palatable. The school eventually enclosed the event with a long fence, inside which it sold beer but denied it to students under 21. Underage drinking dropped sharply and alcohol poisonings began a steady decline.

By 2002, the executive director of Cornell's health center, Janet Corson-Rikert, began making mental health a communitywide responsibility. The 1999 shootings at Columbine High School had shocked educators into recognizing the danger of failing to spot troubled students. Like most colleges, Cornell was starting to see more students enrolled with severe mental-health problems, as reduced stigma and improved medications allowed more of them to reach college. The counseling center was often overwhelmed with demand for appointments.

Dr. Corson-Rikert asked Dr. Marchell and others to build a network to train people to notice problems and give them ways to report them, while still respecting student privacy. An advisory council on mental-health strategies made up of Cornell staff, faculty and student leaders had its first meeting in early 2004, and members had a realization: In school post-mortems after tragedies, "each person knew pieces of the story but no one saw the whole picture," says Dr. Marchell. "If they had shared the information, maybe we could have intervened."

Dr. Marchell spoke with several suicide-prevention organizations, who pointed the school to a surprising model: the Air Force.

In the 1990s, the service decided to try to reduce suicides by airmen and studied each case for warning signs. They learned to look at behavior changes, discipline problems and poor performance ratings as possible indicators of depression. Four-star generals began to talk publicly about mental illness and encourage all service members to watch for warning signs. Each member of the Air Force is now given training in detecting depression and other mental disorders. The Air Force's protocol is one of few suicide-prevention programs proven effective: The average annual suicide rate dropped by a third, from 13.5 per 100,000 people to 9.9.

Cornell adapted parts of the program. Dr. Corson-Rikert enlisted the university's president, David J. Skorton, to use his speeches and articles to encourage everyone on campus to watch out for each other's mental health. Counselors began seminars to teach the signs of emotional problems or addiction. Last spring, Cornell's health center began screening students who come in for any reason for signs of depression, asking them about trouble sleeping, poor appetite, difficulties concentrating or thoughts of self-harm.

In September, Meredith Shepard, a 20-year-old freshman, went to the health center with a sinus infection. On her questionnaire, she scored high for depression and was referred to a counselor, who saw her the same day. Miss Shepard told her counselor she was feeling overwhelmed with stress from roommate problems and some "deeper struggles," she says. When she was 13, she had experienced depression and anorexia, triggered by suffering she had seen on a family trip to Nepal. Now, after volunteering last year with genocide survivors in Rwanda, she was finding the transition to college difficult. She'd begun over-exercising and under-eating. The counselor referred Miss Shepard to another therapist, who also referred her to a nutritionist, a psychiatrist and a medical doctor. "It's easy to feel lost, uncared for and alone," she says, but her "team" makes her feel "constantly aware of having a safety net."

Cornell therapists also make a form of house calls: They hold free, no-appointment consulting hours in 10 locations across campus. About halfway through each semester, professors in some of Cornell's seven undergraduate colleges are asked to report students who have bad grades, seem disconnected or are failing to come to class. "That kind of checking out is a very serious thing," says Alan Mathios, interim dean of the College of Human Ecology. "So, waiting for the end of the semester to come is often too late." Two psychologists work full-time just consulting with professors and staff when they have concerns about students.

Last August, a review panel on the Virginia Tech massacre recommended that colleges do more to share information about troubled students. About half the colleges in the country had teams of administrators aimed at doing so, and as many as a quarter more have quickly added them, according to a risk-management firm that specializes in colleges' insurance.

Dr. Corson-Rikert and Dr. Marchell had started their own multidisciplinary "alert team" in 2005. It includes the director of counseling, an associate dean of students, the campus police captain, the university's judicial administrator, therapists and sometimes other administrators. The team typically has several students on its agenda each week.

Sometimes administrators are worried that a student has stopped going to class or, as happened recently, is attending classes despite having been suspended. Often the police report a student who has been arrested for excessive drinking or drugs. Therapists are legally required to keep their own patients' information confidential, so they say they don't share that. But they can receive information from other team members and follow up, and can give general professional advice.

Recently, campus police responded to 911 calls about an alarmingly disheveled and agitated young man in a campus building. They took him to the local hospital, where doctors diagnosed him as psychotic and admitted him. The next day, members of the Alert Team planned travel arrangements for the student's parents and set up a medical leave so the student wouldn't fail classes.

"We were trying to put a system in place so that when a problem gets to this level, it doesn't get worse," says Gregory Eells, the school's director of counseling and psychological services.

Protests haven't arisen over the university's interventionist approach, but administrators say many of the mental-health initiatives work privately and students know little about them. Some students say, however, that the university may spend so much time caring for the most emotionally vulnerable students that it has fewer resources left for those who are merely stressed out. Dr. Marchell admits that's a potential problem with the school's approach.

Erin Geld was disappointed by Cornell's services last year after a good friend became seriously ill. Miss Geld says she fell behind in classes, suffered mood swings, felt depressed and slept constantly. But when she called the counseling center, after a triage interview she was told she had to wait three weeks to see a school therapist, and was offered referral to a community health resource for faster help if she wished. Miss Geld says she felt the off-campus therapy was ineffective and soon quit.

"Despite stepping to the plate and asking for help, I did not really get the support I needed from Cornell," the 23-year-old from São Paulo, Brazil, who graduated in May, wrote in an editorial last March in the Cornell Daily Sun, the student newspaper. Dr. Corson-Rikert notes Ms. Geld had the choice of waiting for a school counselor appointment; she says the counseling center schedules many appointments within hours or days based on their urgency, and tries to schedule others within two weeks but doesn't always manage.


Catherine Savage had a better counseling experience. The 24-year-old, whose father committed suicide when she was seven, has seen a therapist and taken antidepressants since she was in middle school. At Cornell, Miss Savage struggled with depression. She saw a therapist at the counseling center on and off. One night during her junior year, Miss Savage called the health center crying, and said she didn't want to live. The nurse on the line told Miss Savage to go to the hospital. She was admitted for 11 days.

Some schools have been sued for requiring suicidal students to leave dorms or campuses. Miss Savage got a call from her Cornell counselor, and one of her teachers visited her. At Miss Savage's request, the counselor arranged extensions in her classes and a voluntary medical leave, and found her a treatment program in her hometown. Miss Savage went home to Madison, Wis., and attended the University of Wisconsin. Her Cornell adviser helped her pick classes that would earn Cornell credit. A year and a half later, in the fall of 2005, she came back to Cornell.

She enjoyed her classes, rejoined the Cornell University Chorus and continued to see her therapist at the health center. "All parts of the school made it clear that my mental health had to be among my priorities if I wanted to have a happy life and do all the things I came to Cornell to do," says Miss Savage, who graduated in May 2006 and works as a hospital dietician in Salt Lake City. "And they gave me the support."

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A HIDDEN SHAME: DANGER AND DEATH IN GEORGIA'S MENTAL HOSPITALS - Atlanta Journal Constitution

More deaths blamed on errors, neglect
Preventable deaths continue at understaffed, overcrowded facilities

By ALAN JUDD, ANDY MILLER
The Atlanta Journal-Constitution

An ongoing pattern of medical errors and neglectful care contributed to as many as 21deaths this year in Georgia's state psychiatric hospitals.

These deaths occurred amid intense scrutiny of the hospitals' performance, an investigation by The Atlanta Journal-Constitution shows. The seven state-run facilities remain overcrowded and understaffed, and patients still are dying under circumstances similar to those that led to more than 100 other questionable deaths in the previous five years.

One patient died this year after doctors prescribed enough anti-psychotic medication to possibly kill a person. Those doctors "were not practicing the standard of care," another physician wrote.

Another man died from a misdiagnosed bowel obstruction. "I thought maybe it was something he ate," a nurse said later, explaining why the patient's symptoms went untreated. "We were not monitoring his intake or output."

In yet another case, nurses and aides disregarded a doctor's instructions to take a vulnerable patient's vital signs — more than 700 times. When he died, hospital staff members were merely guessing his body temperature.

The continuation of preventable deaths in 2007 — at a pace similar to that of recent years — underscores the scope of the troubles that have plagued the state hospitals for years.

The facilities have been under a spotlight since January, when the Journal-Constitution reported that at least 115 patients had died from neglect or abuse or under other suspicious conditions from 2002 through 2006. State authorities substantiated almost 200 reports of patient abuse during the same period.

The newspaper reported that poor care persisted in the hospitals during those years even as federal regulators cited widespread deficiencies. In 2002, for instance, regulators ordered Georgia Regional Hospital/Atlanta to correct overcrowding and patient care problems. But in a 2006 inspection, the regulators found that many of the same failings still existed.

In response to the Journal-Constitution's articles, the U.S. Justice Department is investigating whether conditions at the hospitalsviolate patients' civil rights. The agency could ask a federal judge to appoint a monitor to supervise the facilities. It also could force the state to spend millions of dollars expanding services, creating space for more patients or otherwise improving the hospitals. The results of the federal inquiry are expected to be released in 2008.

Meanwhile, consultants hired by the state have produced scathing reviews of hospital performance. And a commission created by Gov. Sonny Perdue is studying ways to overhaul the state's mental health care system.

Officials at the Georgia Department of Human Resources, which operates the hospitals, declined to comment late last week. Over the past several months, they have said they are trying to improve all aspects of mental health care. They speak of "rebalancing" the system to emphasize community-based treatment rather than hospital admissions. But they acknowledge that community services often don't exist or, when they do, are not plentiful enough.

Georgians with serious mental illness remain about three times more likely to end up in a state hospital than residents of other states. Georgia's state hospitals readmit a significantly higher percentage of patients than the national average. And at any time, nearly 100 hospital patients are ready for discharge, but have no place to go.

Citing privacy regulations, state officials refuse to identify deceased patients or to explain why they died. The Journal-Constitution relied on hospital reports, autopsies, death certificates, a database of vital statistics and interviews with patients' families and the families' lawyers to compile a picture of conditions inside the facilities.

The newspaper's review indicated that the state hospitals are arguably as dangerous as they were a year ago. In all, 55 hospital patients died of all causes this year through mid-November, the latest date for which reports are available. Of those, as many as 21 died after what appears to have been negligent care by physicians, nurses, aides or technicians, the Journal-Constitution's examination found. They died from causes that have become familiar in the state hospitals in recent years.

At least three choked on food, vomit or foreign objects. Two died from medication errors. Two developed fatal intestinal blockages, the same condition that killed 14-year-old Sarah Elizabeth Crider at the Atlanta hospital in 2006. Her death, highlighted in the Journal-Constitution in January, prompted hospital officials to create new policies requiring staff members to monitor patients' bowel movements.

But, as the deaths from intestinal blockages show, hospital workers still often failed to recognize symptoms of life-threatening illnesses or to provide adequate emergency treatment for injuries.


A missed clue

When Keith Ross developed a high fever last April, caregivers at Southwestern State Hospital in Thomasville thought he had the flu. "His condition was not life-threatening," a nurse manager said later.

But Ross, 19, a patient in Southwestern's forensic unit, which houses criminal defendants for mental illness, died shortly after hospital workers sent him to a local emergency room. The cause of death: appendicitis and a heart inflammation.

The medical director for the state's mental health division at the time determined later that the hospital staff should have sought emergency treatment much sooner. Ross' persistent fever, she wrote, should have been "a big clue."

Ross' grandmother, Beatrice Wilson of Albany, said doctors at Southwestern State gave him antibiotics for several days before seeking emergency treatment. She still wonders why they waited, and what made her grandson so sick.

"Those questions have not been answered for me," Wilson said.

Questions also remain about the death of a 71-year-old patient last May at Central State Hospital in Milledgeville.

The woman fell to the floor as a nursing assistant put her to bed. But the patient received no medical treatment for her injuries for five days – until just a few hours before she died. The aide apparently never told the patient's physician about the fall.

The woman's "right to appropriate medical treatment was violated," a state investigation concluded. The hospital fired the nursing aide.


Breakdown

The death of a 55-year-old patient at Central State in July shows how a breakdown in communication between physicians and other staff members could result in a breakdown of care.

The patient had been blind and mute since birth. He needed a safety belt and a lapboard to keep him from falling out of his wheelchair. He came to the state hospital, a report said, when his family in DeKalb County could no longer handle his "uncontrollable and destructive behavior."

The man was prone to dangerously low body temperatures. In April, his physician at Central State instructed nurses to take the patient's temperature rectally every two hours for 90 days, and to notify him if it fell below 96 degrees.

The nurses and aides rarely followed the doctor's orders. During the last three months of the patient's life, records show, they failed to record his vital signs as instructed 739 times.

Late on July 3, according to state records, the patient had been vomiting continually for more than 24 hours. His condition worsened overnight. He vomited at least three more times, twice throwing up what nurses and aides described as "coffee-ground" material – most likely, blood from his gastrointestinal system.

The hospital staff called the doctor at 2 a.m., but he did not come to examine the patient. The staff, he said later, assured him the man's vital signs were "stable." However, a nursing aide later said she merely thought the man's temperature was 97.6 degrees — or "somewhere around there," as she put it.

The doctor ordered a suppository for the patient and told the staff to disconnect his feeding tube until morning.

Records indicate the staff next checked on the patient at 4 a.m. He had vomited again. At 5, an aide returned and found the man "just lying there," she told investigators. A nurse issued an emergency code and attached a defibrillator device to the man's chest. Nine efforts to force his heart to beat failed. At some point, a nursing aide dialed 911 to summon paramedics to the hospital.

The doctor arrived at 5:26 a.m. and pronounced the man dead 12 minutes later. Officials performed an autopsy, but the report won't be finished until January.

The state's investigation found the man's vital signs had last been checked 13 hours before he died. A report on the inquiry concluded that one nurse and one aide had been neglectful in the patient's care.

The report's recommendation for avoiding future lapses: training for the hospital staff in how to follow physicians' orders.


A barrier to care

The deaths in Georgia's state hospitals, psychiatric experts say, show the need to focus not just on patients' mental conditions but also their physical ailments.

High-quality medical care in psychiatric facilities is "extraordinarily important," said Dr. Charles Nemeroff, chairman of the psychiatry department at Emory University School of Medicine.

As a member of the commission examining Georgia's mental health care system, Nemeroff heads a subcommittee that will study quality of care issues for the hospitals, including the credentials of state-employed physicians. The state hospitals, he said, should hire physicians who have been certified by the boards overseeing specialties such as internal medicine, not just psychiatry.

Of the 190 doctors employed by the state hospitals in the fiscal year that ended June 30, just 88 had any board certification, according to the Journal-Constitution's analysis of medical licenses. Thirty-six of the 88 were certified in areas other than psychiatric medicine.

Nemeroff said people with serious mental illnesses are prone to medical disorders, such as heart disease, stroke and diabetes. They often receive poor, or no, medical care in the community. And, he said, they have "a fundamentally shorter life span" than other adults.

"This conspiracy of reasons comes together to, unfortunately, present a barrier for psychiatric patients — particularly state hospital patients — to get good medical care," said Nemeroff.

"It's a reason," he said, "to consider them an at-risk population that ought to get more attention, not less attention."


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The fight for autism - Denver Post

Parents of kids with autism struggle to free their children from the grip of the mysterious disorder - and find ways to foot the bills.

By Karen Auge

Therapist Ashley Rein swings 4-year-old Abby Tappert as her mom, Jill, watches. Rein provides Applied Behavioral Analysis therapy for Abby three hours a day, four days a week, something the Tapperts just managed to get their insurer to pay for. ( Helen H. Richardson, The Denver Post )There was a time, Jill Tappert said, when she didn't think she'd ever hear the word "Mama" from her daughter.

Abby Tappert was, in her mother's words, born limp. She couldn't suck. She didn't seem to care whether her parents were in the room or not, whether they held her or didn't. At 9 months, she couldn't sit up, and she didn't take a step until she was almost 2.

As her mother recalled Abby the baby this month, Abby the 4-year-old twirled around the family's Boulder living room, a blur of purple tights and floating ponytails.

"Look at me, look at me," she sang softly. "Look at me! Look at me!"

People are, in fact, looking at Abby Tappert.

Last month, a judge ordered the family's insurance company, Anthem Blue Cross/

Therapist Ashley Rein reads with Abby Tappert, 4, during a recent session. Applied Behavioral Analysis therapy, which some insurers deem "investigational," has proved helpful to Abby. (Helen H. Richardson, The Denver Post )Blue Shield, to cover the therapy her parents say has cost them $110,000 over the past two years.
That has gotten a lot of people's attention.

The number of children diagnosed with autism, a mysterious and often devastating neurological disorder, has exploded. But answers, proven treatment options and help for anxious and financially strained parents and their children have not kept pace.

So while arguments continue in courts, schools and insurance offices across the nation, autism continues to exact an enormous toll, emotionally and financially, on parents and taxpayers.

This year, the federal Centers for Disease Control and Prevention estimated that as many as 1 in 150 children in the United States have some form of autism. In Colorado, the estimate is 1 in 169.

In the late 1960s when she entered the medical field, the estimate was 1 in every 10,000 children, said Cordelia Robinson, director of the University of Colorado Denver School of Medicine's JFK Partners.

The medical school, JFK Partners and Children's Hospital this month were named two of 15 Autism Treatment Network centers by Autism Speaks, a nationwide advocacy group.

There is no standard treatment for autism. Science is still struggling to

Five-year-old Mikaila Griffin-Williams, above, has her mom, Sandy, lift her legs, which is part of Mikaila's occupational therapy. Sandy says Applied Behavioral Analysis therapy has been a godsend for Mikaila, who has autism. "We've got a nighttime routine now; she sleeps in her own bed, eats at the dinner table." (Mark T. Osler, The Denver Post )explain the condition itself.
In the meantime, parents often wind up searching out treatments on their own. When they do, they discover a dizzying array of options — from speech or behavior therapy to gluten-free diets to hyperbaric oxygen therapy and even something called the Weighted Therapy Belt, available on the Internet for $43.95.

Whatever they choose is likely to be very expensive, and not covered by insurance.

There is a saying in autism circles: " 'The bad news is, your child has autism. The good news is, it's treatable. The bad news is, you can't afford it,' " said Betty Lehman, executive director of the Autism Society of Colorado.

Some help is available

State and federal programs offer some

Sandy helps Mikaila calm herself as she lets out a prolonged ahhh. Sandy says Applied Behavioral Analysis therapy has been a godsend for Mikaila, who has autism. We ve got a nighttime routine now; she sleeps in her own bed, eats at the dinner table. (Mark T. Osler, The Denver Post)help, but that can be hard to come by. Programs can be fragmented, and waiting lists are the rule.
This year, Colorado's legislature funded a special program within Medicaid specifically for children with autism. There is money for 75 children 5 and younger to get up to $25,000 worth of autism therapy each year.

As of Nov. 30, 64 kids were enrolled in the program, according to the state agency that runs it.

A federal program called the Individuals With Disabilities Education Act also provides some money — although states must provide the lion's share — for treatment of children with a variety of developmental disabilities, including autism.

In Colorado, that program is administered regionally by 20 Community Centered Boards, which coordinate services for each child from birth until age 3. According to state officials, the services available vary widely from one county or region to the next. At age 3, the responsibility falls to the school district in the child's home community.

"All of our school districts are independent," Lehman said. "They don't share resources; they don't share information. The wheel is reinvented in every single school district."

The autism society is hoping lawmakers will create a statewide autism task force, much like the nationwide group Congress assembled in 2000 to better coordinate treatments.

Most insurance companies' coverage is similar to what Anthem offered the Tapperts: a lifetime maximum of 20 hours each of occupational therapy, physical therapy and speech therapy.

Among major insurance providers in Colorado, there is slight variation, but virtually none would cover the therapy the Tapperts credit for Abby's improvement, according to information provided by Cigna and Kaiser Permanente, among others .

That therapy is part of a group of approaches that fit under the heading of Applied Behavioral Analysis therapy.

The common thread among all of them is that therapists work with families to determine each child's specific problem areas — what causes a particular child, for instance, to withdraw into a repetitive behavior or begin screaming, said Phil Strain, director of the University of Colorado's Positive Early Learning Center.

Strain has developed one take on ABA therapy, called Learning Experiences An Alternative Program for Preschoolers and Parents, or LEAP.

LEAP therapists visit preschoolers with autism at home and figure out what daily activities cause the most stress and produce antisocial or noncommunicative behavior.

"Based on that analysis, we try to change things in the environment that happen before or after the behavior, and if we're lucky, we get it right and you see really significant behavior changes," Strain said.

The program is one of six the state has a contract with to provide therapy with the new Medicaid funding.

Since Medicaid began paying for LEAP therapy, therapist Kelley Bramlege has seen her caseload jump to six or seven families a week, she said.

Before Medicaid stepped in, few families could afford the $4,000-a- month cost.

Sandy Griffin-Williams said her 5- year-old, Mikaila, "has just blossomed" since beginning LEAP therapy.

"We went from not being potty trained to completely potty trained. We've got a nighttime routine now; she sleeps in her own bed, eats at the dinner table. We can go out and eat at a restaurant now," she said.

Strain, who testified on behalf of the Tapperts, said such LEAP results have been documented in hundreds of peer-reviewed articles.

"When Anthem argues that this is experimental, you have to say, if 600 studies aren't enough, are you looking for 601?"

Abby Tappert's mother isn't.

"We can't wait for perfect science," Jill Tappert said. "We're in an epidemic."

To Jill Tappert, the very fact that Abby can say, 'Look at me!' is a huge leap. That she might actually want someone to look at her, to interact with her, is bigger still.

Even as autism's hold on Abby lessens a bit, it envelops her parents' lives entirely.

Abby doesn't sleep well — so neither do her parents. Like many autistic children, Abby for years had no fear — so her parents had to constantly fear for her. Until a therapist helped teach her boundaries, and fear, Abby would blast out of her mother's grasp and into the street. So her parents moved to a cul-de-sac where passing cars are the exception. Abby needs constant attention, tireless effort, so her mother provides it.

When Abby goes to bed, Jill Tappert starts what she calls "my Abby work" — filling out forms for various programs, researching therapy, conversing via the Internet with other parents of children with autism.

One of the rare facets of autism that parents, scientists and therapists agree on is the importance of diagnosing and treating autism as early as possible.

To Jill Tappert, that meant giving up her work as an attorney and devoting her days to working with Abby.

"I even felt guilty taking a shower."

"Not medically necessary"

Anthem contended, and still contends, that the therapy Abby Tappert was getting is "investigational and not medically necessary," said Anthem spokeswoman Sally Vogler.

Anthem reviewed its autism coverage in August, Vogler said. A committee that included "physicians from various medical specialties" examined peer-reviewed medical literature and concluded no changes to coverage were needed.

Anthem officials have not decided whether to appeal, but in any case, the insurance company says the decision sets no precedent.

That hasn't kept parents across the country from watching the Tapperts' case, and e-mailing:

"My family is very interested in any information you have on this case. We have a 5 y.o. son who we pay out of pocket for private ABA therapy. We have all but given up on having insurance cover any of it "

Tappert said she and her husband, Stephen, weighed carefully the personal cost of taking on an insurance company, knowing that hours invested in the case meant hours not working with Abby.

"But we also have to weigh the benefit now with the benefit later. Even if we lost, I would absolutely not have regretted taking this on," Tappert said.

"I'd do it again."

Karen Auge: 303-954-1733 or kauge@denverpost.com


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Scientists baffled by the biology of autism

More than 60 years after psychiatrist Leo Kanner first described treatment of children with severe social, communication and behavioral problems, the condition Kanner called autism remains an enigma.

"We are still struggling to understand what the biology of autism is," said Dr. David Amaral, research director at the M.I.N.D. (Medical Investigation of Neurodevelopmental Disorders) Institute at the University of California at Davis.

In people with autism, parts of the brain seem to develop too quickly — before the receptors are ready to interpret signals, Amaral said.

"Notably, the frontal lobe, which controls things like planning and social decision-making, seems to have a rapid growth spurt between 1 and 3 years of age" in children with autism, Amaral said.

As for autism's causes, Amaral said a strong genetic link is undeniable, but environmental triggers are at play as well.

"There is no doubt that in the end, we will identify multiple causes for the disorder," he said.

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Into the minds of children - Boston Globe

December 28, 2007

EDITORIAL

CHILDREN with undiagnosed mental illness can be a harm to themselves, their families, and their schoolmates. The conditions often go undetected because parents, while sensing that something is wrong, do not press the issue with their pediatricians, who themselves are often too busy to ask the right questions. So by requiring that pediatricians treating Medicaid patients screen for common mental illnesses, Massachusetts is taking a major step forward in promoting children's mental health.

For young children, parents will be asked, but not required, to fill out questionnaires asking about sleep problems, failure to show emotion, difficulties in concentrating, and other possible symptoms of underlying conditions. Adolescents will supply the answers themselves. It will be up to the families to decide whether to pursue any recommended course of treatment.

The screening, for which pediatricians already receive reimbursement from most private insurers, will benefit both the children who get timely attention and society as a whole. Early detection of bipolar disorder, autism, or depression can lead to effective treatment that will avoid costly periods of institutionalization if the condition is left unattended. Screening also helps to take away the stigma that many people still attach to mental illness, and to create data to measure the prevalence of disorders.

There are legitimate concerns that the screening will increase caregivers' caseloads and add to the difficulties parents already experience in getting care for troubled children. One solution is the state's Child Psychiatry Access Project, in which pediatricians seeking advice by telephone from a child psychiatrist get a response within 30 minutes.

The screening will not serve its purpose if it simply becomes a pipeline to the powerful psychotropic drugs that some experts believe are used too heavily with children. More likely, though, the screening will help to galvanize children's best advocates, their parents, in pushing for more care for them from the healthcare system and their schools.

Sometimes it takes more than just one screening result to get a parent to follow up on a child's evident needs. "Some parents have to hear things three or four times," said Lisa Lambert of the Parent/Professional Advocacy League. But eventually a long-term source of frustration with a child can become a diagnosis. "With the diagnosis," Lambert said, "doors and services can open to you."

Opening doors and services for the mental-health needs of the state's poor was the goal of the federal court case Rosie D. v. Romney, which is resulting in several systemic changes. Medicaid screening is the most basic. It will make Massachusetts a leader in ensuring that children's mental disorders get the same attention as any physical ailment.

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N.Y. Law Raises Issues of States' Reach in Patient Care - Washington Post

By Chris L. Jenkins
Washington Post Staff Writer

NEW YORK -- Susan Wezel had been committed to the city's hospital wards more than a dozen times in 10 years. Her psychosis was so deep and debilitating that she lost her career and her relationship with her son, as she refused to take her medication or follow treatment.

But because of a New York state law, Wezel hasn't been hospitalized in more than a year. She doesn't wander the streets alone at night anymore. She takes her medication willingly. She even has plans to follow her dream of singing at a neighborhood nightspot, something that was unthinkable 18 months ago.

Wezel and her caseworker agree that the transformation occurred because of the law, which allowed officials to force Wezel into an outpatient treatment program after she was discharged from a hospital.

Known as Kendra's Law, it is considered one of the most far-reaching mental health statutes in the country. It gives great latitude to doctors, social workers and relatives to take mentally ill people before a judge to force them into treatment, and it provides money for clinical services.

Just how far states can go to get mentally ill people into treatment is a key issue in Virginia. The state is struggling with changing its mental health system after a mentally ill gunman shot and killed 32 students and teachers at Virginia Tech in April before killing himself.

"All of this has saved my life," Wezel, 50, said in an interview at her caseworker's office in Queens. As part of the treatment order, she was given immediate access to a caseworker who closely monitors her through visits and phone calls. If Wezel fails to comply with her treatment, she can be picked up by police and taken to a hospital.

Wezel's experience with forced treatment underscores one of the most controversial issues in the care of the mentally ill. Seung Hui Cho, the Virginia Tech gunman, had been ordered into outpatient treatment, but officials didn't monitor whether he received it, and he never did.

Had something as detailed as Kendra's Law been in place, with its high expectation of accountability, officials might have been forced to monitor whether Cho got treatment, supporters of such measures say.

Virginia has an outpatient treatment law, but it is rarely used. Judges interviewed since the Virginia Tech rampage have said that they prefer institutionalization for the most severely endangered patients. Some judges said they think that ordering outpatient treatment is a waste of time because the lack of resources would make follow-up nearly impossible.

A survey conducted this year by the Virginia Supreme Court's Commission on Mental Health Reform found that judges used the outpatient treatment option in 5.4 percent of cases during the month studied.

Kendra's Law, named after Kendra Webdale, a 32-year-old woman who was killed in 1999 when she was pushed in front of a New York City subway train by a severely mentally ill man, allows courts to use a much lower standard than Virginia's to force outpatient mental health treatment.

To qualify for forced treatment under Kendra's Law, among other criteria, a person must have been hospitalized twice within the previous three years; must have shown violent behavior toward himself or others in the previous four years; and must need treatment to "prevent a relapse or deterioration which would be likely to result in serious harm to the person or others."

Across the country, supporters of such programs, known as preventive outpatient commitment laws, have called them pragmatic approaches in addressing the needs of the millions of mentally ill people who are not in institutions.

But there is intense debate among experts and policymakers about whether coercive statutes would be necessary in cases in which states increase the availability of services to the mentally ill.

Maryland does not have an outpatient commitment law. The District has a standard like Kendra's Law, but it is used sparingly.

The Supreme Court commission in Virginia recommended this month that the state expand the use of outpatient treatment for those who don't meet the criteria for forced hospitalization. The panel also called for specific procedures to monitor those receiving outpatient treatment and suggested ways to enforce it. But lawmakers also expect debate over a more expansive law that mirrors the New York statute when the General Assembly convenes next month.

"These arguments over outpatient commitment are some of the most emotional and contentious debates you'll find in mental health law," said Jeffrey Swanson, a professor of psychiatry and behavioral sciences at Duke University who is involved in a three-year study of Kendra's Law for the state of New York. "It really goes to the heart of whether we believe community mental health care can be effective without coercion and at what point we're willing to say that coercion might be necessary, legitimate and humane."

The New York statute outlines the responsibilities of local mental health agencies, spells out monitoring requirements and incorporates provisions for ordering noncompliant mentally ill people into hospitals. Those who are taken into outpatient treatment under Kendra's Law get immediate access to services. The petition process can be started by a roommate, parent, spouse, adult child or sibling, a hospital director or a caseworker, among others.

"There was nothing I could do to get her into any help before this," said Chris Wezel, 50, Susan Wezel's husband.

New York officials say the law has been effective. They conducted a survey in 2005, when the measure was up for reauthorization. The study found that a sample of patients treated under Kendra's law were more likely to participate in care, take their medication and follow up with caseworkers than when they were not treated under the law.

In addition, for those treated under the law, homelessness, arrests, hospitalizations and incarcerations dropped at least 74 percent and as much as 87 percent, the statewide survey found. Other studies conducted by mental heath researchers over the years have found similar outcomes the longer that mentally ill people stay in such coerced treatment programs.

"Coercion does work, if it's done the right way," said Mary T. Zdanowicz, former executive director of the Treatment Advocacy Center in Arlington County. She said that Virginia needs a law "that incorporates involuntary treatment, both inpatient and outpatient." Such laws get patients complete help the first time, rather than partial help over and over, she said.

But opponents of Kendra's Law say that the New York study did not use a control group for comparisons. The state's legislators were so skeptical of the available research that they called for a separate study and declined to make the law permanent. That study is due in 2009, and the law will come up for reauthorization a year later.

Advocacy groups and other mental health experts who oppose Kendra's Law say that it came with money for services, proving that coercion alone is not a solution.

The statute was accompanied by $32 million a year in state funding, much of it for medication and more caseworkers.

The law also affects a small population. Last year, about 1,800 New York residents fell under its guidelines at any given time, out of more than 400,000 mentally ill adults in the state, New York state health officials said.

"You have to consider the increase in services. It's not a slam-dunk to say that just because of the law itself, we have these better results," said Peter Beitchman, a longtime advocate for the mentally ill in New York City.

As opponents of the law have said, Andrew Goldstein, the schizophrenic man who pushed Webdale, had been denied outpatient services before the incident. He was told that there was no room for him at local treatment centers.

The issue of forced outpatient treatment resonates in Virginia because of the Virginia Tech shootings. Cho had been given an outpatient treatment order 16 months before the rampage. But it was never enforced by the local community services board or Virginia Tech's counseling center, and it was never specified which one was required to do so.

"Sometimes, those that need mental health treatment don't know they need help," said state Sen. Henry L. Marsh III (D-Richmond), who has unsuccessfully submitted bills like Kendra's Law in previous years and will do so again next month. Marsh will be chairman of the Senate Courts of Justice Committee next year, which will consider the legislation.

Staff writer Tom Jackman contributed to this report.

Virginia is going through an unprecedented

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Mo. Tries New Approach on Teen Offenders - Associated Press

By TODD LEWAN
The Associated Press
Saturday, December 29, 2007; 9:35 PM

MONTGOMERY CITY, Mo. -- At age 9, Korey Davis came home from school with gang writing on his arm. At 10, he jacked his first car. At 13, he and some buddies got guns, used them to relieve a man of his Jeep, and later, while trying to outrun a police helicopter, smacked their hot wheels into a fire hydrant.

For his exploits, the tough-talking teen pulled not only a 15-year sentence (the police subsequently connected him to three previous car thefts) but got "certified" as an adult offender and shipped off to the St. Louis City workhouse to inspire a change of heart.

It didn't have the desired effect.

"I wasn't wanting to listen to nobody. If you wasn't my momma, or anybody in my family, I wasn't gonna listen to you, period," says Korey, now 19. "I was very rebellious."

At that stage, most states would have written Korey off and begun shuttling him from one adult prison to the next, where he likely would have sat in sterile cells, joined a gang, and spent his days and nights plotting his next crime.

But this is Missouri, a place where teen offenders are viewed not just as inmates but as works in progress _ where troubled kids are rehabilitated in small, homelike settings that stress group therapy and personal development over isolation and punishment.

With prisons around the country filled to bursting, and with states desperate for ways to bring down recidivism rates that rise to 70 and 80 percent, some policymakers are taking a fresh look at treatment-oriented approaches like Missouri's as a way out of America's juvenile justice crisis.

Here, large, prison-style "gladiator schools" have been abandoned in favor of 42 community-based centers spread around the state so that now, even parents of inner-city offenders can easily visit their children and participate in family therapy.

The ratio of staff to kids is low: one-to-five. Wards, referred to as "clients," are grouped in teams of 10, not unlike a scout troop. Barring outbursts, they're rarely separated: They go to classes together, play basketball together, eat together, and bunk in communal "cottages." Evenings, they attend therapy and counseling sessions as a group.

Missouri doesn't set timetables for release; children stay until they demonstrate a fundamental shift in character _ a policy that detainees say gives kids an added incentive to take the program seriously.

Those who are let out don't go unwatched: College students or other volunteers who live in the released youths' community track these youths for three years, helping with job placement, therapy referrals, school issues and drug or alcohol treatment.

The results?

_About 8.6 percent of teens who complete Missouri's program are incarcerated in adult prisons within three years of release, according to 2006 figures. (In New York, 75 percent are re-arrested as adults, 42 percent for a violent felony. California's rates are similar.)

_Last year, 7.3 percent of teen offenders released from Missouri's youth facilities were recommitted to juvenile centers for new offenses. Texas, which spends about 20 percent more to keep a child in juvenile corrections, has a recidivism rate that tops 50 percent.

_No Missouri teens have committed suicide while in custody since 1983, when the state began overhauling its system. From 1995 to 1999 alone, at least 110 young people killed themselves in juvenile facilities nationwide, according to figures from the National Center on Institutions and Alternatives.

Does this "law-and-order" state know something others don't?

Hardly, says Mark Steward, who, as director of the state's Division of Youth Services from 1987 to 2005, oversaw the development of what many experts regard as the best juvenile rehabilitation system in America.

"This isn't rocket science," Steward says. "It's about giving young people structure, and love and attention, and not allowing them to hurt themselves or other people. Pretty basic stuff, really. It's just that a lot of these kids haven't gotten the basic stuff."

Take Korey Davis. He didn't meet his dad until he was 5. He and his siblings were raised largely by aunts and uncles. If the judge handling his case had left him in county detention centers until he reached adult age _ 17, in Missouri _ then had him serve the rest of his sentence in prison, few eyebrows would have been raised.

But a chance to save a life would have been missed. "In jail, I wouldn't never have changed what I always done," Davis says. "There was no treatment at all." He contemplates this for a second, and adds with a near-whisper: "Right now, I'd probably be dead."

In Missouri, judges can keep serious felons in the juvenile system until they are 21. That's what happened with Davis. At 15, he was sent to the Montgomery City Project, where robbers, rapists and the like get one last shot.

At first, he didn't want it.

But a year into his stay, two things knocked him back on his heels: the news that his younger brother had been shot and wounded in a gang fight, and an invitation from a counselor to sit down, after class, to read a book out loud with her.

To a boy accustomed to hiding his illiteracy, the offer felt awkward. But because this woman had given him a chance, he responded, and "when I actually learned how to read, it made everything in the world easier for me."

Three years later, Davis is a group leader _ and no softy with his peers, either. "We don't let each other get by with slick stuff, just doing the bare minimum," he says. He reads voraciously (recently, "The Bond," about three fatherless teens in Newark, N.J.). He's been accepted by a community technical college, plans to study carpentry. And, he's proud to say, his kid brother has taken to heart this advice:

"Put the guns down."

___

Many states are trying to bring down high rates of repeat offending by juveniles.

Wisconsin now treats some repeat offenders with mental health counselors in hospitals, instead of corrections officers in jails.

Illinois offers them drug treatment, job placement _ or an expedited return to custody.

And Washington state targets kids at risk of becoming its most serious offenders with early, intensive anger-management, drug and family therapy.

Research guided these approaches. One 2006 study, for example, found that anger-management, foster-care treatment and family group therapy cut recidivism drastically among teens, resulting in taxpayer savings up to $78,000 per child. Programs that tried to scare kids into living a clean life were money losers, according to the study, conducted by the Washington State Institute for Public Policy.

Missouri employs similar carrot-and-stick techniques. But it takes rehabilitation one step further by normalizing the environments of children in custody, says Barry Krisberg, president of the National Council on Crime and Delinquency, a nonprofit based in Oakland, Calif.

"It's a pretty simple concept: The more normal the environment, the more likely these young people will be able to return home and not be sucked into a criminal subculture," he says.

Montgomery City, built for Missouri's worst juvenile offenders, could be mistaken for a college campus.

In a literature class, students analyze plot lines in "Julius Caesar" and "A Farewell to Arms." In a computer lab, they write resumes and peck out cover letters to employers. In a central courtyard, they celebrate "Victim Empathy Week" by huddling in a circle with lit candles, praying silently for those harmed by their crimes.

The cottages where they sleep resemble college dorms, with one notable difference: These are all immaculate.

Ten teens are assigned to a cottage. Each gets a bed with quilt, pillow, nightstand, and an understood "space." In this space are often collected the precious remnants of a truncated childhood: dream catchers, stuffed animals, Dr. Seuss books.

"When you walk into these facilities and see 17- and 18-year-olds with dolls on their pillows, that's when it hits you: 'Hey, these really are just kids,'" says Ned Loughran, executive director of the Council of Juvenile Correctional Administrators.

Some things you won't see in this detention center: razor wire, barred windows, uniformed guards, billyclubs, or kids in orange jumpsuits with broken noses.

"We're all about creating a safe environment for our kids," Larry Strecker, Missouri's northeastern regional administrator, explains.

Here, boys wear _ well, what boys wear: jeans, knee-length Bermudas, an occasional earring, T-shirts. Staff members dress almost as casually.

To the teens, many of whom have done long stretches in adult jails awaiting adjudication, the sight and feel of Montgomery City come as a shock.

It was for Josh Stroder, who at 15 was arrested by a SWAT team in 2004 at his home in Dexter, Mo., and charged with 12 crimes, including terrorism. He confessed to improvising a bomb, which took off the front door of an appellate judge's home. No one was hurt by the blast. Police also found a car bomb in his basement.

The youth was detained in a juvenile center for a year, then sat in the Dexter City jail for 5 months before being sent to Montgomery City.

In a 6-by-9 cell, says Stroder, now 18, "there's really nothing to challenge you, nothing to stimulate you. It becomes easy to succumb to apathy, bitterness, or whatever is boiling in your brain."

He contrasts that with Montgomery City: "Here, you are faced with the possibility of reconciliation with so many people, and forgiveness. I was expecting a treatment program, but not so intense _ not the way it is here. I expected maybe to crack the surface of the ice, but not go in so deep."

Treatment comes in "group builders" _ sessions in which detainees open up to one another about traumas, crimes and family conflicts that have scarred them. Kids can also call a "circle," in which team members stand and face each other to air grievances, fears, anguish.

Two staff specialists, college graduates in counseling, psychology or social work, sit in on the circles, but the kids generally run them. "Adults lived in a different generation _ they can only tell us so much," says Korey Davis.

Teams that interact more are rewarded _ day furloughs to visit family, fishing trips, bicycle excursions, an afternoon volunteering at a food bank or a soup kitchen. Those who pull against the program _ generally, new arrivals _ quickly find themselves pressured by their peers to shape up.

"We know that when we do positive things as a group, we earn things," says Chan Meas, 17. Three years ago, he ran with a gang in Columbia, Mo., smoked dope, broke into people's homes. "Now, I look for positive people that care about others."

Montgomery City is no fairyland. It's a "Level 4" facility, meaning high security. It has isolation rooms, and every door locks automatically. Video cameras in walls and ceilings film everything, everywhere, 24-7. Kids need passes to go from one room to the next.

Kids are trained to restrain peers who threaten the team's safety. Only staff may authorize a restraint, but once they do, team members grab arms and legs and pin their peer to the floor until the child stops resisting.

This practice has its critics, such as Loughran, a former commissioner of the Massachusetts state Department of Youth Services, who called it "very, very dangerous."

"The juveniles have learned violence all their lives, and we're going to use them to control other residents? It's a confusion of roles," he says.

But Tim Decker, Missouri's youth services director, says there's never been a serious injury during a restraint, and rates of injury are markedly lower here than in states that rely on billyclubs and mace.

Besides, he says, the restraint policy reinforces the notion that "everyone in the facility takes responsibility for keeping it safe."

___

A half hour west of Montgomery City, in the university town of Fulton, there is a house that looks just right for a summer camp. It's brick, with a maple tree out front, a wide lawn and a wrought-iron sign that reads, "Welcome Friends."

Inside are comfy sofas, bookcases holding trophies, vases full of flowers, and 11 girls, ranging in age from 12 to 17, who've been convicted of truancy, assault, drug crimes, theft and forgery _ bright kids carrying darkness around inside.

This is the Rosa Parks Center, a detention home on the campus of William Woods University. Here, the girls get counseling, schooling, a feeling of togetherness.

"I had a lot of problems being angry," says Brooklyn Schaller, 15, who was arrested on drug charges and for violating a parental curfew. "I would be aggressive. I didn't care about anyone else, or anything else." But after just a year, even she has noticed a change.

"Last weekend I went home for a furlough, and me and Mom got into an argument, and so I left her alone. I let her have her space, and she came back and I listened to everything she had to say and she listened to me. And that was the most amazing thing, to sit down and talk and have someone listen to you."

What's been the difference?

Good role models help: The girls get to mingle with college students in the campus dining hall and attend campus plays and other cultural events. At the start of the school year they describe their experiences to incoming students during orientation week.

But the biggest plus, Schaller says, is that "you have people to talk to here, you have people who truly do care."

Rosa Parks Center opened in 2001, part of Missouri's response to the notion _ resurrected about a decade ago _ that it might be worthwhile to punish teen offenders by locking them up in adult prisons or in remote, sprawling juvenile prisons.

In the early '90s, a series of high-profile crimes had prompted dire predictions of teen "superpredators." Legislators across the country backed "scare-kids-straight" approaches.

But Missouri was on a different path by then, and stayed with it.

It had tried the traditional approach: From 1887 to 1983, young offenders from truants to attempted murderers were confined either at the Boonville Training School for Boys, or the Chillicothe Training School for Girls.

Boonville warehoused 650 boys, most of them minorities, in grim, two-story brick structures. There was rape and other brutality by guards, and a solitary confinement room atop the facility's administration building known as "The Hole," until judges demanded its closure.

"You had rural, white staff with inner-city kids of color, thrown in together with kids from all across the state who were disconnected from their families and neighborhoods," recalls Steward, the former director of youth services. "It wasn't a terribly successful formula."

Which is why conservatives such as John Ashcroft, the former Missouri senator and U.S. attorney general, and state Supreme Court Justice Stephen Limbaugh, a cousin of radio commentator Rush Limbaugh, joined with liberals such as the late Gov. Mel Carnahan to stick by systemwide reforms initiated in the late 1970s.

"What is remarkable about Missouri's system is that is has been sustained by conservative and liberal governments," says Krisberg, of the national crime and delinquency council. "They've seen that this is not a left-right issue. In many ways, its a commonsense issue."

A common-cents issue, too _ since it costs states between $100 and $300 a day to keep a juvenile in so-called "punitive" correctional facilities, according to a 2005 report by the Youth Transition Funders Group, a philanthropy network.

Missouri's per capita cost of its juvenile rehabilitation program is $130 a day.

"The fact is that most kids from punitive states get out, get re-arrested, and get thrown back into correctional facilities," Krisberg says. "What amazes me is that taxpayers in these punitive states put up with such rates of failure."

Miriam Rollin, vice president at Fight Crime: Invest in Kids, a nonprofit in Washington, D.C., with a membership of 3,500 police officials, prosecutors and crime victims, agrees:

"Twenty years ago, people threw up their hands and said, 'We don't know what works.' But now, we actually do know ... We're just not doing it _ or not doing enough of it."

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They Have Beds, but Not the Ones They Want - New York Times

By JENNIFER BLEYER

NORMAN BLOOMFIELD sat hunched over on his sagging twin bed at Surf Manor, a small adult home in Coney Island, and wondered why he was still there.

An elfin man with a shock of fine gray hair, Mr. Bloomfield, 60, spent three months in the psychiatric ward of Maimonides Medical Center in 2001. He then applied to Surf Manor, a faded red brick building on a bleak stretch of Surf Avenue, thinking it would serve as a temporary residence between the hospital and independent housing.

But his months at Surf Manor have turned into years, because he cannot find another place to live.

Surf Manor is one of 65 private, state-licensed facilities in the city that house a total of more than 8,000 residents. These institutions, known as adult homes, have become de facto repositories for people who have psychiatric disorders but who, like Mr. Bloomfield, can live independently.

“Some people need day-to-day assistance, but some are extremely high functioning,” Mr. Bloomfield said one afternoon in his drab yellow room, which he shares with a roommate. “It’s unfair and irrational when people who could be independent end up in a place like this and languish for years.”

Over the summer, Mr. Bloomfield and other members of an advocacy group called the Coalition of Institutionalized Aged and Disabled took steps to dramatize their plight and pressure government to take action. They set up a list of people who are waiting for independent accommodations. A few weeks ago, the number of names on the list passed the 200 mark.

The list, which the group termed the “people’s waiting list,” is a nod to the Mental Health Housing Waiting List Bill, legislation passed by the Assembly and the Senate but vetoed in 2006 by Gov. George Pataki and again in August by Gov. Eliot Spitzer.

The bill would have required a census of people who have mental illnesses and are waiting to move into specially designated housing, known as supportive housing, that would meet their needs.

The signatures gathered by the advocacy group include the names of residents of 20 adult homes who want to move into such housing. Typically, this involves individual apartments where people are responsible for their own cooking, cleaning, laundry and health care, but receive visits from support workers.

According to Geoff Lieberman, the coalition’s executive director, the goal is to prompt the state’s Office of Mental Health to help create more supportive housing specifically for adult-home residents. Sixty units of supportive housing are now in the pipeline — 20 each for Brooklyn, Queens and the Bronx — but, he said, “many more people want to move than 60.”

Jill Daniels, a spokeswoman for the Mental Health Office, confirmed that there were no more than those 60 apartments being created for adult home residents in the city, but added that such people were given priority when “housing needs and vacancies arise.”

Mr. Lieberman said that to the contrary, those people are often ignored.

“People are being warehoused in adult homes,” he said. “It’s not being viewed as it should be for many, as a steppingstone to greater independence.”

Mr. Bloomfield, sitting on his narrow bed, agreed. “We have a roof over our head,” he said. “But it’s not appropriate housing. It’s a dead end.”


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The Running Mate Who Wasn’t - New York Times

By FRANCIS WILKINSON

The federal courthouse in St. Louis is named for him. Accomplished men and women have recounted how they were awed by his intellect, influenced by his humanity, inspired and enlisted by his passion. Thomas Eagleton was a giant of Missouri politics. But he was a giant bound by ties of his own peculiar design. He spent the first part of his career in the grip of a secret. Later, he was fettered to a question he answered countless times but never resolved.

“He was a man of decency, honor, humor, integrity,” George McGovern told me recently, rattling off Eagleton’s virtues until they veered abruptly off a rhetorical cliff, “with an incredible cover-up.”

Thomas Francis Eagleton grew up in St. Louis, the second son of a successful lawyer whose own political ambitions were thwarted. As a boy, Eagleton accompanied his father on political rounds. After college at Amherst, Eagleton attended Harvard Law School, where he surrendered a coveted post on the law review in order to return home and help manage his father’s campaign for mayor of St. Louis. The senior Eagleton lost. The son never did. After law school, he initiated an unbroken string of political victories. Eagleton was elected circuit attorney of St. Louis at age 27, Missouri’s youngest attorney general at 31 and, in 1964, the state’s youngest lieutenant governor at 35. Four years later, he claimed a Senate seat.

Yet Eagleton was an unlikely running mate for McGovern, the 1972 Democratic presidential nominee. He supported a McGovern rival in the primaries, and according to the columnist Robert Novak, he spoke damagingly of McGovern off the record. But after Edward M. Kennedy and others refused McGovern’s entreaties, the call went out to Eagleton.

In a room with staff members, friends and even reporters present, Eagleton spoke on the phone with McGovern for less than a minute. McGovern’s aide Frank Mankiewicz subsequently asked Eagleton if he had any skeletons rattling around his closet. A terse denial inaugurated a latter-day industry of vice-presidential vetting.

Eagleton’s occasional hand tremors and tendency to perspire heavily were somehow overlooked in Washington. At a meeting before Eagleton’s official nomination, the McGovern campaign manager, Gary Hart was surprised, he told me rcently, to see Eagleton “pouring with sweat” in the air-conditioned room.

In the 1960’s, Eagleton and his family had taken great pains to hide his hospitalizations for mental illness, even diverting reporters with a tale about a stomach ailment. But after his nomination, an anonymous caller tipped off the McGovern campaign and the Knight news organization. The unraveling began.

With reporters rapidly closing in, Eagleton divulged at a news conference in South Dakota on July 25, 1972, that he had been hospitalized in 1960, 1964 and 1966 for what he first called “nervous exhaustion and fatigue” and later qualified as “depression.” He also said he had received electric-shock therapy. Many Democratic politicians and donors, sensing disaster, were irate. Nixon aides reveled in the Democrats’ misfortune.

Eagleton later explained that he had never considered his health history “sinister” — no closet, no skeleton. Years after, in his own narrative housed at the University of Missouri archives, Eagleton said that he had a “brief and random” exchange with his wife, Barbara, before he was asked to join the ticket. “If you should get [the nomination], won’t your health history come out?” she asked. Eagleton responded, “It could, I suppose.”

In two interviews, McGovern told me Eagleton related a longer version when they met just before Eagleton’s startling news conference. We had a meeting with Tom and his wife and Eleanor and me in Sylvan Lake in the Black Hills of South Dakota,” he said. It was Eleanor McGovern who asked the question that dogged Eagleton then and ever after. “Why didn’t you tell George about this illness?”

According to McGovern, now 85, Eagleton responded that he and his wife had had a lengthy discussion “back and forth, back and forth” and concluded that McGovern would reject him if the truth were known. “ ‘We decided you wouldn’t ask me [to join the ticket] if I told you,’ ” McGovern said Eagleton explained.

The political consultant Robert Shrum, a McGovern friend who worked on the ’72 campaign, said that in the mid-1970s McGovern told him the same story and that he heard it a second time from Eleanor McGovern many years later.

But Barbara Eagleton, the only other surviving member of the meeting’s discordant quartet, flatly denied McGovern’s assertion. “It never happened,” she told me. “Can you imagine asking that question? I think there would have been total animosity on the part of McGovern if that had happened.”

When I spoke with him, McGovern also characterized his private telephone conversations with two of Eagleton’s doctors, which took place immediately before Eagleton’s withdrawal from the race. “They both said we think he can do fine in the Senate,” McGovern told me. “But when it comes to trusting the whole country to one man, that’s different.” McGovern said Eagleton had bipolar disorder — manic depression. Barbara Eagleton said: “It was not manic depression. It was depression.”

To leave the ticket, Eagleton demanded a statement from McGovern that his health was not a factor. He got it. In a measure of the public’s ambivalence, Gary Hart said calls to the campaign, which had been overwhelmingly negative about Eagleton after the revelations, suddenly switched to overwhelmingly positive after his departure.

The public trial enhanced Eagleton’s stature. He resumed telling jokes in the Senate cloakroom, led debate on a war-powers resolution and passionately argued for an end to the Vietnam War. He was particularly proud of his successful amendment to stop funds for the bombing of Cambodia.

For years, friends in Washington sensed tension between the McGoverns and Eagletons. Eleanor’s anger barely softened. Eventually, George’s did. “I know a little about political ambition,” he told me.

Eagleton retired from the Senate in 1987, undefeated. The Eagletons returned to St. Louis, where he took up law, teaching and a hefty civic load. Though he gradually lost his health and hearing, Eagleton remained passionate about public affairs, firing off letters to protégés, friends and political leaders. He was outraged by the Iraq war, pleading with Bill Clinton in a 2006 letter to forgo “the traditional silence of an ex-president in wartime.”

Late in life, Eagleton began collecting art. He was particularly fond of the German photographer Candida Höfer, whose work features public architecture of uncluttered environs and clear boundaries. Her photographs convey the scale of the public sphere. But her libraries, theaters and government halls are containers devoid of people, empty of the struggle and striving of human affairs. In a singular political life, Eagleton had experience enough to fill the void.

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Schizophrenia takes a daughter away - LA Times

Even a loving family with ample financial resources is powerless against the disease.

By Scott Gold and Lee Romney
December 29, 2007

By the time she landed at Metropolitan State Hospital in 2006, Tiffany Sitton had been haunted by delusions for 15 of her 23 years. Spiders burrowed under her skin. Ghosts ordered her to hurt people. Schizophrenia and psychiatric drugs dulled her eyes and numbed her brain.

Hers was the most vexing kind of case, blending severe mental illness with a rebellious disposition and drug abuse. When she got to the austere Norwalk hospital known simply as Metro, she'd bombed out of virtually every other option the mental health system had to offer.

She had mastered the art of institutional life. If her caretakers wouldn't give her a match to light a cigarette, she knew how to use a gum wrapper and a light socket to set fire to a tampon. She wore studded dog collars and shredded stockings, and her hair, once as wispy as the crown of a dandelion, had been hacked off and dyed.

None of that changed the fact that she was a wealthy kid from the suburbs whose bedroom, back home in a pocket of horse ranches and eucalyptus groves in San Juan Capistrano, was waiting for her.

She was scared at Metro, and perhaps she was right to be.

Past the red sign at the door of Unit 410 -- "HIGH AWOL RISK" -- was a prove-yourself hierarchy of bulimics and cutters and patients known as picas, who swallowed staples and keys and whatever else they got their hands on. During her six-month stay, three patients attacked her. One tried to rape her.

She called home, again and again, begging to get out.

Her parents refused.

Cynthia and Michael Sitton believed they had no choice. Before she could start getting better, they thought, she had to hit bottom.

The strategy seemed to work. When Tiffany was ready to leave Metro six months later, she seemed finally willing to embrace treatment.

"I don't ever," she told her mother, "want to be in this place again."

So, one year ago, they made a pact. Tiffany would quit sabotaging her treatment, getting in fights, snorting other patients' meds. She would remember why it was good to be alive. Her parents would find a top-of-the-line hospital. When she was able, she could visit at home. They would keep her safe. They would keep her out of Metro.

The next year would be a test -- of Tiffany and her parents, and also of California's mental health system, which so often fails the toughest cases.

Unlike most who suffer from severe mental illness, Tiffany had everything going for her.

Her doctors had found the right cocktail of pills to ease her symptoms. She had a full-time advocate in her mother. Wealthy through Michael's flooring company, the Sittons had spent more than $250,000 on her care. Now they pledged to redouble their efforts.

Would it be enough?

It came out of nowhere.

Tiffany tugged on the sheets next to her mother's head and whispered into the darkness. She'd seen dogs in her room, menacing dogs with red eyes. Cynthia told her she'd had a nightmare.

"She insisted," Cynthia said recently, "that she had been awake."

And she had been.

Tiffany was 8.

Hers had not been the easiest of childhoods. Cynthia's first marriage, to Tiffany's biological father, had not ended well. Mother and daughter had spent several years living like gypsies, poor and mobile.

Still, they were unusually close, and Tiffany's gregarious spirit seemed unaffected by the turmoil. Their lives had stabilized. Cynthia married Michael, like her a recovering alcoholic. Michael adopted Tiffany, and he and Cynthia had two more children.

The Sittons dismissed the hallucination at the time. They know now that it was the first symptom of schizophrenia, a disease shared by an estimated 2.5 million Americans.

At 12, Tiffany became convinced that she was personally involved in stories that appeared on the TV news. At 13, she began hearing voices. At Aliso Niguel High School, she shaved her eyebrows and announced that she was a member of a gang called the Slick 50s, though there was no evidence that she knew any actual members.

At 15, after she pulled a knife on a schoolmate, a county psychiatrist told Cynthia to order a pizza and give Tiffany more hugs. It was the first of many times the system would fail them.

After she stole a car, Tiffany landed in juvenile hall, where a doctor diagnosed schizophrenia. It was a particularly early onset of the disease, and the timing was devastating. Tiffany had exchanged the normal, vital chapters of adolescence -- algebra homework, prom, her first kiss -- for a bewildering and often terrifying fantasy world.

Cynthia steeled herself "to do anything I had to do to make her better." She believed that there was help coming, that they could beat this.

"I still had the luxury," she said, "of naivete."

That wouldn't last long. After Tiffany got out of juvie, she ran away, hitchhiking to Los Angeles, where she lived on the streets, eating uncooked ramen noodles and using any street drug she could find. A friend found her in Compton, badly beaten.

Not long after that, despite 24-hour care at home and the efforts of a $220-an-hour psychiatrist to devise the right cocktail of medicine, Tiffany plunged a knife into her arm in the Sittons' kitchen.

She was involuntarily committed to an acute-care mental ward. That was four years ago, and it was the end of her life on "the outside," as Tiffany calls it.

"She's my kid," Cynthia said. "You feel terror. Just terror."

When the news came in December 2006 that Tiffany was ready to leave Metro, Cynthia was ready. In keeping with her pledge, she helped find her daughter a bed at Royalé Mission Viejo, a small psychiatric hospital. Papier-mache butterflies adorned pastel walls and the halls smelled of air freshener. It seemed a world away from Metro.

In the past, every time she'd bounced to a new facility, a new treatment team had evaluated her, often starting from scratch with little regard for what had been tried before. Tiffany had been diagnosed, at one time or another, with schizophrenia and five other disorders: bipolar, obsessive-compulsive, borderline-personality, antisocial personality and post-traumatic stress. With each new diagnosis came new medications.

Here, the staff seemed unusually attentive, and Tiffany hit it off with several nurses and social workers. It was a strict and rigorous treatment program, and Tiffany seemed to thrive.

She quickly became the president of her ward at Royalé, a job that required her to act as a liaison of sorts between patients and staff. She earned new privileges, such as outings with her mother: lunch, or a trip to her favorite spot, a thrift store where she spent hours assembling zany outfits of platform shoes and leopard-fringed skirts.

Cynthia had trained herself to be skeptical of the good times.

"There is a fear of enjoying it too much," she confessed one day. "The crash is just so horrible. It's like she dies, every time. You don't go to a funeral. But it's like your kid dies, again and again and again."

Still, it had been a long time since Tiffany had seemed so lucid, so self-aware.

"You're doing really well, girl," Cynthia told her one day in March, over lunch at Tiffany's favorite Chinese buffet.

"I'm trying," Tiffany said.

Her bedroom at Royalé, which she shared with a roommate, was immaculate. She kept a Bible on the nightstand. She made friends and started playing billiards in the recreation room.

She became articulate and self-aware, even poking fun at her illness. (One day at an exotic bird store, another favorite haunt, she held a parrot on her arm for a minute, then turned and whispered conspiratorially: "This bird wants to kill me.")

And she began taking responsibility for her troubles. She called her siblings -- Matthew, then 16, and Jessica, then 13 -- and apologized for being a bad role model and sabotaging her treatment.

"I don't want to do this anymore," she said one day. "I'm here because of me."

In June, Tiffany was granted a pass for an overnight home visit. The family gathered in the backyard over steaming bowls of Michael's pasta e fagioli, with kidney beans.

Tiffany excused herself regularly to smoke cigarettes and collect her thoughts on the other side of the yard. But it was a pleasant, normal evening, or as close as the family had come for a long time. They laughed about a relative who used outlandish amounts of rouge. Michael even poked fun at Tiffany's shaved head, and she smiled.

"I've always felt," she said that night, "that my life had a purpose."

There was a part of her, she confessed, that missed the drama of Metro -- the "action," she called it.

Still, she wanted desperately to recapture an independent life, and that drive was paying off. She was placed on the waiting list to move onto the A level of Royalé, reserved for patients nearly ready for release. On Level A, she would attend independent-living classes and prepare for life in a board-and-care facility on the outside.

"I think she's ready for it," Cynthia said in July. "I really do."

The Sittons had been burned by hope plenty of times.

Tiffany's schizophrenia is complicated by her bipolar disorder. Like many schizophrenics, she had also been a serious drug abuser: heroin, Vicodin, by her account just about anything that came along. Each had impeded treatment by mixing poorly with prescribed medications.

"It's like part of me wants to be sick. So I do bad things," she said on a recent afternoon. "I know I do bad things."

But as much as the Sittons seek to hold Tiffany accountable, their odyssey also speaks volumes about the mental health system.

Treatment was laughably poor in some facilities: "exercise" classes consisting of patients walking in a small circle, group therapy sessions offering the same counseling to a schizophrenic, an anorexic and an elderly patient with dementia.

Even in locked facilities, Tiffany managed to get her hands on street drugs like methamphetamine. At one point she had ground up and snorted so many medications prescribed for other patients that her insides were pocked with ulcers.

At each place Tiffany was admitted, the Sittons provided a document detailing her illness and past treatment. But on three occasions, Tiffany was prescribed antidepressants -- despite an explicit warning in the document that such drugs sent her into a manic state because of her bipolar condition. (Tiffany's caretakers declined comment for this article, citing her privacy.)

"They don't look at the history. They just talk to the patient, who is psychotic," Cynthia said. "I'm in there every day, advocating, and she still falls through the cracks. Imagine what happens to the thousands of people who don't have that."

Even at the best facilities, like Royalé, the smallest fissure can lead to disaster.

In July, Tiffany told her mother how much she liked her new roommate. That struck Cynthia as odd. The roommate was very sick and was quiet and meek, not the sort of person Tiffany was typically drawn to.

Days later, Tiffany extinguished a cigarette with the heel of her shoe and turned to walk back inside Royalé. A staff member asked her to pick up the butt. Tiffany went ballistic.

She ranted in the hallway, then stomped into her bedroom, shattered a compact disc case and threatened to cut people with the plastic shards.

The staff soon caught her with a razor blade she had hidden in her belongings. The voices, she told her mother, were back.

Two weeks later, Tiffany's increasingly deteriorating condition caused Royalé to transfer her to an acute-care center in Anaheim.

The next day, Cynthia got a message to call the facility immediately. She dialed the phone, her fingers trembling. Tiffany, they said, had tried to commit suicide. Cynthia got her on the phone.

"So," Tiffany mumbled through her drugs, "I guess I tried to strangle myself."

It took weeks for the full story to emerge. The new roommate, Tiffany eventually confessed, was "cheeking" her pills -- taking them from nurses but spitting them out later. She'd been handing them over to Tiffany, who ground them up and snorted them, sending her brain back into a tailspin.

Life, meanwhile, marched on.

Matthew was about to start his senior year of high school, juggling his studies, school theater and the shaolin kempo martial arts classes he taught. Jess, a freshman, was hoping to maintain her 4.25 grade-point average, despite softball and dance recitals.

Cynthia, a painter of intricate realist scenes inspired by mythology and her own life, needed to tend to her career. She also needed to tend to her marriage.

She and Michael were fighting. It fell along the usual fault lines: He accused her of coddling Tiffany; she accused him of being too hard on Tiffany and of checking out entirely.

"I have been guilty of taking my pain out on him," Cynthia said. "And vice versa."

Cynthia feared, more than anything, that their two other children were starting to pay the price for Tiffany's illness. Sometimes, she said, it feels as if there is time only for crisis management -- for Tiffany.

"It's the two of them who comfort each other, and it's great that they're close," Cynthia said, and then burst into tears. "They shouldn't have to do that. I want to be with them when I'm not exhausted. I should not have to pick between my kids."

In August, Royalé agreed to take Tiffany back, but when she refused to sign a contract stating that she wouldn't kill herself, she was transferred again, this time to an acute-care facility in La Palma. There, she started abusing another patient's methadone, a synthetic narcotic used to treat heroin addiction.

"This lady got 80 CCs a day," Tiffany said later, using common medical shorthand for cubic centimeters. "She would break it down between me and my friend. The first time I got 10. But the second time she gave me 20 CCs. I was out of it."

When they made their pact at Metro, Tiffany had promised to stop abusing drugs. Now Cynthia and Michael felt they had no choice. In September, they cut off contact with Tiffany.

The acute-care center, meanwhile, was anxious to free up Tiffany's bed. She was, once again, running out of options. A social worker had tried a host of longer-term care facilities: in Huntington Beach, in Riverside. None would take her, some because they were full, others because she had been there before and had burned her bridges.

Last month, a bed opened at Metro. There were no other options.

On Nov. 6, Tiffany was placed in an ambulance and driven back to the one place she and her parents had pledged to avoid at the beginning of the year.

Unit 410 was just as she remembered.

"There's boogers on the wall in the bathroom," she said a few days after she arrived, as she walked toward the fenced courtyard to have a cigarette. "People piss their clothes and leave them on the floor. There are fights. It's not a nice place."

"Watch out," she said as she walked through the door with a visitor. She pointed to a large drying splatter of vomit.

Tiffany soon began telling members of her treatment team that her mother was conspiring to keep her inside the institution and urging her doctors not to tell Cynthia about medical decisions they were making. She told them that it was her mother who was mentally ill, not her. Tiffany had also reconnected with Cynthia's mother, from whom Cynthia has been estranged for years. She announced that she wanted to move in with her grandmother.

"She knows where my jugular is. She's going for it," Cynthia said.

The Sittons were losing hope.

"It's just breaking my heart," Cynthia said earlier this month. "I don't know who to blame anymore or what to blame."

After anguished discussions with Michael, she filed court papers seeking to give control over Tiffany's future to a public guardian. If the petition is accepted by a judge in coming weeks, Cynthia will go from having the legal right to monitor every one of Tiffany's pills to not having the right to even find out where she is.

"I don't want to do this. But I don't have anything left in my bag of tricks," Cynthia said. "I have to use our relationship as leverage. That's all I have left."

On Nov. 10, Cynthia, 45, and Michael, 46, went to Metro. It was the first time they had seen Tiffany in three months. When Cynthia and Tiffany saw each other, they stood for several minutes, their foreheads pressed together, their bodies wracked with sobs.

"Hi, cutie," Cynthia said.

Tiffany had made, in the four years leading up to that day, 18 stops at 11 facilities -- nearly every hospital Orange County had to offer and several in Riverside and Los Angeles counties.

Acute-care facilities wouldn't keep her because she's often not in crisis.

Short-term facilities said she was too sick and disruptive.

Long-term facilities said she was too healthy to stay.

She had seen at least 50 psychologists and psychiatrists.

She had been placed on nearly 40 combinations of psychotropic drugs.

They were all exhausted.

"How are you guys?" Tiffany said, finally.

"We're worried about you," Cynthia said.

"I'm fine."

"Not really."

Silence.

Tiffany bowed her head.

Cynthia wiped away a tear and rubbed Tiffany's knee.

"I don't ever stop loving you," she said.

scott.gold@latimes.com

lee.romney@latimes.com Read more!