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Critical Care

For more than 30 years, when local children have needed psychiatric help, they have turned to the New Orleans Adolescent Hospital. Now, the hospital may be facing a crisis of its own.

By Katy Reckdahl

Pushpa Ramaiah, a graduate social-work intern from Tulane University, reassures a child. The state Office of Mental Health (OMH) calculated that 110,000 Louisiana children are "severely and seriously ill"; only 7 percent receive help.

Photo by David Rae Morris

Wilson runs and plays like any 8-year-old boy, until he grabs the rag dolls. Without fail, he buries them in the sandbox.

His narratives are usually similar to today's: "Never put the kids in the house with champagne," he says, sprinkling sand from above. He points at the dolls. Their house was filled with rats and rat traps, he tells Pushpa Ramaiah, a graduate social-work intern from Tulane University. "And the rats almost got 'em," he says as he completely buries the two adult dolls. Then, says Wilson, he came in. He saved the child -- her name is Rosa Parks. He killed the rat. And then, he says, the government took the money away.

Children like Wilson (whose name, like all children's names in this story, have been changed to protect privacy) may not discuss their abuse or neglect. But often they will reveal key insights into their past in the play-therapy room at the New Orleans Adolescent Hospital (NOAH).

Upstairs, behind the locked doors of the children's ward, Jason, who's 12, quietly arranges Jungle Book figures on the dresser in his room. Just outside his open door, a psychiatric aide sits in a chair round-the-clock. It's called one-on-one. Some kids require it because they're feeling suicidal. With Jason, the watch is necessary because he sexually abused his little brother and seems to be at great risk to reoffend. Hospital staff think that he endured severe abuse at a young age, because -- despite his yearlong stay -- he still won't discuss anything that happened before the age of 5.

Near the psychiatric emergency room, Christa Albert-Watson oversees the hospital's crisis intervention services. "We see kids with everyday behavior problems, HIV, suicidal ideations, actual stitches in their wrists, kids who witnessed someone being murdered, substance abusers," she says. One girl slept with a knife under her pillow because she saw her father beating her mother. Many children are diagnosed with post-traumatic stress disorder after witnessing violence in their neighborhood or home. Only the most grave cases will actually stay in the hospital.

But if one of its 30 beds is open, the hospital will admit any child between the ages of 6 and 17 who threatens suicide or murder or experiences severe distress like psychosis or hallucinations. This big brick building is considered the safety-net hospital for this area's emotionally disturbed kids.

Is there a safety net for this safety net? Lately, that question has been on the minds of parents and hospital workers alike. Last month, they got word that NOAH had been eliminated from the state budget. Since then, the news has been somewhat more reassuring. But if past legislative sessions are any guide, the future of NOAH is far from guaranteed.

It seems like the same old story, says one hospital worker, who pauses in the hallway before entering a child's room. "No matter what we do," she says, "it seems like the state is always saying 'Cut NOAH. Cut NOAH. Cut NOAH.'"

Earlier this year, on Valentine's Day, this woman and everyone else under the auspices of the state Department of Health & Hospitals received a grim email message from DHH Secretary David Hood. "As most of you will read in tomorrow's papers or see on television tonight," Hood wrote, "our agency today presented our response to the Governor's Executive Budget." The proposed budget had left DHH $1.5 billion in the red. In order to bring his department into the black, Hood explained, he had two options: make across-the-board cuts of 30 percent or select particular eliminations. He had chosen the latter.

This was only a proposal, he emphasized: "[I]t is important to point out that we've faced budget crises before, and the end result is always much different than what was first discussed. Please keep this in mind as the months move forward."

To NOAH staff, the words were all too familiar. Three years ago, in early 2000, DHH's proposed budget eliminated all of the hospital's residential beds. The hospital ultimately stayed, but with devastating layoffs -- on Oct. 30, 2000, 69 NOAH employees were told that their positions would be eliminated in December.

Yet in the end, says Dr. Martin Drell, "the state hitched up a disaster with an opportunity." In order to save the hospital, Drell -- the hospital's clinical director since 1991 -- had proposed that the hospital reconfigure itself. He told the state that he and his staff could create a new NOAH, one that would focus less on inpatient beds and more on outpatient work in the community.

The state agreed and NOAH delivered on Drell's promise. It cut inpatient admissions in half, created a transition team that worked with kids during the day and sent them home at night, and collaborated with existing neighborhood clinics to deliver mental health care within the community. The hospital went from serving 250 kids annually to more than 1,600. As recently as this past fall, DHH was hailing the facility as "the NOAH model" -- its flagship mental hospital.

Still, NOAH wasn't spared the chopping block.

"I'm not stupid like my dad," says Neal. "I told him, 'I ain't never gonna follow in your footsteps.'"

Neal is a tall 17-year-old -- 6-foot-2 -- who has been living with his two aunts for two years. Before that, he and his sister spent most of his childhood living with their father. Until, says Neal, "the incident happened."

A lot of people had been suspicious, he says. "I used to go outside and play with my friends. But my dad always kept my sister inside. So my friends would ask me, 'Neal, why don't your sister come outside? I only see her when she's going to school.' And then a neighbor lady asked me if my dad was messing with my sister."

One day, Neal says, he just got tired of it. He went next door to the neighbor's house, dialed 911, and said that his daddy had raped his sister. The police arrived and asked Neal's sister if her dad ever had sex with her. She said yes. The police arrested their father, who's now serving time for aggravated rape and incest.

"I was proud of my sister," Neal says. "Because some girls don't tell the truth."

Neal was also abused. He'll talk about some of it. Like his father kicking him in the stomach, pushing him onto the floor, or hitting Neal and his sister if their homework was wrong. "I try not to let that old stuff get to me," he says, and he thinks that his sister does the same. His sister, now 19, lives nearby with another aunt, but she talks to Neal on the telephone every day and sees him every Saturday.

Altogether, Neal has been to NOAH at least four times, he guesses -- mostly for feeling "sad or suicidal." The first time he was about 12, playing hooky from school when his dad found him hiding under the house and said, "You know where you need to go? The hospital." He stayed for three weeks, he says.

Days at NOAH always begin the same way, he says. "In the morning, the staff turns your lights on, knocks on your door, tells you it's time to get up." You're supposed to make your bed, wash your face, and brush your teeth and hair. If you do, you get points or tokens -- Neal saves them up to "buy" his sister stuffed animals and other small gifts from the ward's reward cabinet. Kids enter at Level I and move to Level III and then are released according to their progress.

During the day, there's school on the fifth floor. Neal says that currently at a local public high school he is "acing lunch," but that he got good grades at NOAH, where there are eight teachers and typically five or six kids in a class.

"If kids don't receive help in the mental-health system, they may end up in the forensic (justice) system," says New Orleans Adolescent Hospital clinical director Dr. Martin Drell.

Photo by David Rae Morris

The rest of the day is filled with arts and crafts, group therapy, and daily one-on-one meetings with psychiatrists. Neal also liked going outside to play football or just to enjoy the view. "It's never dirty, no trash. And the grass is cut every day," he says.

State Sen. Diana Bajoie, one of the legislators who in 2000 was vocal about keeping NOAH intact, says that those grounds have been coveted for many other purposes. "I've heard proposals about building condominiums there," she says. She believes it's perfect for fragile kids. "The serenity of it, it's a wonderful place for children with mental illness. And it's close to home."

Because Neal was close by, say his aunts, they were able to visit him and attend meetings about his care. Both aunts work with young kids and speak in the calm, precise way that is common among teachers. They explain that Neal's mother -- their sister -- had her first breakdown when she was 16 years old and spent quite a bit of time afterward in mental hospitals. She died when Neal was two.

Because of this, Neal's father would often refer to Neal as a sick child, says the aunt. "You can plant an idea in a child's head: 'If mama was sick, then you must be sick, too.'"

But Neal's illness is much less severe than his mother's. He's also helped by pharmaceutical drugs that hadn't yet been developed when his mother was alive. "Lately, for a couple of months now, it's been pretty good," says his aunt. He's been especially helped, she says, by the antidepressant Wellbutrin, which he started taking two stays ago at NOAH.

Neal's last visit to the hospital was only one day long. He was feeling depressed and hearing voices, and so NOAH placed him in the newly developed "crisis respite cottage." It's a quiet apartment with round-the-clock, one-on-one watch on the hospital grounds. Here, kids like Neal can have access to hospital doctors and social workers and some quiet time to themselves without having to be admitted to the hospital itself.

Since that stay, people from NOAH's new seven-person Assertive Community Treatment (ACT) team check up on him. They take Neal to all his appointments and they stop in during the day at his school. Says Neal: "They ask if I'm taking my medication like I'm supposed to; they ask me if I do my chores; they ask me how I'm doing in school."

With the help of the ACT team, his aunts believe that they can keep Neal at home with them. "I tell him," says one of his aunts, "'I am going to try my ever-loving best to keep you out of the hospital."

That's exactly what Drell likes to hear. "We're a hospital doing things to keep people out of the hospital," he says.

The idea of community-based systems of care for children first took hold 30 years ago, after the American public got a few wake-up calls. In 1978, the President's Commission on Mental Health found that few communities could meet children's mental health needs. Four years later, in her book Unclaimed Children: The Failure of Public Responsibility to Children and Adolescents in Need of Mental Health Services, Jane Knitzer concluded that two-thirds of kids with severe emotional disturbances didn't receive necessary services. Instead of serving children, she alleged, public agencies were leaving them "unclaimed."

People called it an outrage. In response, the U. S. Congress in 1984 appropriated funds for the creation of "systems of care" that could help kids in their own homes and neighborhoods.

During the midst of this, in December 1981, the Louisiana Legislature created NOAH, in the former U.S. Public Health Hospital, a fenced-in group of buildings on 17 acres of lush land off State and Tchoupitoulas streets, on the down-river side of Audubon Park.

Today, in addition to NOAH, New Orleans has a network of community mental health clinics. Still, very few children get help. Part of that has to do with limited funding, says Drell. For instance, the hospital's ACT program can now handle 20 patients at one time. Obviously, "there are more than 20 kids," he says.

Nationwide, the widely accepted statistic is that one in five people -- children and adults -- suffer from a diagnosable mental disorder. For children, about half of those -- or a total of one in 10 children -- experience serious emotional disturbances. In Louisiana, the state Office of Mental Health (OMH) calculated in 2002 that 110,000 children in this state were "severely and seriously ill." Only 7 percent, according to OMH estimates, receive help.

Because most recent efforts have focused on community-based care, there's a perception that mental hospitals are a thing of the past. That may make them an easier target in state budgets. "Many states have already closed their adolescent hospitals," says Mary Crosby, director of government affairs for the D.C.-based American Academy of Child & Adolescent Psychiatry. But, she adds, hospital beds are still necessary. "Kids don't need hospitalization very often," she says, "but when they do, it's because there's a serious illness."

Tracie, who's now 18, had been hospitalized three times at other places -- "for suicide allegations, suicide attempts" -- before checking herself in at NOAH last year. Her mom was a longtime crack user and so, until she was 12, Tracie had been raised by three of her mother's elderly friends. When the last of the friends died, Tracie moved in with her mother, who was still smoking crack and had contracted AIDS from an ex-boyfriend. An aunt and the aunt's boyfriend molested Tracie several times. Then the series of hospitalizations began.

"NOAH was the best hospital I'd been to -- it really helped," Tracie says now. Unlike other places, she says, NOAH's staff people weren't "scared or offended by anything in discussions." Plus, she saw a psychiatrist every day, someone who -- by coincidence -- had worked with her mother in the past. Before Tracie was discharged, the psychiatrist held family meetings with mother and daughter. "A lot of people had tried to do that but they couldn't," she says. She's now been out about a year and still keeps in touch with the hospital's ACT team.

If NOAH hadn't been there, "I don't think I would be here," says Tracie. "I was very suicidal."

Parts of Drell's desk at NOAH are piled with cartoonish stuffed animals. It jibes with his neckties, often Tweety Bird or some other character, and with the way he punctuates serious psychiatric discussions with phrases like "it's no longer 'me doctor, you patient.'"

You can see Drell's sense of humor in the handouts from his classes at Louisiana State University, where he's head of the department of infant, child, and adolescent psychiatry. In his "Primer on Mental Disorders in Children and Adolescents," he outlines what he called "The System of Halves": "20 percent (of kids) have disorders that could use help, 10 percent could really use help, 5 percent could really really use help; 2.5 percent could really, really, really use help."

One recent morning, Dr. Bert Quintana peeks his head in the doorway of Drell's office. Drell waves him in. Drell brought Quintana in from Pittsburgh a few years ago. He's an expert psychopharmocologist, the doctor Drell turns to when he is trying to figure out what to prescribe for a complex patient.

The two talk about the changes they've seen during the past few decades. Drell says that they used to measure NOAH hospital stays in months. Now it's weeks, even days. The emphasis is now on outpatient, community care.

The New Orleans Adolescent Hospital provides a perfect environment for fragile children, says state Sen. Diana Bajoie. "The serenity of it, it's a wonderful place for children with mental illness," she says. "And it's close to home."

Photo by David Rae Morris

Some people think, says Quintana, that community care should be cheaper because it eliminates expensive hospitalizations. "That's really a misconception," he says. What you're doing instead is spreading $10,000 of care over an entire year instead of concentrating it on one month's hospital stay. "It's a different way of providing care," he says.

But, Quintana believes, not everyone has made the philosophical switch. When psychiatric hospitals began being viewed as undesirable and expensive, more kids started ending up in other places -- such as the juvenile-justice system, says Quintana.

Imagine a graph, he says, that compares psychiatric admissions during the past decade or so with the number of "forensic beds" -- court-ordered mental health care through the juvenile correctional system. He makes an "X" with his hands to demonstrate what the graph looks like. As psychiatric admissions go down, the number of forensic beds go up.

"That may not be a coincidence," says Drell.

The American Academy of Child & Adolescent Psychiatry's studied this relationship between community mental-health and juvenile-justice systems. "[The results] sort of confirm common sense," says Mary Crosby. "If you have your mental-health system and your juvenile-justice system working together, you're going to have less recidivism. You could even have some prevention." The same idea is also being suggested for kids in foster care, who have high rates of emotional disorders.

In fact, as the state discusses the reform of its juvenile-justice system, groups like the Juvenile Justice Project of Louisiana are demanding a system that mirrors this new mental health model. "What they want is exactly what we're doing at NOAH. Treat kids in the community. Same movement, same thought," says Drell.

"It's clear that, if kids don't receive help in the mental health system, they may end up in the forensic (justice) system," Drell explains. Research also indicates that kids of different races may receive different mental health diagnoses. "If you're a black male," Drell says, "there's a better chance that you'll make it into the juvenile justice system as opposed to the mental health system."

These connections are not lost on policymakers. The National Conference of State Legislatures noted the link in its recent report on mental health services for children. "An emphasis on providing needed services to children with mental-health needs ... increases the likelihood that they will not need costly services through the juvenile justice or child welfare system," said the report, which noted that a number of states are now looking at a collaboration between their mental health, juvenile justice and child welfare systems.

Warren T. Price Jr., the assistant secretary for the state Office of Mental Health, says that Louisiana is interested in doing just that for its child and adolescent mental health systems. "Although it's not a done deal, it's being looked at real hard," he says. The office is especially interested in replicating a program similar to one in New Jersey and one in Wisconsin called Wraparound Milwaukee, which pools various funding streams into one pot in order to coordinate and streamline services.

A central pot of wraparound funds allow for expenses not commonly associated with mental health services, says Drell. "Lots of times," he says, "for lack of a cab ride, a kid doesn't make his appointment." Still, collaboration is a more difficult proposition in Louisiana, because each agency's individual budget is so tight. "If you don't have any money, it's hard to come to the potluck dinner with anything," he says.

Last week, DHH Secretary David Hood told Gambit Weekly that the original DHH shortfall of $1.4 billion has now been cut in half. That will be reflected in the budget he presents to the House appropriations committee within the next few weeks. That budget, he says, would not include the closure of NOAH. He believes that the staff at NOAH "could certainly rest easier" -- but he still has to go through the legislative process.

Julie Savoy, the hospital's director of clinical social work, says that this news is certainly reassuring. But because the year 2000 is such a "vibrant and unpleasant memory," she will remain anxious until the end of the legislative session. And then, next year, she hopes they won't have to endure this. That may be wishful thinking. "It seems like, just about every spring, the doomsday scenario comes out," she says.

It's now been five years since Neal's father first took him from his hiding place underneath their house to NOAH. Neal says that the hospital helped him cope with his ups and downs. If he feels sad now, he will usually "sit somewhere and just think or take a walk or talk to my auntie."

Now that he's feeling better, Neal believes he can offer some advice to kids who are still struggling. Last week, Neal says, a kid brought a gun to his school and was showing it off. "I looked at him and thought, 'He needs to go to NOAH."