Nevada sent more than 150 children in its juvenile justice and child welfare systems out of state for behavioral health treatment last year, some of them thousands of miles away to far-flung facilities in Detroit, Nashville and Savannah.
But the information, contained in a report compiled by the state last month as required by a law passed earlier this year, has raised more questions than answers for children’s mental health advocates. The report highlights some of the reasons children are sent out of state — lack of specialty providers, long waiting list and unsuccessful treatment at in-state facilities — but does not look at whether the treatment has proved effective, especially compared to its cost.
“It’s nice to know a number, but I think it’s really all you’re getting out of this — a number,” said Denise Tanata, executive director of the Children’s Advocacy Alliance.
According to the report, three-fourths of the 170 children sent out of state during the last fiscal year were referred by a juvenile justice agency, or 127 cases, with another quarter, or 43 cases, coming from child welfare. More boys were sent out of state, 68 percent, than girls, 32 percent. The report only looked at youth covered under Medicaid, as well as Medicaid ineligible children paid for by Nevada.
“How big the percentage of juvenile justice cases versus child welfare cases was one of the surprising things to me in the report,” said Ross Armstrong, administrator of the Division of Child and Family Services.
Armstrong suggested that the higher share of juvenile justice cases may have to do with the fact that those kids have tried a number of in-state options and that those facilities will no longer accept them because of violent outbursts or other behavioral health issues.
The state that received the most placements was nearby Utah, where 136 kids were sent, followed by Texas, which received 10 kids, and Colorado, with six kids. The other states that received children from Nevada are Missouri (five kids), Arizona (three kids), Georgia (three kids), Michigan (two kids), Indiana (two kids) and Tennessee (one kid).
The root of the issue, Armstrong said, is that the services children need aren’t available in the state. For instance, nine children were sent to the Texas NeuroRehab Center in Austin, which is able to provide treatment for children with both developmental disability and mental health issues.
“I think this report helps us start that conversation and really identify where there’s a critical mass or enough of a population to bring in services,” Armstrong said.
The division operates two lower-level residential treatment homes in Las Vegas and Reno; a higher-level residential program in Sparks; and a psychiatric hospital for the most severe cases in Las Vegas. It also runs three juvenile justice centers in Las Vegas, Caliente and Elko.
It can also place children into private facilities that have beds for youth, such as Willow Springs in Reno, Reno Behavioral Health and Montevista Hospital in Las Vegas.
Children are generally sent out of state, Armstrong said, because they have exhausted all of their options here.
“Generally if a youth is going out of state, it is because we’ve tried everything within the state,” Armstrong said. “For instance, they may have been to a facility in Nevada but were kicked out for assaulting staff.”
Armstrong said that a child welfare or juvenile justice agency will take into consideration the child’s primary and secondary needs when deciding where to place them, in addition to looking at which facilities have open beds. He added that facilities that have shown “good outcomes” for children in similar circumstances may have preference when placing the children.
But advocates for children’s mental health are concerned about the oversight of out-of-state placements and whether there is any proof that they are working.
“All of the reports we’ve had to date — this one included — look at quantities. Not in one place do we have a discussion about outcomes and meaningful change,” said Lisa Durette, a child psychiatrist and assistant professor at the UNLV School of Medicine. “I could send you to 20 hospitals and if no true treatment is occurring, nothing is going to be different. I think the disconnect between reporting on quantities and looking at whether this is an effective intervention is one of the core problems.”
Armstrong noted that there are more specific requirements for reviewing child welfare cases placed out of state than there are for juvenile justice cases, and while there is a group that is looking at what residential services are available for children and where they could be expanded, he said there is no group specifically studying children who are sent out of state and what could be done to bring them home.
“Certainly the requirement to report has started conversations for us internally,” Armstrong said. “We have a Family Programs Office that really takes a look at child welfare in a holistic way, and there’s opportunity within our entire quality and oversight team to look at these across the system with both child welfare and juvenile justice.”
The report recommends a number of changes to prevent out-of-state placements, including intensive outpatient treatment programs, partial hospitalization programs, and short-term care facilities that can focus on stabilizing children, in conjunction with wraparound care coordination services that help children remain in their homes and communities.
“I think the next step would be limiting the amount of time they spend out of state and getting prepared on this end for their return, including a wraparound worker and setting up in-home resources,” said Susie Miller, deputy administrator over DCFS residential services.
Tanata said that it was a “little disappointing” that the state didn’t put forward more specific recommendations for concrete action it can take or set goals for itself in this first report.
“I look at this report, and I don’t know what policy we would put forward with this,” Tanata said.
Robin Reedy, executive director of National Alliance on Mental Illness (NAMI) Nevada, noted steps Nevada has taken to divert its adult population from the traditional criminal justice system and into mental health courts, addiction courts and veteran courts and suggested a similar focus on recidivism with children.
“They’re really on the cusp of a lot of these studies trying to minimize the criminalization of a problem because they do recognize that there are other ways of dealing with this to eliminate recidivism,” Reedy said.
For Durette, the primary goal is getting kids home from residential treatment facilities from out of state.
“If you look at the publicly available practice guidelines for children involved in the juvenile detention and child welfare systems, nowhere is residential treatment the recommendation for intervention,” Durette said. “In fact everywhere — up, down and sideways — including all of the core principles of the system of care indicate that daily and community involvement in a treatment plan are necessary and the most important ingredients for success.”
She noted that kids placed out of state may be able to Skype or FaceTime with those from back home, but it isn’t the same.
“We’re not doing anything to change the ecological structure around the kids that would prevent a hospitalization in the first place and prevent recidivism when they’re discharged,” Durette said. “None of these reports talk about recidivism rates.”