May 24, 2012

How Indiana rigged its mental health system

Indiana might just have the worst child welfare agency leaders in America. They have figured out how to use a respected mental health evaluation tool to deprive children of the care they need.

Indiana has a “no-fault” child protection statute called CHINS 6. It is intended to allow state Division of Children’s Services (DCS) officials to provide medical care for kids at risk of harm to self or others. Unfortunately DCS refuses to use this authority, leaving children and families across Indiana to suffer. There’s money in the DCS system to provide care, but DCS does not spend it. It has returned over $300 million in “surplus funds” to the state treasury in the last three years.

“Quite simply, the system for reviewing/filing cases by the DCS is broken when it comes to CHINS 6/mental health, which begs the question whether the entire system is currently broken.” That’s what Morgan County Circuit Court Judge Matthew Hanson wrote in a court filing on May 15.

The DCS director has said that he does not believe filing CHINS 6 is good for children or parents as it “pits” them against one another. Yet the only alternative is so much worse: Parents must put themselves on the child abuse registry in order to get state help for their children. It’s the very thing the CHIN 6 statute is designed to eliminate.

And even that depressing option does not work. Parents quoted in media reports say children can’t access necessary (but expensive) residential care even with the most severe issues. Indiana DCS denies care to children who try to burn down houses and shove siblings down flights of stairs, even when terrified parents go to court and ask for a finding of neglect. DCS will not provide care even when the alternative is juvenile prison.

When questioned by the media, DCS officials say they prefer less-expensive community-based care (which of course sounds benign enough). They say they use an evidence-based tool, the CANS, to determine the level of care children need.

That’s where the system gets rigged --  in the connector, the place where the CANS assessment meets the decision about level of care.

The CANS is just a questionnaire. Clinicians rate dozens of aspects of a child’s life on a scale of zero (“no problem”) to three (“big trouble”).  Here’s the CANS question about “Danger to Others.”
DANGER TO OTHERS
This rating includes actual and threatened violence. Imagined violence, when extreme, may be rated here. A rating of 2 or 3 would indicate the need for a safety plan.
0 - Child has no evidence or history of aggressive behaviors or significant verbal aggression towards others (including people and animals).
1 -  History of aggressive behavior or verbal aggression towards others but no aggression during the past 30 days. History of fire setting (not in past year) would be rated here.
2 - Occasional or moderate level of aggression towards others including aggression during the past 30 days or more recent verbal aggression.
3 - Frequent or dangerous (significant harm) level of aggression to others. Any fire setting within the past year would be rated here. Child or youth is an immediate risk to others.
The CANS system collects all these rating numbers and reports them in a format that makes it easier for clinicians to decide what to do.

Indiana went a step further. It convened a workgroup to develop computerized algorithms to interperet CANS reports and determine the level of care workers would use in every case. That step virtually eliminated clinician discretion, and outlawed residential care. Once the algorithms were in place, rigged to eliminate residential care, the system wiped it out.

In other words, Indiana developed an app that denies sick children mental health care.

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Sources:

Indiana Statutes http://www.in.gov/legislative/ic/2010/title31/ar34/ch1.html

State of Indiana, Family and Social Services Administration, Division of Mental Health and Addiction. (2007). Business Case for Adoption and Implementation of the Child and Adolescent Needs and Strengths Assessment.

In the Matter of AA, Morgan County Circuit Court, May 15, 2011.

Indiana Law Blog (2012) http://indianalawblog.com/archives/2012/05/ind_decisions_a_170.html

Children in Peril - http://www.nwitimes.com/news/local/lake/crown-point/region-parents-struggle-to-get-help-for-children-with-mental/article_ff8d4edb-b7f7-5863-a256-06cb6f65c123.html

CANS-MH Manual (2003)

Mentally ill kids caught in Catch-22 http://www.indystar.com/article/20120524/LOCAL/205240370/Mentally-ill-children-caught-state-s-Catch-22

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