[Senate Hearing 108-696]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 108-696
 
                  JUVENILE DETENTION CENTERS: ARE THEY
                       WAREHOUSING CHILDREN WITH
                            MENTAL ILLNESS?

=======================================================================

                                HEARING

                               before the

                              COMMITTEE ON
                          GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE


                      ONE HUNDRED EIGHTH CONGRESS

                             SECOND SESSION

                               __________

                              JULY 7, 2004

                               __________

      Printed for the use of the Committee on Governmental Affairs





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                   COMMITTEE ON GOVERNMENTAL AFFAIRS

                   SUSAN M. COLLINS, Maine, Chairman
TED STEVENS, Alaska                  JOSEPH I. LIEBERMAN, Connecticut
GEORGE V. VOINOVICH, Ohio            CARL LEVIN, Michigan
NORM COLEMAN, Minnesota              DANIEL K. AKAKA, Hawaii
ARLEN SPECTER, Pennsylvania          RICHARD J. DURBIN, Illinois
ROBERT F. BENNETT, Utah              THOMAS R. CARPER, Delaware
PETER G. FITZGERALD, Illinois        MARK DAYTON, Minnesota
JOHN E. SUNUNU, New Hampshire        FRANK LAUTENBERG, New Jersey
RICHARD C. SHELBY, Alabama           MARK PRYOR, Arkansas

           Michael D. Bopp, Staff Director and Chief Counsel
              Priscilla Hanley, Professional Staff Member
      Joyce A. Rechtschaffen, Minority Staff Director and Counsel
           Donny Williams, Minority Professional Staff Member
                      Amy B. Newhouse, Chief Clerk
















                            C O N T E N T S

                                 ------                                
Opening statements:
                                                                   Page
    Senator Collins..............................................     1
    Senator Lautenberg...........................................     3
    Senator Carper...............................................     4
    Senator Durbin...............................................    26

                               WITNESSES
                        Wednesday, July 7, 2004

Hon. Henry A. Waxman, a Representative in Congress from the State 
  of California..................................................     7
Carol Carothers, Executive Director, National Alliance for the 
  Mentally Ill of Maine..........................................    10
Tammy Seltzer, Staff Attorney, Judge David L. Bazelon Center for 
  Mental Health Law..............................................    12
Leonard Dixon, President, National Juvenile Detention 
  Association, and Executive Director, Wayne County Juvenile 
  Detention Facility, Detroit, Michigan..........................    14
Hon. Ernestine S. Gray, Chief Judge, Orleans Parish Juvenile 
  Court, New Orleans, Louisiana..................................    17
Kenneth J. Martinez, Psy.D., Director, Children's Behavioral 
  Health, Department of Children, Youth and Families, State of 
  New Mexico.....................................................    19

                     Alphabetical List of Witnesses

Carothers, Carol:
    Testimony....................................................    10
    Prepared Statement...........................................    57
Dixon, Leonard:
    Testimony....................................................    14
    Prepared Statement...........................................    76
Gray, Hon. Ernestine S.:
    Testimony....................................................    17
    Prepared Statement...........................................    87
Martinez, Kenneth J., Psy.D.:
    Testimony....................................................    19
    Prepared Statement...........................................    89
Seltzer, Tammy:
    Testimony....................................................    12
    Prepared Statement...........................................    63
Waxman, Hon. Henry A.:
    Testimony....................................................     7
    Prepared Statement with attachments..........................    31

                                APPENDIX

National Council on Disability, prepared statement...............    99
Edward J. Loughran, Executive Director, Council of Juvenile 
  Correctional Administrators (CJCA), prepared statement.........   117














 JUVENILE DETENTION CENTERS: ARE THEY WAREHOUSING CHILDREN WITH MENTAL 
                                ILLNESS?

                              ----------                              


                        WEDNESDAY, JULY 7, 2004

                                       U.S. Senate,
                         Committee on Governmental Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:01 a.m., in 
room SD-342, Dirksen Senate Office Building, Hon. Susan M. 
Collins, Chairman of the Committee, presiding.
    Present: Senators Collins, Lautenberg, Carper, and Durbin.

             OPENING STATEMENT OF CHAIRMAN COLLINS

    Chairman Collins. The Committee will come to order.
    Good morning. Last summer, the Committee on Governmental 
Affairs held a series of hearings to examine the difficult 
challenges faced by families with children with mental illness. 
We heard compelling testimony from families who described their 
personal struggles to get mental health services for their 
severely ill children. They told us about the limitations in 
both public and private insurance coverage, the shortage of 
mental health professionals, and the long waiting list for 
desperately needed mental health services.
    They discussed the lack of coordination and communication 
among the various agencies and programs that serve children 
with mental health needs. And most disturbingly, they told us 
that some parents are actually advised that the only way to get 
the intensive care and services that their children need is to 
relinquish custody and place them in the child welfare or 
juvenile justice system. This is a wrenching decision that no 
family should ever have to make. No parent should have to give 
up custody of his or her child just to get the health care 
services that that child so desperately needs.
    Today, we will be examining another consequence of our 
tattered safety net for children with mental illness, and that 
is the inappropriate use of juvenile detention centers as 
holding areas for people who are waiting for mental health 
services. Like custody relinquishment, these inappropriate 
detentions are a regrettable symptom of a much larger problem, 
which is the lack of available, affordable, and appropriate 
mental health services and support systems for these young 
people and their families in the communities in which they 
live.
    Serious mental illness afflicts millions of our Nation's 
children and adolescents. It is estimated that as many as one 
in five American children under the age of 17 suffers from a 
mental, emotional, or behavioral illness. What is even more 
disturbing is the fact that two-thirds of all young people who 
need mental health treatment are not getting it.
    If two-thirds of children with cancer were not getting the 
treatment that they needed, there would be a huge public 
outcry. Yet we have a situation in this country where two-
thirds of the children with serious mental illness are not 
getting the services that they need.
    When a child has a serious physical health problem like 
diabetes or cancer, the family turns to their doctor. But when 
a family includes a child with a serious mental illness it is 
often forced to go to child welfare or the juvenile justice 
system to secure treatment. Yet neither system is intended to 
serve children with serious mental illness. Child welfare 
systems are designed to protect children who have been abused 
or neglected. Juvenile justice systems are designed to 
rehabilitate children who have committed criminal or delinquent 
acts. While neither of these systems is equipped to care for a 
child with a serious mental illness, in far too many cases 
there simply is nowhere else for the family to turn.
    In extreme cases, families may feel forced to actually file 
charges against their child or to declare that they have abused 
or neglected them in order to get the care that they need. As 
one advocate observed, ``beat them up, lock them up, or give 
them up'' characterizes the choices that some families face in 
their efforts to get help for their children's mental illness. 
Those are clearly no choices at all.
    According to a General Accounting Office study that I 
requested last year with Representatives Pete Stark and Patrick 
Kennedy, parents placed more than 12,700 children into the 
child welfare or juvenile justice systems in 2001 so that these 
children could receive mental health treatment. Of these 12,700 
children, 9,000, the vast majority, entered the juvenile 
justice system.
    I believe that this statistic represents just the tip of 
the iceberg since 32 States, including five with the largest 
populations of children, did not provide the GAO with any data. 
Other studies indicate that the problem is even more pervasive. 
A 1999 survey by the National Alliance for the Mentally Ill 
found that 36 percent of the families surveyed placed their 
children in the juvenile justice system to access mental health 
services that otherwise were not available to them.
    The question is, what happens to these children when they 
are turned over to the juvenile justice system? Unfortunately, 
the report that Congressman Henry Waxman and I are releasing 
today shows that too often they are simply left to languish in 
juvenile detention centers which are ill-equipped to meet their 
needs while they wait for scarce mental health services.
    A compelling series of stories by Barbara Walsh of the 
Portland Press Herald in Maine detailed the obstacles that many 
Maine families have faced in getting care for their children 
with mental illness. One of her stories was entitled, ``Locked 
Up, Waiting for Help.'' It told the story of a clinically 
depressed 14-year-old boy who was held in limbo in the 
Cumberland County Jail while he waited for a bed in a 
residential treatment center. While he was supposed to be 
placed within a few weeks, he wound up sitting in a jail cell 
for 4 months without any treatment. While he waited his illness 
grew worse. He was also locked up with many older, more violent 
kids, and was ultimately sexually assaulted. Later he attempted 
suicide.
    Unfortunately, this sad story is not unique. The report we 
are releasing today demonstrates that this terrible problem 
exists nationwide. Based on a national survey of the juvenile 
detention center administrators, the report finds that the use 
of juvenile detention facilities to warehouse children with 
mental disorders is a serious national problem. Over the 6-
month period covered by our report, nearly 15,000 incarcerated 
youth were detained solely because they were waiting for mental 
health services. Many were held without any charges pending 
against them, and the children who were incarcerated 
unnecessarily while waiting for treatment were as young as 7 
years old.
    Finally, the report estimates that juvenile detention 
facilities are spending an estimated $100 million of taxpayer's 
money each year simply to warehouse these children and 
teenagers while they are waiting for services. This morning's 
hearing will provide an opportunity for representatives of the 
juvenile justice and mental health systems, as well as 
advocates for children and their families, to respond to this 
report. My hope is that this hearing will not only heighten 
public awareness of the difficult problems confronting these 
children and their families but also help us to make the case, 
help us to press for legislative and administrative reforms at 
both the State and the Federal level to reduce the barriers to 
care for children who suffer from mental illness.
    In closing, I want to commend Congressman Henry Waxman for 
his outstanding leadership on this issue. He has long been a 
leader on health care issues, and it has been a pleasure to 
work with him on this report. I am hoping that our bipartisan, 
bicameral efforts will produce real reform because it is 
desperately needed. I also want to salute the Congressman's 
staff for the excellent research that they did in compiling 
this report. The Congressman will be our leadoff witness, just 
as soon as I turn to Senator Lautenberg for his opening 
comments.

            OPENING STATEMENT OF SENATOR LAUTENBERG

    Senator Lautenberg. I thank you, Madam Chairman, for 
holding this hearing and for your statement which I think is 
very accurate and at the same time descriptive, especially in 
that cryptic comment about give them up, beat them up. What was 
that exactly?
    Chairman Collins. Beat them up, lock them up, or give them 
up. It is awful.
    Senator Lautenberg. Terrible. It conveys a sense of the 
desperation that families go through. I am pleased also, Madam 
Chairman, that we have Congressman Waxman here and that the two 
of you have worked together. I think that is excellent. 
Congressman Waxman and I have worked on many things together 
and I always find him especially circumspect about the things 
we do, and searching for accuracy in his presentations. And the 
outcome often points to the research having been so effective.
    Right now, the results of the survey that you have 
conducted about juvenile detention centers and the population 
of those who are mentally ill in these institutions presents a 
sad picture of neglect. There is a national scourge with regard 
to treating our children who suffer from mental illness. 
Millions of our kids are going without the needed mental health 
care that they need. Studies show that 70 percent of our young 
people are in need of some mental health service and do not 
receive it.
    When children with mental or emotional disorders cannot get 
the help they need, appalling and often entirely preventable 
outcomes result. They and their families suffer through 
unnecessary crises which can lead to school failure, dramatic 
out-of-home placements, and in some cases, arrest or suicide. 
Families unable to pay for services through private insurance 
or ineligible for services through the public health systems 
relinquish custody of their children to obtain state-funded 
services. Again, these are desperate moves. There are very few 
families who want to see their child punished without any 
prospect of a light at the end of the tunnel.
    No family should feel that it has to relinquish custody of 
a child to obtain needed mental health services. Yet scores of 
parents across the Nation have surrendered their influence on 
key aspects of the children's lives to get access to public 
mental health services for their kids. This is a difficult 
problem to address, to be sure, and there are a couple of bills 
that would help. One, Madam Chairman, is yours, the Keeping 
Families Together Act, and I would like to be included as a co-
sponsor. I think it has been done, but if not, I certainly want 
to be there.
    Chairman Collins. We are pleased to have you.
    Senator Lautenberg. I want to help you work with this 
problem, see if we can find a solution jointly. That one would 
lay a strong foundation for needed reforms by promoting access 
to these services and reducing fragmentation in service 
delivery.
    Another is a bill that has overwhelming support in 
Congress, and that is the Senator Paul Wellstone Mental Health 
Equitable Treatment Act. This bill would build on a 1996 law 
prohibiting health plans that offer mental health coverage from 
setting lower annual and lifetime spending limits for mental 
illness treatment. In an April 2002 speech to mental health 
professionals in New Mexico President Bush said, the health 
insurance system must treat mental illness like any other 
ailment stating ``that Americans deserve a health care system 
that treats their illnesses, their mental illnesses with the 
same urgency as a physical illness.'' I agree with the 
President's sentiment and I hope the administration, in the 
short time remaining in this session, becomes more involved in 
the issue. The President's support would go a long way in 
getting these bills signed into law before we adjourn in the 
fall.
    I thank you, Madam Chairman, for doing this.
    Chairman Collins. Thank you. Senator Carper.

              OPENING STATEMENT OF SENATOR CARPER

    Senator Carper. Thank you, Madam Chairman. I just came to 
see Henry Waxman. Henry, you are holding up well. I have known 
him for about 22 years. He looks today just like he did--either 
he is aging gracefully or he just got old quick. I am not sure 
which. It is great to see you, and appreciate your work on so 
many issues.
    Senator Collins and I are especially aware of the good work 
he is doing over in the House with Congressman McHugh on postal 
reform. We are mindful of that work and grateful for the 
opportunity to partner with you on that front.
    I want to add a comment or two with respect to the issue 
that is before us today. I am not going to speak to serious 
mental disorders but I do want to talk about some of the 
briefing materials that I read on the hearing today, talk about 
a lot of students who are in special ed and how they end up in 
prisons. I do not know if you remember a fellow named Barry 
McCaffrey. Barry McCaffrey was the Nation's drug czar, retired 
general. He came to our State several years ago when I was 
governor, and he came to our State in order to put a spotlight 
on a program that we had put in place in all of our prisons 
called a Key and Crest program. Whenever people are within a 
year of leaving prison we would put them through an extensive 
program, last about half a year. We would follow up with them 
outside of prison. And we cut the rate of recidivism for people 
who completed the program from about 70 percent for most of our 
population down to about 40 percent, which is real progress. It 
is not zero, but it is a much-improved reduction in the number 
of people who come back to prison after they have been 
released.
    I remember a conversation that he and I had with a lot of 
inmates in a room just a little bit smaller than this one. We 
had really about an extra half an hour to kill on our tour of 
Gandry Hill Prison in Wilmington, Delaware. We had about 70 
inmates in the room with us. I said to the inmates--Delaware is 
a small State and you literally know almost everybody, and I 
knew a bunch of them. I said, how did you guys end up here? And 
a lot of them were young, late teens, early 20's. I said, how 
did you guys end up here? Just tell us your story.
    About three or four took the advantage to do that and they 
told a story that was frighteningly similar. I was born when my 
mom was young. I never knew my dad. I started school and other 
kids knew how to read, they knew their letters, they knew 
numbers. They could already do that when they got to 
kindergarten. I could not, and I started behind. They knew 
words that I did not. I started behind and just got further 
behind. And I finally learned when a teacher called on me, in 
an effort to not be embarrassed by how little I knew, just to 
be disruptive, and to make them wish they had not called on me. 
Eventually they put me out in the hall or maybe sent me down to 
the principal's office. When I got older I found that if I was 
disruptive enough, rather than be embarrassed every day with 
just how little I knew, they would suspend me and maybe 
eventually expel me.
    And I got out on the streets and did not have any skills or 
any knowledge, could not read or write, and the way that I 
could enhance my self-esteem was to turn to drugs or alcohol. 
And since I didn't have any skills to make a living, I turned 
to crime in order to get the money to buy the drugs or alcohol 
and make me feel better about myself. It was interesting, one 
after the other really told stories very much like that.
    The point I want to make is this, and I know I have used 
too much time, there are amazing things that we can do with 
very young people to make sure that when they walk into 
kindergarten at the age of five and first grade at the age of 
six, they are ready to roll. They are ready to be successful.
    In my State, we have just completed not long ago a 
longitudinal study where we took early age, we work with their 
parents to make sure that they had the skills that they needed 
to help prepare their kids for success, pre-K age three, age 
four, full day kindergarten for those kids, and then to use 
afterschool programs to work with those kids once they got in 
the first grade. We found at the end of the study period that 
we were studying these hundreds of kids, that we reduced by 
more than half the referrals to special ed. We found that those 
kids reached the third grade, that they were performing on par 
just about as well as other kids from normal, intact two-parent 
families where they had every opportunity.
    The last thing I would say is this, we had a debate--not 
really a debate, but a discussion on the Senate floor a couple 
of months ago when welfare reform came up, and the issue we 
were debating was the Snowe amendment on the adequacy of 
funding for child care, quality child care for those whose 
parents are going off of welfare and going to work. Having a 
colloquy with Senator Chris Dodd, and I made the point, if you 
have got kids who grow up in a family where somebody reads to 
them literally from the start, just works with them on their 
vocabulary and exposes them to all kinds of experiences, good 
experiences, and works on their intellect, those kids will walk 
into the first grade with a 25,000-word advantage in their 
vocabulary over kids who have not had that opportunity.
    And Chris Dodd said, no, you are wrong. It is 100,000 
words. It is 100,000 words, the deficit that kids bring from a 
disadvantaged background where no one has been involved, no one 
has been preparing them. And we should not be surprised that 
when those kids get to school they fall behind, and they get in 
trouble. And when they get in trouble, they do not finish 
school. And when they do not finish school, they end up out on 
our streets and they commit crimes. A lot of them were in that 
prison that day, and some of them are probably still there. But 
we can do something about that.
    Last P.S., if I may, Madam Chairman. It is a great story 
about an accelerated reading program in our State that has been 
introduced in a couple of elementary schools, actually in 
kindergarten. They have been able to work with kids in 
kindergarten so that by the time they finish kindergarten they 
are reading at a first and second-grade level. These are kids 
from from 30, 40, 50 percent free and reduced price lunch 
schools, and these are schools where they have taken the kids 
from almost nobody reading at a first or second-grade level to 
as many as 80 percent of the kids reading at a first or second-
grade level. Kids you would never expect that to happen.
    So I want to mention those things that happen in the real 
world every day. This is the real world too, but I wanted to 
share them. Thank you very much.
    Congressman Waxman, Hon. Henry Waxman, great to see you.
    Chairman Collins. Thank you.
    It is now my pleasure to welcome our leadoff witness, 
Representative Henry Waxman. He represents California's 30th 
Congressional District. I understand that you first came to 
Congress in 1974. That was the same year that I first came to 
Congress, but I was a lowly intern for then-Congressman Bill 
Cohen, whereas you came as a powerful congressman, so there was 
quite a difference.
    Since 1997, Representative Waxman has served as the ranking 
member of our companion committee in the House, the Government 
Reform Committee. He has established a special investigations 
division staff that has prepared many investigative reports, 
including the one that we are releasing today. As I mentioned 
in my opening statement, Representative Waxman has been a 
longtime leader on health care issues in the House of 
Representatives and I am very pleased that he is here today.
    After your statement, Congressman, I would invite you to 
come up and join us up here, because I know you will want to 
participate further in the hearing. So please proceed with your 
statement and again, thank you.

TESTIMONY OF HON. HENRY WAXMAN,\1\ A REPRESENTATIVE IN CONGRESS 
                  FROM THE STATE OF CALIFORNIA

    Mr. Waxman. Thank you very much, Chairman Collins, for your 
leadership on this important issue, for holding this hearing, 
and for the extraordinary kindness you are showing me by 
inviting me to join you at the hearing. I think it is unusual 
to have a member of the House sit with the Senators, but on 
this issue we are not House members or Senate members, we are 
not Democrats or Republicans. We are people who care about an 
issue that we hope we can do something about. Senator 
Lautenberg and Senator Carper, thank you for your kind words. 
Senator Lautenberg about my work, Senator Carper, about the way 
I look. I will take whatever good comments I can get. But you 
two in your statements have expressed an extraordinary 
understanding of the loss to all of us in this country if we do 
not do all we can to help children realize their full 
potential.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Waxman, with attachments, appears 
in the Appendix on page 31.
---------------------------------------------------------------------------
    What we are discussing today is a small issue. There are 
huge issues of how to make sure that everyone has the 
opportunity to succeed to the full extent possible. But in this 
particular situation there is an issue that I think we need to 
pay attention. Too often there is little connection between 
issues Congress addresses and the real problems facing our 
Nation. When foreign sales corporations seek change in the tax 
laws, as they are currently doing, hundreds of lobbyists come 
out of the woodwork and campaign contributions flow like water, 
and the attention of legislators become riveted on arcane 
provisions that have little relevance for most Americans.
    But when there is a crisis in access to children's mental 
health services, that same sense of urgency is lacking. The 
problem is real and affects millions of families, yet without 
corporate lobbyists in the hallways or the prospect of sizable 
campaign contributions, the needs of children with mental 
illness have received little attention. That is why your long 
term commitment to children's mental health care is so rare and 
so extraordinary. The fact that all three of you are taking 
your time to be here shows your commitment to trying to 
understand the problem and trying to think through what we can 
do about it.
    The report we are releasing today is so important. I hope 
we can finally jolt Congress and the administration into 
action. Two years ago, at the request of Senator Jeff Bingaman 
and Representative Tom Udall, my staff investigated the fate of 
youth with mental illness in New Mexico who could not obtain 
care in their communities. What we found was deeply disturbing. 
One in seven youth in juvenile detention in New Mexico were 
there solely to wait for mental health services. Over 700 young 
people jailed simply because treatment was not available.
    It was apparent to you, Chairman Collins, and to me that 
these inexcusable conditions were likely to extend beyond New 
Mexico, so at our joint request we asked the staff to expand 
its investigation. We surveyed every juvenile detention 
facility in the United States. We heard back from more that 500 
administrators in 49 States, a response rate of over 75 
percent. The resulting report is the first ever national study 
of unnecessary incarceration of children suffering from mental 
illness and here are some of the key findings.
    Two-thirds of juvenile detention facilities in the United 
States lock up mentally ill youth because there is no place 
else for them to go.
    Every day, about 2,000 young people are incarcerated simply 
because community mental health services are unavailable. This 
represents about 7 percent of all youth in juvenile detention.
    In 33 States, juvenile detention centers hold young people 
with mental illness who have no charges against them of any 
kind.
    Over 160 detention centers report that youth held 
unnecessarily have attempted suicide.
    And children as young as 7 years of age are incarcerated 
because they do not have access to care.
    Many of the detention centers we surveyed responded with 
written pleas. A detention center in Louisiana wrote, ``We 
appear to be warehousing young people with mental illnesses due 
to lack of mental health services.'' A Washington State 
administrator said, ``We have had a number of juveniles who 
should no more be in our institution than I should be able to 
fly.''
    A Tennessee administrator implored, ``The last place some 
of these kids need to be is in detention. . . . Those with 
depression are locked up alone to contemplate suicide. I guess 
you get the picture.''
    And we get the picture, too, and it is deplorable.
    The findings of this report indict how our society treats 
children suffering from mental illness in the United States of 
America in the 21st Century.
    The report recalls the 19th Century. It recalls Charles 
Dickens and what he wrote about how people were treated in 
London at that period of time; and in this country, when 
reformer Dorothea Dix traveled from jail to jail gathering 
stories of individuals suffering from mental illness who were 
abandoned and ignored. Her work led to the creation of the 
Nation's first asylums.
    Since the mid-1800's, psychiatry and associated professions 
have learned to diagnose and treat complicated mental 
illnesses. Hospitalization is now recognized as a treatment of 
last resort. It is well understood that many children with 
mental illness can recover and lead productive lives.
    Yet even as scientific knowledge has advanced, our social 
policy has faltered. We have seen the emptying of psychiatric 
institutions without the establishment of community services. 
We have seen the starvation of public budgets that support the 
basic needs of millions of Americans with mental illness.
    And today, the backbone of financing for children's mental 
health services, the Medicaid program, is in grave danger. 
Proposals to turn a guarantee of care into block grants for 
States could seriously compromise what little is left of the 
safety net.
    The findings of this report call on us to reverse course.
    Congress must ensure that adequate mental health services 
are available to all who need them. We must reform a confusing 
and bewildering mental health care system so that it works for 
the benefit of children and their families.
    And we must insist upon accountability so that someone is 
held responsible each and every time a child is jailed to wait 
for mental health services.
    We must work together--not as Democrats or as Republicans, 
but as Americans who care about children and their families--to 
end this warehousing of young people who are in need of 
treatment.
    In closing, let me again thank you, Chairman Collins, for 
your leadership. I look forward to hearing the distinguished 
witnesses who will testify about these serious problems later 
this morning.
    I hope we can learn more about this problem, draw some 
attention to it, and then think together how not to just ignore 
this problem but be constructive on a serious matter.
    Thank you very much.
    Chairman Collins. Thank you for your excellent testimony. I 
would invite you to come join us. To avoid giving my Republican 
colleagues a heart attack, I would suggest you sit on the 
Democratic side. [Laughter.]
    But we would welcome you to come join us for the second 
witness panel.
    I do want to salute you again for your excellent survey. It 
really was not only comprehensive--and I was pleased to join in 
supporting it--but it gave us for the first time a picture of 
just how widespread and serious this problem is. As you stated 
in your testimony, the fact that we have 2,000 children on any 
given night incarcerated who have done nothing wrong but are 
just simply ill ought to be a call to action for all of us. So 
thank you for your good work, and please do come join us.
    Mr. Waxman. Thank you very much.
    Chairman Collins. The Committee will now hear from 
representatives of the juvenile justice and mental health 
systems as well as from advocates for young people with mental 
disorders and their families.
    First, I am pleased to welcome Carol Carothers, who is the 
Executive Director of the National Alliance for the Mentally 
Ill in the State of Maine. She is also, I am very proud to say, 
the recipient of this year's highly prestigious Robert Wood 
Johnson Community Health Leadership Program Award for her 
efforts to prevent inappropriate incarceration and her advocacy 
for improving treatment for people with mental illness who have 
become involved with police and correctional institutions in 
Maine.
    I will tell you, for the benefit of those of you who do not 
live in Maine, that Carol is known throughout the State for her 
tremendous advocacy on behalf of people who are suffering from 
mental illness. She is a hero with local law enforcement and 
sheriffs who too often find that people with mental illness are 
in their jails and prisons. And we are very pleased to have her 
here today.
    The Committee is also very proud to welcome back Tammy 
Seltzer, the senior staff attorney for the Judge David L. 
Bazelon Center for Mental Health Law, which is a leading 
national legal advocacy organization for adults and children 
with mental disabilities. We worked with the center in our 
previous hearings last year, and we are very pleased to welcome 
Ms. Seltzer back.
    Next I would like to introduce Leonard Dixon, who is the 
Executive Director of the Wayne County Juvenile Detention 
Facility in Detroit, Michigan. Mr. Dixon is also the President 
of the National Juvenile Detention Association and will be 
testifying on behalf of that association, as well as the 
American Correctional Association, and we are very pleased to 
have you here as well.
    The Committee is also pleased to welcome the Hon. Ernestine 
S. Gray. Judge Gray has served in the Orleans--that may be a 
Maine pronunciation--Parish Juvenile Court in Louisiana as a 
judge for more than 19 years, and she has received national 
recognition for her work on behalf of children and their 
families. Welcome to you.
    And last, but certainly not least, we will hear from Dr. 
Ken Martinez, the Director of Children's Behavioral Health for 
the Department of Children, Youth and Families in New Mexico. 
Dr. Martinez will tell us about some of the very innovative 
programs that have been initiated to address this problem in 
New Mexico, and we are very pleased that you could be with us 
as well so that we can see what can be done in a very practical 
way.
    As you can see, we have assembled a very distinguished 
panel of witnesses. I am very pleased you could all be with us, 
and we are going to start with Ms. Carothers. Thank you.

 TESTIMONY OF CAROL CAROTHERS,\1\ EXECUTIVE DIRECTOR, NATIONAL 
             ALLIANCE FOR THE MENTALLY ILL OF MAINE

    Ms. Carothers. Thank you, Chairman Collins and Members of 
the Governmental Affairs Committee. I am Carol Carothers, the 
Executive Director of NAMI Maine, which is the Maine State 
chapter of NAMI--the National Alliance for the Mentally Ill. 
Thank you for the opportunity to testify.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Carothers appears in the Appendix 
on page 57.
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    I can tell you that the findings contained in today's 
report are accurate. Youth with mental illnesses are held in 
juvenile detention because they cannot access treatment. We 
would not dream of placing a child with cancer, for example, in 
juvenile detention to await treatment. It is outrageous that we 
do this to children with mental illness, and there are four 
points I would like to make today.
    One, children and families are suffering unthinkable 
consequences from this crisis. My first involvement with this 
issue was the death by hanging of an 18-year-old whose mental 
illness and substance use disorder had been untreated for 
years. He died in Maine's most restrictive prison--the super-
max--because he was suicidal and no hospital bed could be 
found.
    More recently, Maine settled a lawsuit on behalf of a child 
committed to the youth center at age 13. He was suffering from 
depression and suicidal ideation, held in isolation for 152 of 
his first 240 days. Each of five future admissions also 
resulted in long periods of isolation, behavior deterioration, 
depression, aggression, and eventually self-mutilation.
    Just last week, I spoke to two moms. Both tried 
unsuccessfully for years to secure school-based services for 
their mentally ill sons. The schools sent them home or 
suspended them for not following school rules. The moms nearly 
lost their jobs. The other children begged to have their 
brothers kicked out. Eventually, the courts, with few 
resources, incarcerated them. Once incarcerated, the boys lived 
with more accomplished juveniles. One mom said, ``If I could 
ask anything, I would ask, `What money did you save by denying 
my son mental health treatment and services? ' '' The second 
mom said, ``My son learned to cut himself in there.''
    Two, juvenile detention centers are the worst possible 
environment for children with mental illnesses. Many of the 
techniques used in correctional settings, like prolonged 
isolation and restraint, actually lead to increased, not 
decreased, acting out and self-harm, particularly among youth 
with mental illnesses. When children are detained in juvenile 
centers in Maine, they are housed in a single unit where 10-
year-olds can be housed with 20-year-olds. Providing for their 
individual needs is extremely difficult. Staff can spend most 
of their time protecting the vulnerable kids from the predatory 
kids, especially when a unit designed for 30 houses 43. 
Correctional settings are slow to respond to kids with 
undiagnosed disabilities, leading to deterioration in mental 
status, increased violations of rules, and increased 
discipline. The unfortunate reality is the more experiences 
youth with mental illness have in juvenile detention, the more 
likely they will descend deeper and deeper into the criminal 
justice system.
    Three, Maine, like most States, lacks adequate home and 
community-based services. Most States lack adequate home and 
community-based mental health services. Maine spends 60 percent 
of its scarce dollars on institutional services, despite the 
fact that home and community-based services cost less and 
produce better outcomes. It costs between $50,000 to $80,000 a 
year for detention and about $30,000 to provide intensive in-
home services for a family for 1 year.
    Too many youth housed in juvenile detention centers 
graduate to the adult correctional system. The United States 
has the largest number of incarcerated citizens in the world, 
and we open four new correctional institutions every month. We 
must not become a Nation that spends more to incarcerate 
children than to educate or provide treatment for them. Money 
cut from mental health and substance abuse services is shifted 
to corrections budgets, a waste of taxpayer money and an 
inhumane and counterproductive way to treat children and adults 
with mental illnesses.
    Four, what can be done to help end this crisis? Enact the 
Keeping Families Together Act, which would help end the tragedy 
of custody relinquishment.
    Enact legislation to help improve access to essential 
evidence-based, community-based services for youth with mental 
illness and their families.
    Enact the Mentally Ill Offender Treatment and Crime 
Reduction Act which would authorize funding to help States 
reduce the high percentage of youth and adults with mental 
illnesses locked up in jails and prisons.
    Enact the Senator Paul Wellstone Mental Health Equitable 
Treatment Act, which will assure access to treatment.
    And enact the Family Opportunity Act to allow families with 
children with serious disabilities to buy into the Medicaid 
program.
    In closing, I would like to thank Senator Collins and 
Representative Waxman for their leadership in requesting this 
report. I would also like to share with the Committee that in 
preparing my remarks for this hearing, I spoke with families, 
inmates, and advocates, asking: What is the most important 
thing that I should say? The answer they all agreed upon was: 
Make sure they understand the urgency of this issue. Thank you.
    Chairman Collins. Thank you. Ms. Seltzer.

 TESTIMONY OF TAMMY SELTZER,\1\ STAFF ATTORNEY, JUDGE DAVID L. 
              BAZELON CENTER FOR MENTAL HEALTH LAW

    Ms. Seltzer. Good morning, Chairman Collins, Senator 
Lautenberg, and Congressman Waxman. Thank you for the 
opportunity to speak.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Seltzer appears in the Appendix 
on page 63.
---------------------------------------------------------------------------
    On any given night, nearly 2,000 children and youth--some 
as young as 7 years old--languish in juvenile detention 
facilities around the country solely because they need mental 
health services.
    Until now, public policy circles have largely ignored this 
issue, but thanks to Chairman Collins and Congressman Waxman, 
we now know how widespread this tragedy is.
    I am not going to highlight any of the findings of the 
report, just to say that they are consistent with what we have 
been hearing from families and advocates around the country. 
Although the issue of victimization was not addressed in the 
report, I think it is important to note that these incarcerated 
youth are also more likely to be victims of violence in these 
detention centers because they are perceived as more 
vulnerable.
    My testimony today will address the causes of this tragedy, 
describe the kinds of services and supports that children need 
to avoid ending up in juvenile detention centers, and outline 
steps that the Federal Government can take to make a difference 
for these children and their families.
    According to the detention center administrators, these 
children they identified for the survey should not be in their 
facilities and would not be there if appropriate community 
mental health services were available.
    Children with mental disorders are funneled into the 
juvenile justice system through a variety of ways. Number one 
is the lack of access. In most communities, the public mental 
health system is open from 9 to 5, when most children are in 
school. The police department, on the other hand, is open 24 
hours a day. I think that fact right there explains why so many 
children are ending up in detention facilities.
    But there is also a lack of accountability and a bias 
toward law enforcement solutions. The agencies responsible for 
supporting parents and treating their children pass the buck by 
telling parents that they should call the police for help. In 
one case, a mental health crisis line designed to aid parents 
in just these situations called the police rather than sending 
out a mental health crisis team.
    There is also a lack of comprehensive private and public 
insurance for mental health problems, as was mentioned earlier, 
and a lack of coordination. The public agencies that serve 
children are so uncoordinated that children can end up with 
several diagnoses, and each agency ends up referring the child 
to another agency for services that do not even exist.
    While model programs are far too rare, effective 
alternatives to incarceration do exist. One such program, 
Wraparound Milwaukee, works closely with parents to provide 
services tailored to the needs of each child so children can 
stay out of crisis and out of the juvenile justice system. The 
program is reducing costs and--more important--reducing the 
number of children who end up in juvenile detention centers.
    Fortunately, we know the principles that make programs like 
Wraparound Milwaukee successful. Children and their families 
must have ready access to mental health services and supports. 
This access has to be based on real kid time and not bankers' 
hours. Services and supports must be designed to enable 
children to succeed and not just avoid detention, and child-
serving agencies need to work together and be held accountable. 
And the Federal Government can play a key role in addressing 
this problem, both through Federal agency actions and through 
specific legislation.
    According to today's report, the General Accounting Office 
recommended that the Department of Justice ``track the 
inappropriate detention of mentally ill across the country.'' 
Given the seriousness of this situation, we urge lawmakers to 
require the Department of Justice to reconsider GAO's request 
and also encourage the Department to enforce the law.
    But simply closing the door to juvenile justice is not a 
panacea. For example, the report notes that many children are 
languishing in these detention centers because there is a lack 
of specialized foster care placements. Obviously, children 
should be kept at home whenever possible, and necessary 
services should be brought to them there. But when that is not 
possible, therapeutic foster care has proven effective.
    States can use Medicaid to help pay for the services that 
are provided with therapeutic foster care, but far too few 
States take advantage of this because they are confused about 
Medicaid law. CMS, the Center for Medicare and Medicaid 
Services, could clear up these misunderstandings by issuing a 
memo to State Medicaid directors.
    In 1997, the Individuals with Disabilities Education Act 
was reauthorized to explicitly require schools to respond 
proactively to problem behavior of students when it affects 
their learning or the learning of others. But too few schools 
have embraced these positive behavioral supports. Instead, they 
rely on zero tolerance policies, suspensions, and expulsions, 
and, increasingly calling the police--tactics that do nothing 
to improve student behavior and only increase the likelihood 
they are going to end up in the juvenile justice system. The 
Department of Justice must do more to enforce IDEA.
    In terms of specific legislation, the Family Opportunity 
Act, as Ms. Carothers mentioned, is something that would enable 
more families to have access to Medicaid. And the Keeping 
Families Together Act, which Chairman Collins has introduced, 
along with others, is a very important specific piece of 
legislation that would help reduce the number of children with 
mental or emotional disorders by supporting States' efforts to 
develop coordinated systems of care.
    When I last appeared before this Committee last year to 
talk about custody relinquishment, I discussed the GAO study 
that Chairman Collins mentioned. And as someone working in 
mental health for 8 years, what was shocking to me was not the 
number of children that families were giving up, because I 
think that 12,700 number is actually an underestimate. But what 
was the most shocking is where those children were ending up. 
Two-thirds were ending up in the juvenile justice system, not 
child welfare.
    I want to commend Senator Collins and Congressman Waxman 
for commissioning this important report, and hopefully by 
providing this kind of information, we can address the problems 
so that parents do not have to face this tragedy. These 
children languishing in juvenile detention centers are being 
thrown away like yesterday's garbage, but they are tomorrow's 
adults. And as Congressman Waxman said, if we are denying them 
their potential, that would be the greatest tragedy of all. 
Thank you.
    Chairman Collins. Thank you. Mr. Dixon.

  TESTIMONY OF LEONARD DIXON,\1\ PRESIDENT, NATIONAL JUVENILE 
  DETENTION ASSOCIAITON, AND EXECUTIVE DIRECTOR, WAYNE COUNTY 
         JUVENILE DETENTION FACILITY, DETROIT, MICHIGAN

    Mr. Dixon. Good morning. Thank you for the opportunity to 
testify before you today, and I would like to ask that my full 
written testimony be entered into the record.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Dixon appears in the Appendix on 
page 76.
---------------------------------------------------------------------------
    Chairman Collins. Without objection.
    Mr. Dixon. I am Leonard Dixon, President of the National 
Juvenile Detention Association and the Executive Director of 
the Wayne County Juvenile Detention Facility in Detroit, 
Michigan. I wish to thank Chairman Collins, Senator Lieberman, 
and Representative Waxman for their leadership on this issue 
and for inviting me here today to discuss with you my views on 
the report submitted by the Government Reform Committee on 
incarcerating mentally ill youth awaiting community placement 
in the United States.
    The report serves to highlight the seriousness of one of 
the most difficult issues facing all juvenile detention centers 
across the Nation, and its impact on the daily operations of 
these facilities across the country cannot be underestimated.
    In Wayne County last year, there were 4,152 youth between 
the ages of 10 and 17 that were identified in our facility, 
that came into our facility. Of that, 2,331 of those youth, 56 
percent, needed and received mental health services. There are 
several factors within the field of juvenile justice that 
constitute a reasonable argument to ensure that the 
inappropriate placement of youth with mental health issues in 
detention ends. The most compelling argument is that detention 
for youth is generally short term and does not include nor 
guarantee the provisions of any type of formalized treatment to 
address identified disabilities, including mental illness. 
Youth with mental health issues require support and management 
services that often exceed the level of training provided in 
detention facilities.
    A second reason for ensuring that youth with mental 
illnesses are not detained in juvenile detention facilities is 
that they are more difficult to manage, more explosive, more 
easily agitated, require more intensive supervision, and create 
more strain on direct care staff than other youth within the 
juvenile facility. Management of youth with mental health 
issues results in a higher number of injuries to both staff and 
youth, the destruction of property with building repairs. Most 
juvenile facilities do not have the luxury of separating youth 
with mental health issues from the general population. This 
creates an atmosphere of conflict and unrest for everyone, and 
the potential for crisis can be very high.
    I would like to give you a couple of stories. The first 
involves an 11-year-old female youth. At the age of 8, she was 
hospitalized in a psychiatric facility for the first time 
because of aggressive behavior towards her mother. Before 
entering the juvenile justice system, she had two more 
inpatient psychiatric hospitalizations. She still began to 
develop anxiety about school and in the fifth grade refused to 
go to school. Because of her mental health history, she came 
into our facility. At that time, it was very apparent to the 
mental health team that her difficulties were related to her 
relationship with her mother and would be best addressed by 
family therapy.
    The youth was returned to our facility in less than 5 weeks 
because her mother told the court that her daughter was 
refusing to follow directions. She remained in detention for an 
additional 3 months as she awaited placement for community 
services.
    The second case is a clear example of the failing of our 
Nation's foster care system. It involves a 15-year-old male who 
entered the foster care system when he was 9 because of abuse 
and neglect. The youth had never returned home since that time. 
He has been in and out of our facility at least eight times. He 
has had stints in short-term psychiatric hospitals and has been 
in many residential facilities.
    During his last stay at our facility at Christmas, he was 
very depressed and began to engage in self-mutilating behavior. 
As a result, he was placed on constant watch. He told the 
detention staff that he had swallowed a piece of glass and was 
sent to the emergency room. From there he was transferred to a 
psychiatric hospital for treatment of his depression. After 3 
days, he pulled the fire alarm at the hospital and escaped.
    He had planned all along to go back to his old neighborhood 
and look for his family. He managed to elude the authorities 
for several months. He found some relatives. Upon his return, 
he was disillusioned about his family and sadly reported that 
he felt unconnected to them.
    The need for collaboration with mental health agencies in 
the community is often very difficult but extremely important 
in terms of taking care of these youth. The most critical 
reason for the gap in networking on behalf of youth is the lack 
of coordinated communication between mental health and juvenile 
justice systems. The correction community has long been 
sympathetic to the need of juvenile offenders with special 
needs. In 2001, the National Juvenile Detention Association 
adopted the following position statement--which I will not read 
for the lack of time.
    Despite our efforts to ensure that those in need of mental 
health services do not end up in our custody, parents are often 
forced to choose the confinement of their children with mental 
health issues in a detention center as a two-pronged solution 
to the crisis.
    In closing, I have nine areas that will be in the record, 
but one I would like to cite particularly: The issue of 
Medicaid funding. What happens in our country is that when a 
youth is brought into a public detention facility, the Medicaid 
funding is usually cut off, which means that the money is not 
following the kid, the kid is following the money. And with 
that, it has become--other funding sources identified for youth 
services must follow the youth and not become available only 
when the youth enters the system as designated levels of care. 
Special emphasis must be placed on mental health parity with 
medical services for our most vulnerable resource. And I would 
say what my father would say a long time ago: You cannot 
cripple a person and then criticize the way that they walk. 
When we place kids in institutions without having the proper 
services, the proper appropriate services for them, then we are 
asking the facilities to perform at a level that they are not 
capable of doing. And most detention centers in the country do 
not have mental health services, so you are placing kids with 
those problems in with kids who are purely delinquent kids, and 
we are asking for a good result. That will never happen.
    So I would like to thank you again, and the bills that are 
currently before Congress are two bipartisan proposal that 
merit consideration and swift approval, which would help to 
fill the gap between treatment and detention: The Keeping 
Families Together Act, introduced by Senator Collins and 
others, and the Mentally Ill Offender Treatment and Crime 
Reduction Act.
    Thank you very much.
    Chairman Collins. Thank you, Mr. Dixon. Judge Gray.

 TESTIMONY OF HON. ERNESTINE S. GRAY,\1\ CHIEF JUDGE, ORLEANS 
         PARISH JUVENILE COURT, NEW ORLEANS, LOUISIANA

    Judge Gray. Good morning, and thank you for the invitation 
to participate in this hearing. I am a juvenile court judge 
from New Orleans, Louisiana, having been on the bench for over 
19 years, and my 19 years on the bench has given me a wealth of 
knowledge and experience dealing with the juvenile justice 
issues. I have served on many boards and commissions regarding 
juvenile justice issues. I have served as a member and past 
president of the National Council of Juvenile and Family Court 
Judges. I want to thank you for your efforts in this area and 
your attention to this important issue, and I would like to say 
that this is long overdue.
---------------------------------------------------------------------------
    \1\ The prepared statement of Judge Gray appears in the Appendix on 
page 87.
---------------------------------------------------------------------------
    No one can doubt that there is a serious issue as it 
relates to the mental health of our children, and an equally 
serious issue with the way we provide treatment, when and if 
treatment is provided.
    All of my experience over the past 19 years is consistent 
with the findings of the report being released today. All too 
often, children charged with delinquent behavior are identified 
early on as needing mental health services. However, because 
those services are not available, the children are sent back to 
their families with no supports until there is another 
violation. Many times it is only after several brushes with the 
law, each time a little bit more serious, before everyone is 
fed up and then the solution is to incarcerate the children for 
a reason, and the reason being so that they can get mental 
health services that they need.
    Judges I can tell you, are frustrated on a daily basis by 
having to be put in a position of knowing that the only reason 
really we are incarcerating children is so that they can get 
mental health services. I am a judge who believes very much in 
due process and procedural rights, and I have been known on the 
bench to say daily, ``This is not right. We should not 
incarcerate children just because they are ill.'' And many 
times I have found in cases that we seem to be just making up 
violations so that we can get them into the system and get them 
services. And you have already heard from Mr. Dixon that those 
services that they need are generally not provided because 
those facilities are not equipped to provide the mental health 
treatment that the children need.
    Judges are faced with families many times a day who are 
saying, ``We cannot do it any longer. We are unable. We do not 
know what else to do. And so I want you to take them. I am not 
taking them home. I refuse to take them home because I am 
afraid of them, I am afraid of what they might do to me, what 
they might do to themselves, or what they might do to someone 
else.'' And so they bring them to court many times, and they 
leave them on the doorsteps of the court, and the judges are 
then faced with what to do with these children.
    These issues cut across both delinquency and dependency 
cases, and it is not a surprise that many children who are 
abused and neglected many times end up in the juvenile 
delinquency side. It is unfortunate that there is a high 
correlation between the children who are in our dependency 
caseload and those who are also in our delinquency caseload. 
Children who have been abused and neglected many times end up 
incarcerated, again, because we are not able to provide the 
services that they need. They have bombed out of their foster 
home placements. The caretakers are saying, ``We can no longer 
provide the services that they need in the home, and so you 
need to find another placement for them.'' And many times, the 
only placement we can find, especially on short notice, is a 
placement that is in a detention facility.
    Status offenders, children who are runaways, who are 
truant, who are ungovernable and unruly, many with mental 
health issues, are detained or locked up ``for their own 
good''--because that is the only way that judges think they can 
keep them safe.
    I have looked at many of the bills that are pending and 
that have been introduced to address this issue. My concern is, 
for example, on S. 1704, it sets up a competitive grant 
process. I long for the day--I do not mean this to be 
disrespectful. I think that it is good. But I long for the day 
when children will be able to receive services that they need 
in their State, regardless of whether or not a State agency is 
able to write a competitive grant. We are concerned about the 
families relinquishing their children to get services. Are we 
also setting up a situation in which they will have to move to 
another State to get services? In this country, I do not 
believe that is appropriate. It is inconsistent with what we 
say about children being our greatest natural resource. 
Children deserve the services that they need no matter what 
State they are in purely because they are in this country and 
are part of our citizenry.
    One of the problems that I see that I do not believe is 
addressed, I think that there is a lack of specialists--
psychiatrists and psychologists with the special training to 
deal with young people. And one of the things I would hope that 
we might be able to do is sit down with some of the medical 
schools and universities and try to figure out if there is a 
way that we can develop a larger pool of people who are 
specially trained to deal with children--child psychiatrists 
and psychologists. And I believe that we can do that, perhaps 
looking at what was done in the area of legal aid when there 
was a lack of attorneys in the South. There were programs that 
were developed that would recruit and then help those persons 
pay back their school loans, any number of things so that we 
would be able to recruit the kinds of people that we need. So I 
would urge working with medical schools and universities to 
address that issue.
    There are a couple of recommendations that I would like to 
make, and I think we all know what is needed, but I would just 
say them for the record so that we can be clear:
    Twenty-four hour availability of services.
    Standardized screening and assessment. It seems to me it 
makes no sense to have one screening for juvenile justice and 
one screening for mental health when we know the children are 
all the same. So let's get together and decide what is the best 
assessment tool that we all can use that will provide the 
information that we need in order to be able to effectively 
treat the young people who are appearing in our systems.
    Better communication and coordination interagency and 
intersystem. This means developing the capacity and ability to 
share information across systems about the children that we are 
working with.
    Community-based programs. It has already been talked about.
    Integrated treatment across all systems, that is, child 
welfare, juvenile justice, mental health, special education, 
and substance abuse.
    More research on the prevalence of mental health disorders 
among youth. And it has already been suggested and I would 
second that: We are urging the Department of Justice to track 
the inappropriate detention of youth with mental illnesses 
across this country.
    No matter how hard we try, we may not be able to treat all 
children outside of detention. Nonetheless, children who are 
rightfully detained, these children need treatment for their 
mental illness, mental disorders, and you have already heard 
that in the juvenile detention centers that is not appropriate. 
And so we need to work on the treatment that we are providing 
for those children who are legitimately detained.
    In order to effectively serve this population, the juvenile 
justice system and the mental health system must work together 
to develop programs and services for these children. These 
services need to be appropriate for the child's age, gender, 
and culture, individualized and family-focused.
    I would also urge--I would be remiss if I did not urge you 
to look closely at what happens to youth of color in the 
juvenile justice system. They are overrepresented in the 
juvenile justice system and many times underserved by the 
mental health system. So as you are looking at this issue, I 
would encourage you to pay some attention to that as well.
    I thank you again for the opportunity to be here this 
morning and look forward to having a discussion with you during 
the question-and-answer period. I would tell you that the 
juvenile judges from around the Nation are profoundly 
interested in this work, and we are willing to work with you to 
find solutions that improve the lives of these children and 
families. Our detention facilities should not be used as 
substitute mental hospitals. Thank you.
    Chairman Collins. Thank you, Judge. Dr. Martinez.

    TESTIMONY OF KENNETH J. MARTINEZ, PSY.D.,\1\ DIRECTOR, 
CHILDREN'S BEHAVIORAL HEALTH, DEPARTMENT OF CHILDREN, YOUTH AND 
                 FAMILIES, STATE OF NEW MEXICO

    Dr. Martinez. Thank you, Senator Collins, for the 
opportunity to be here today, and thank you to Senators Durbin 
and Lautenberg, and Congressman Waxman also.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Martinzes appears in the Appendix 
on page 89.
---------------------------------------------------------------------------
    I would like to share with you some approaches that we have 
in dealing with juvenile justice clients in our system in New 
Mexico, but first I am going to make some key points about the 
national scene.
    First, the prevalence of mental health disorders among 
youth in the juvenile justice system is two to three times 
higher than among youth in the general population. Anywhere 
from 70 to 100 percent of youth in the juvenile justice system 
have a diagnosable mental health disorder.
    Second point: The mental health and substance abuse needs 
of the juvenile justice population have been neglected. There 
is a growing concern over the criminalization of mental illness 
among our juvenile population. The juvenile justice system as 
well as the child welfare system are becoming the systems of 
last resort.
    And the third point: There are new and effective tools and 
services that are demonstrating real promise for youth in the 
juvenile justice system. We now have screening and assessment 
tools that have been specifically designed for youth in the 
juvenile justice system that have proven to reduce long-term 
rates of re-arrest, improve family functioning and school 
performance, and decrease substance abuse and psychiatric 
symptoms.
    Now I would like to take the opportunity to comment on 
Representative Waxman and Senator Collins' report.
    First, I want to thank Representative Waxman, 
Representative Udall, and Senator Bingaman for choosing New 
Mexico to highlight the problems that are occurring around the 
country. We were the first to be highlighted, and that has 
really helped us move forward in taking the next steps to 
remedy the situation. So thank you, Congressman Waxman.
    As was implied in the report, juvenile detention centers--
and, I might add, State correctional facilities--have become 
the de facto psychiatric hospitals and residential treatment 
centers for mentally ill youth. These youth require appropriate 
clinical services, professional clinical staffing, and 
evidence-based programs.
    Second, detention, especially unnecessary detention, for 
children and youth with mental health needs who are not 
properly screened, evaluated, and treated causes harm to these 
children and youth. Undiagnosed and untreated mental health 
disorders are exacerbated by the conditions of confinement.
    Third, youth who are detained for the sole reason of 
awaiting treatment in the community are predictably going to 
have a deterioration of functioning and an increase in 
symptoms, such as suicidal ideation and attempts, and those are 
the only likely outcomes that will occur while they await 
transfer. Consequently, their course of treatment may be 
lengthened when they eventually receive it.
    And, fourth, community-based services are needed and yet 
are not plentiful to meet the need. Culturally competent 
treatment that involves the family is a necessary prerequisite 
to success.
    The following describes some of the work that we are 
working on in New Mexico, and we admit that we still have a 
long way to go.
    From 1991 to 1999, the Bernalillo County Juvenile Detention 
Center, which is where Albuquerque is located, housed 130 to 
140 clients ages 8 to 18, with an average length of stay of 33 
days each. Through collaboration and ongoing support of the 
Annie E. Casey Foundation, and utilizing best practices from 
other States, the Bernalillo County Juvenile Detention Center 
managed to accomplish many things. It now has an average daily 
census of 65, down from 140; with an average length of stay of 
9 days, down from 33 days, including for the most serious 
youthful offenders; a recidivism rate of 13 percent, down from 
46 percent; and the cost for secure detention a day was $96, 
and now the cost of the community custody program is $19. 
Still, we have 73 percent of currently detained clients having 
at least one mental health diagnosis in those clients that are 
in detention.
    Now, how was all this accomplished? The Children, Youth and 
Families Department, the department that I work for--which is 
responsible for children's behavioral health, juvenile justice, 
and child welfare--along with the Human Services Department--
which is the Medicaid State agency--the Department of Health--
which, among other things--the Bernalillo County, the 
University of New Mexico Health Sciences Center, the three 
Medicaid managed care organizations, and children's court 
judges all collaborated, culminating in the Children, Youth and 
Families Department licensing the Bernalillo County Juvenile 
Detention Center as a ``Children's Community Mental Health 
Center,'' which allowed for Medicaid billing of all medical and 
behavioral health services provided to non-adjudicated youth. 
The University of New Mexico also contracted child psychiatric 
staff and other providers to staff the center. Since it opened 
in 2002, the Children's Community Mental Health Center, on the 
campus of the Bernalillo County Juvenile Detention Center, has 
seen 1,200 children.
    The detention center has a relationship with a local 
adolescent shelter care provider to be a reception/assessment 
center in lieu of detention for minor offenses that are 
frequently mental health or substance abuse related. Police 
take juveniles that are picked up to the reception/assessment 
center for mental health/substance abuse screenings and 
evaluations and treatment.
    We have four social workers in the Albuquerque Police 
substation and the sheriff substations to work with youth and 
their families at the time that they are picked up to avoid 
unnecessary detention.
    The Bernalillo County Juvenile Detention Center operates a 
Youth Reporting Center on its campus that is open 7 days a week 
from 8 a.m. to 8 p.m., offering academics, recreation, 
workshops, and other similar activities.
    The detention center has a community custody program to 
supervise youth at job sites and at schools.
    In addition to the county initiative, the Children, Youth 
and Families Department's Juvenile Justice Services has worked 
closely with the New Mexico Juvenile Parole Board to parole 
technical violators and low-risk clients with low to high 
needs, who can then be referred to community programs.
    Our Department has reduced its statewide correctional 
facility census from 625 to 270, as of this week, a decrease of 
55 percent. Consequently, we closed our 96-bed maximum security 
correctional facility last week, July 1 of this year. These 
reforms are a result of many factors, including juvenile 
detention reform, juvenile drug courts, re-education of 
juvenile probation and parole officers, law enforcement, 
juvenile court judges and attorneys.
    Additionally, our department has redeployed 41 positions 
that used to be employed in the maximum security facility to 
``front-end'' services in communities, including to provide 
client supervision; regional coordinators to identify and 
develop programs in rural and urban communities; and to become 
functional family therapists and multi-systemic family 
therapists in the community. The Annie E. Casey Foundation is 
assisting New Mexico to replicate this model in seven other 
communities.
    Conclusions: The solutions are not simple. They involve 
cross-system solutions. There is an obvious blurring of roles 
and responsibilities of child-serving systems, and that is a 
good thing because no longer is a child or youth exclusively a 
child welfare client or exclusively a juvenile justice client 
or a mental health client. They are the same child or youth in 
more than one system. They are all our children and youth 
regardless of the system door they enter.
    We in the New Mexico juvenile justice, mental health, and 
child welfare systems applaud you, Senator Collins, and your 
colleagues for introducing Keeping Families Together Act. It 
not only will provide funding for interagency systems of care 
for children and adolescents, but it acknowledges the cross-
system complexity in defining the problem and in defining the 
solution. For too long, our child-serving systems have not 
worked together and, therefore, have missed opportunities to 
collaborate, share resources such as joint planning, program 
development, and human and financial resources. We have failed 
to function either as one child-serving system or as a 
coordinated and collaborating set of jointly responsible and 
responsive child-serving systems. Keeping Families Together Act 
would be one major step forward in promoting the cross-system 
collaboration, and it certainly complements the New Freedom 
Commission Report on Mental Health that also advocates for more 
and effective cross-system collaboration.
    There is much more that needs to happen, and we as 
policymakers need to recognize that meeting the behavioral 
health needs of our juvenile justice population in detention is 
critical.
    Many of the youth detained are in for relatively minor 
offenses. Diversion programs need to be developed, and we need 
to advocate for and fund more community-based options that will 
provide mental health and substance abuse treatment to these 
youth in their own communities and give judges, such as Judge 
Gray, options other than incarceration. The research suggests 
that this is the most effective approach.
    While we are doing a better job at screening and 
assessment, we need to advocate for and fund universal 
screening for all youth entering detention and provide 
evaluations and treatment when necessary in appropriate 
community-based settings.
    And, finally, community re-entry programs for youth 
transitioning out of detention and correctional placements need 
to be strengthened to maximize success and reduce recidivism in 
both the detention system and restrictive mental health 
settings.
    Thank you for your concern over this issue. Our collective 
goal is to improve conditions for our youth and provide the 
needed services and supports to them and their families.
    Thank you, Senator.
    Chairman Collins. Thank you. That testimony was very 
encouraging, and I look forward to questioning you, as I know 
the panel does.
    I am going to begin with Ms. Carothers with a question. I 
know that you have done a great deal of work with Maine's 
inmate population with a focus on adult inmates who are living 
with mental illness. Could you give us some idea of how many of 
those adult inmates were also involved in the juvenile justice 
system?
    Ms. Carothers. Most of the inmates that I have worked with 
were involved in the juvenile system. I interviewed 40 inmates 
in Thomaston Prison a couple years ago, and they all told the 
same story, which is poverty, foster care, a youth center, 
Wyndham, which is the first step, and then the higher prison, 
Thomaston. I think the recidivism is enormous, and I think it 
starts in juvenile, absolutely.
    Chairman Collins. I am struck by Dr. Martinez's statistic 
that most youth in the juvenile justice system have diagnosable 
mental disorders. In fact, it may be as high as 70 to 100 
percent, which is huge. Does that suggest to you, Ms. 
Carothers, that if we were to invest in mental health services 
for youth, we would greatly reduce the adult population in 
prisons?
    Ms. Carothers. Prevention is everything, and so if you can 
catch kids early, you would absolutely make a difference in the 
whole system, the numbers in the adult system and the numbers 
in the juvenile system, start earlier.
    Chairman Collins. Judge Gray, could you give us an idea 
based on your 19 years on the bench of how many of the youth 
who come before you either have problems with mental illness or 
substance abuse? What percentage would you guess?
    Judge Gray. I would guess clearly 70 to 85 percent of the 
kids who come before the court have a mental health issue and/
or a substance abuse issue, because we do have co-occurring 
disorders, and so you have some children with both. But 70 to 
85 percent of them have one or the other.
    Chairman Collins. Dr. Martinez, this suggests to me that an 
investment in community-based mental health care for juveniles 
can save not only a great deal of human suffering for these 
individuals and their families and communities, but also save a 
great deal of money as well in the long run. Was it difficult 
to convince the legislature in your State to make the up-front 
investment in mental health services that you are already 
starting to recoup? How did you convince policymakers in your 
State to make that up-front investment when they have to wait a 
bit for the savings to be realized? Even though it sounds like 
you have been able to realize savings as well as considerable 
public policy improvements rather quickly.
    Dr. Martinez. Well, the investment is economic, certainly, 
but most importantly, it is an investment in our youth so that 
they do not become inmates of correctional facilities as 
adults.
    We are still having our struggles in convincing everyone, 
yet our efforts really are a bipartisan effort within our State 
legislature, led by our governor, to really make improvements 
in prevention and early intervention. We have spent many 
dollars in high-end services, as we call them, in correctional 
facilities. Redeploying those 41 full-time employees and 
putting them in communities is going to be an argument that 
hopefully will convince the rest of our legislators that this 
is a worthwhile effort.
    It is a long-term investment. It is very hard to convince 
people without data that, for the short term, prevention is 
worth the effort. And yet everything indicates to us that it is 
the only investment that is going to help us save our children 
and save money as well.
    Chairman Collins. Mr. Dixon, I was impressed in your 
testimony when you said that 56 percent of the people coming to 
your facility actually received mental health services. It 
seems to me that you are more advanced than many facilities if 
you are doing that kind of screening up front to identify 
people who need mental health services.
    Is your experience typical? Or do you think that it is 
unusual to have a system that does that kind of screening and 
provides these kinds of services?
    Mr. Dixon. Madam Chairman, it is almost laughable that we 
do not have this going on in most facilities in the country. We 
are very unique, in Michigan. And, I will say this: One of the 
reasons why that occurred and the reason why I am in Michigan 
is because we were being investigated by the Department of 
Justice. And it is a shame that what is starting to happen in 
this country is that no one wants to fix anything until the 
Department of Justice comes in and says that you have all of 
these problems. And we keep saying fix the problem up front, 
then you do not have to pay for it, because you spend a lot of 
money when you get into lawsuits, into litigation, and all 
those kinds of things.
    And so we have been stressing with folks around the country 
to fix your problems prior to someone coming in to tell you 
that they need to be fixed.
    Chairman Collins. Ms. Seltzer, I was very pleased that you 
gave us some specific actions that we can take, and we would 
like to work with you in encouraging CMS to issue the memo on 
therapeutic foster care that you mentioned.
    My time has expired so I need to wrap up quickly. But could 
you tell us a little more about the Wraparound Milwaukee 
program that you indicated as being a promising approach?
    Ms. Seltzer. Certainly. Wraparound Milwaukee has been 
around for a number of years, and it targets children who are 
in the juvenile justice system. At least initially that is what 
it did, and now it has expanded to focus on children who are at 
risk of entering the juvenile detention system.
    It works very intensely with schools and the mental health 
system and child welfare system to provide services to children 
in their homes where they live so that they are able to not 
only avoid juvenile detention but to be successful in school 
and in their communities and to be able to live with their 
families.
    Chairman Collins. Thank you. Congressman Waxman.
    Mr. Waxman. Thank you very much.
    When we were trying to find out about this problem of 
unnecessary detention of children because they could not get 
access to mental health services, we wrote to the juvenile 
detention facilities, and we got a real strong response, not 
just giving us the information but anger and frustration by 
many of the administrators of these facilities that they were 
being used as warehouses.
    Mr. Dixon, is it true that they cannot turn anybody away? 
And is it your sense that other agencies and insurers are just 
saying no more and that is why they are ending up in your 
facilities?
    Mr. Dixon. Yes, that is correct, Congressman. One of the 
things that we keep saying is that detention has become not 
only the dumping ground, but it is the emergency room of 
whatever goes on in the systems, because no one can handle--no 
one wants to handle the kid. I was struck by an article last 
week in the Miami Herald where three girls who were in a mental 
health facility tried to escape, and they placed them in a 
detention facility for 21 days because they were trying to 
escape from a mental health facility. Well, to me, that is 
backwards.
    And so, yes, it has become almost unbearable because we are 
talking about money here, and we are having staff who are 
injured because they are not trained to deal with kids who have 
these kinds of problems. And if you are going to do it, then 
you are going to have to put in training and all those things 
in the institutions, and that is not happening.
    And so we have been very fortunate in Michigan, but it is a 
major issue for every detention facility in this country.
    Mr. Waxman. Thank you very much.
    Ms. Carothers, I wanted to ask you: Some people might say 
the best way to solve this issue or to deal with it is to get 
services in the detention centers. Is that going to be a good 
way to make sure that children have access to what they need?
    Ms. Carothers. You need services in the detention centers 
for those kids who you cannot keep out. But what you really 
need is diversion, and diversion is just a word unless you have 
something to divert people to, which means services. So you 
actually have to have diversion, and you cannot have diversion 
unless you have a lot of mental health services in the 
community. And those need to be evidence-based blueprint 
services where folks have the understanding to treat people 
with dual disorders and who have criminal justice involvement. 
Oftentimes our mental health centers do not have that 
expertise.
    Mr. Waxman. In other words, a lot of kids just should not 
be in the detention center at all. They should be getting care 
elsewhere, either in the community mental health centers or 
hospitalization or child welfare agencies of one sort or 
another. Is that the----
    Ms. Carothers. I do not think they would be in the criminal 
justice system if the safety net service system was there.
    Mr. Waxman. And, of course, they are not, for many of them, 
even involved in any kind of criminal activity. On that point, 
somebody said ``criminalization'' of mental health is what is 
going on.
    Mr. Martinez, I am pleased to hear what you had to say 
about the fact that when Senator Bingaman and Congressman Udall 
asked us to do this evaluation, we started in New Mexico, and 
it seems to have led to a number of reforms in your State to 
try to actually come up with some ways to deal with this 
problem. You went through some of the points, but I was 
interested, particularly because I have a background in this 
area, how you use the Medicaid funding to accelerate the 
transition from juvenile detention to mental health, and 
community mental health services. Were you able to figure out 
some way to draw more Federal dollars so that these services 
would be available under Medicaid? So many of these children 
are going to be eligible for Medicaid, if not all of them, 
because of the institutionalization.
    Dr. Martinez. Well, what we have done is for non-
adjudicated youth, we have accessed Medicaid services because 
that is certainly allowable. So for those kids that have been 
diverted from detention and can be served in the Children's 
Community Mental Health Center or who are released from 
detention who are Medicaid-eligible by income, we certainly can 
serve them in the Children's Community Mental Health Center. So 
we are not drawing down any more or different kind of funding 
for Medicaid, but certainly we utilize it quickly. And with 
presumptive eligibility, which is allowed under Title 21, the 
State Children's Health Insurance Program, we are able to make 
children presumptively eligible upon release from detention or 
at the Children's Community Mental Health Center itself.
    Mr. Waxman. So you are using the system the way it was 
intended, to make sure that children get preventive services 
through Medicaid, but preventive health services, in this case 
mental health services, to deal with the problem before they 
have to be put into some kind of detention center 
incarceration.
    Dr. Martinez. That is correct, Congressman.
    Mr. Waxman. Any other strategies you have employed for 
preventive purposes?
    Dr. Martinez. Well, again, we have our social workers in 
the police substations and the sheriff substations in order to 
divert kids when they are picked up in the middle of the night, 
or whenever they are picked up. This is to avoid incarceration 
by working with the family at the very moment that the crisis 
is happening because crises do not wait for 8 to 5, and 
families are in need 24/7, as we have heard. So we do not want 
our detention centers to be the emergency rooms anymore. So 
that is one strategy.
    We have worked with our judges and with our probation and 
parole officers to ask them what they feel they need. And 
certainly as the judge was saying here, they need options that 
do not require detention, and those are the community-based 
services to refer children and the families to. Those 
community-based services need to be evidence-based, meaning 
they should work because they have been proven to work in other 
settings.
    Mr. Waxman. Chairman Collins, this has been an excellent 
panel, and I want to thank all of them for their testimony.
    Chairman Collins. Thank you. Senator Durbin.

              OPENING STATEMENT OF SENATOR DURBIN

    Senator Durbin. Thank you, Madam Chairman. And let me say, 
there are few committees and few chairmen who would take the 
time to hold this hearing. It is really unfortunate. But this 
is an exception, and under your leadership, in this Committee, 
together with our friend Congressman Waxman, we are talking 
about a subject which a lot more people should be talking about 
in the Senate and in the House and across the United States.
    If the topic had been that we have discovered through 
investigation that children were starving at these facilities, 
subjected to physical abuse, were not properly clothed, were 
freezing in the winter, I think we would have a bank of cameras 
against that wall, and it would be on the front page of most 
papers tomorrow. But because the underlying issue is mental 
illness, it is not likely. Why?
    Well, I think, frankly, because we as a society view this 
as a curse or a crime, not an illness. We just have not grown 
up to accept the reality that it is an illness that can be 
treated.
    And, of course, the Senate has not done much on its own. 
When Senator Wellstone died, we said one thing we are going to 
do when we get back is deal with mental health parity, you can 
bet, in the name and honor of Paul Wellstone. Almost 2 years 
have passed and nothing has happened. That is a sad commentary 
on the body that we serve in. We should do more. Senator 
Domenici has been a leader in this area. Senator Wellstone was. 
There is a lot more that we can do.
    I am struck by a lot of things at this hearing. A lot has 
been covered so well by the Chairman and Congressman Waxman. 
But a couple things do stand out here. Why do we have such an 
increased incidence of mental illness? Some of the statistics 
among African Americans suggest mental or emotional 
disabilities are up 77 percent in the last 30 years or so. Why? 
Why are we running into more of this? Is it because we now know 
what to look for? It has always been there, we did not know 
what to do with it before, now we can diagnose it and now we 
can suggest treatment? But is there something going on in 
America that has led to this dramatic increase in mental 
illness, particularly among young people? Is this the beginning 
of a trend that is even going to be worse in years to come?
    Would anybody like to suggest an answer?
    Judge Gray. Well, I think I will be brave. I think there 
are a couple of things, Senator. You touched on one. I think 
that now, more than in years past, people are willing maybe to 
speak up and to say we are having a problem in this area. Many 
years ago, it was a shame, it was a curse, and so people tried 
to keep it hidden. I think now people are at a point where they 
just cannot provide for themselves without going somewhere else 
to get help.
    I do think that, unfortunately, in this country many of our 
young people are disillusioned about what their futures are in 
this country. And if you talk about the African American 
community, they are out of work; they do not see a future; they 
do not have a hope for a future. And so many of our young 
people have turned to drugs, and that is a real problem. And, 
actually, I am not just going to say African American because I 
think what we see is that drug usage is high among white kids 
as well. But, unfortunately for African American children, I do 
not believe that they see a way, that they see a future, and so 
they are very disillusioned. They are growing up in families 
where many of their parents are incarcerated, have been 
incarcerated, are also on drugs. And they are being pushed out 
of the school systems. You heard about children who are being 
expelled and suspended. These are the children who are being 
pushed out of the school systems. And so they go home at night 
without a hope for tomorrow that things are going to be better. 
I think that is one of the reasons we are seeing more of these 
kinds of problems prevalent among our young people.
    Senator Durbin. Mr. Dixon, I liked your father's quote. 
[Laughter.]
    Mr. Dixon. Oh, he was smart.
    Senator Durbin. If I wrote it down correctly, ``You cannot 
cripple a child and then criticize the way he walks.''
    Mr. Dixon. Right.
    Senator Durbin. And I think that is part of the problem 
that Judge Gray is pointing to. If we do not get to some of the 
root causes of this despair and family break-up and 
dysfunctional situation, then we are going to continue to treat 
imperfectly the results.
    Ms. Carothers, you talked about what happens once these 
young people reach the age of 18. Has anybody done a study to 
figure out what happens to them once they have been pushed 
around in the system through foster care and detention 
facilities and now, bingo, they are adults out on their own? 
Where do they go?
    Ms. Carothers. I have not seen a study. Anecdotally, 
through my work with adults, I can tell you that recidivism is 
enormous and is highly likely if you are in the juvenile 
criminal justice system for you to be in the adult criminal 
justice system. And, the numbers of people we have in the adult 
system speak to that. We have more people incarcerated than any 
other country anywhere.
    But I have not seen any--I could look and send you some 
recidivism studies if you would like.
    Senator Durbin. I have sat in some of these facilities, 
some of the better ones. They are despairing that, at age 18, 
it is as if they have to walk away in my State from a lot of 
the services and a lot of the help that they could offer to a 
person just because that age has been reached.
    Let me just add, we are about to consider a gang violence 
bill on the floor of the Senate, and no one supports gang 
activity and the criminal violence and the terrible thing that 
is happening. But one of the things that this bill does is 
shift the burden of whether the accused gang member under the 
age of 18 is going to be treated and prosecuted as an adult or 
child. Currently, it is up to the State to argue that this 
person should be treated as an adult even though they are under 
the age of 18. The bill flips the responsibility. Now it is up 
to the young person and his attorney to argue they should be 
treated as children in the system; otherwise, they will be 
treated as adults. That is a dramatic change, and it kind of 
goes to the same argument here when it comes to young people, 
this mindless ``you do the crime, you do the time.'' We get 
into this sloganeering here and forget that those are real 
human beings standing in front of us, some of whom have been 
victims of the system of our own creation. Thank you, Madam 
Chairman.
    Judge Gray. Senator, I would say, if I could, in response 
to your question about the studies, in particular for children 
who are aging out of foster care, there is quite a bit of 
information out there about those children who are 
transitioning out of the foster care system upon their 18th 
birthday and what life looks like for them. And I would be 
happy as well to send you some of that material. But what it 
shows is that those children that we saw are now independent at 
18 or in some States 21, they lack the ability to get jobs; 
they are in the homeless population; they are in the mental 
health institutions because many of them do have mental health 
issues that are not being treated. They do not graduate from 
high school. They are not getting their GEDs, and, therefore, 
they are not going on to higher education. Their lives are 
really not looking very positive when they age out of foster 
care, and so that is a real concern for those of us in the 
juvenile area who are dealing with that population of kids 
every day, trying to figure out what are the safety nets we can 
put in place for them so that they have a chance to make it in 
this society when they are no longer cared for by the State 
child welfare agencies.
    Dr. Martinez. Senator Collins, may I respond to Senator 
Durbin?
    Chairman Collins. Absolutely.
    Dr. Martinez. With regards to your first question about the 
prevalence or incidence of mental illness among our youth, in 
our child welfare system we have an overrepresentation of 
children of color. In our juvenile justice system, we have an 
overrepresentation of children of color. In our mental health 
system, we have an underrepresentation of children of color. So 
when we see the number of children of color being identified as 
having mental illness going up, in some ways that is a good 
thing in that we are now screening and assessing and 
identifying those children better than we ever have before. 
Once they are identified, hopefully we exercise that 
professional and ethical responsibility to treat those 
children. And I think that is a good thing.
    I do not necessarily think that there is a higher incidence 
as there are more children being identified. And, of course, 
there are many societal factors that play into this, whether it 
be poverty, poor education, and other societal issues. But we 
are encouraged to see more numbers of children of color being 
identified so that we can do something about it.
    Chairman Collins. Thank you, Senator Durbin.
    I want to thank all of our witnesses today. You really 
enhanced our understanding of the consequences of the tattered 
safety net that we have for caring for children with mental 
illness. I want to thank in particular Congressman Waxman for 
his participation. It has been a great honor to work jointly 
with you on this. And I really hope that this bipartisan, 
bicameral approach can make a difference, because what is going 
on now is absolutely unacceptable. That we are incarcerating 
children who are ill, who are suffering from mental illness, 
rather than treating them because there is no place for them to 
go is a tragedy, and it just called out for our action. And we 
need a comprehensive approach. We need to pass the Keeping 
Families Together Act, the Family Opportunity Act, a bill that 
I have cosponsored with Senator Bingaman to increase the number 
of mental health professionals for children. But I am sure I 
can speak for my colleagues in saying that we are really 
committed, and I want to thank them for their participation 
today. Thank you so much for sharing your extraordinary 
expertise and your caring with the Committee.
    The hearing record will remain open for 15 days for 
additional statements and questions. And, finally, I would like 
to thank Priscilla Hanley of my staff and also Dr. Josh 
Sharfstein of Congressman Waxman's staff for their hard work. 
We could not have done it without them.
    So thank you, and this hearing is now adjourned.
    [Whereupon, at 11:40 a.m., the Committee was adjourned.]




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