A mother's struggle to help her violent son

June 11--Editor's note: This is the fourth and final story in a series on the weak spots in Maine's care for children with mental health challenges.

One time at school, Kelly Anderson's son didn't like it when a classmate hit him with a ball during a kickball game. He later drew a picture of himself holding a gun, shooting the kid. Another time, a classmate put his jacket on the coat hook belonging to Anderson's son, who got angry and drew a picture of a knife stabbing the student.

He has hit Anderson's other children with a broom, a pot and a shoe. He has refused to go to school and stolen from classmates. He swears at his mother with intensity. Once at school he kept running out of the classroom, trying to pull the fire alarm. When staff contained him in a room, he threw chairs, spit at them and even bit a teacher, said his mother, who lives in the Somerset County town of Saint Albans.

What really worries Anderson is that when other people cry, her son laughs at them. He is 11. Anderson, who has her own physical and mental health challenges, figures he has two more years, before he hits puberty, for someone to reach him and keep him from going down a lifelong path of violent behavior and, potentially, incarceration. Her son has several diagnoses, including conduct disorder.

"If he doesn't get the help he needs by the time he's 13, I've lost him," she said. "If I think it's bad now, it'll get worse then."

But nothing has changed her son's behavior so far, and though he has gotten initial approval for residential mental health treatment, he may have to wait first for a bed to open up. Even if one does, Anderson is is not overly hopeful about the future. She wants something to work: to eliminate her son's outbursts, help him get through school, and end the stress his behavior places on her and her daughters.

Research shows that a promising approach is therapy that works not just with children prone to violence and aggression but their family members, so they know how to respond to such challenging behavior. More than the mental health specialists who work with them for a short time, it's the family and the people near the children everyday who have a strong chance of shaping their future.

"Parents don't typically cause that kind of thing, but they need to be part of treatment. There are evidence-based parenting practices that have been shown to help kids with anger dyscontrol, behavioral dysregulation," said Lindsey Tweed, a child psychiatrist and president of the Maine Council of Child and Adolescent Psychiatry.

Yet one of the most studied treatments that's been shown to work for adolescents who have serious trouble getting along with others, or who are in -- or heading toward -- the juvenile justice system, is being eliminated across Maine. Another, similar program doesn't bring in enough money to cover the costs of providing it, either, putting its future in jeopardy.

There were once 11 teams, at four agencies across Maine, offering what's called multisystemic therapy. But there soon will be four and a half.

Each team consists of a supervisor plus three or four specially trained therapists who work with up to six children each, often around the clock. Decades of research have shown that the treatment reduces criminal behavior, substance use, aggression and school absences, and young people who receive it are more likely to continue living with their families and have fewer mental health problems.

The intensive treatment is delivered several times per week, for up to six months in families' homes and communities. Since youth often don't want to engage in treatment, the therapy involves working with a host of others in the young people's lives, whether it's parents, grandparents, neighbors, friends, teachers or probation officers, to create a consistent approach to addressing the problem behavior.

Most of the teams in Maine also carry out a version of multisystemic therapy for youth who have committed sexual offenses. It's the only adolescent sexual offender model backed by the most robust sort of clinical research, randomized trials.

All four nonprofit agencies in Maine had been offering multisystemic therapy despite the fact that MaineCare, the state's Medicaid program, wasn't paying them enough to cover their costs. But agency officials said they cannot sustain the continued losses any longer:

-- AMHC Aroostook will eliminate its multisystemic therapy team June 30, leaving Aroostook County with no provider of the treatment. The organization expects to lose $100,000 this fiscal year alone from offering the treatment, said Peter McCorison, program director of behavioral health services. The team served at least 146 families over the last five years, and met or exceeded its goals each year to increase kids' participation in school and prevent arrests, McCorison said.

-- Maine Behavioral Healthcare, which is based in South Portland and serves seven counties in southern and coastal Maine, has cut the number of multisystemic therapy teams it employs from three to half of one team over the past four years. The organization loses 31 cents on every dollar brought in by the treatment.

"There is no other program at MBH that loses more money," Michael Abbatiello, senior vice president of operations and finance, told lawmakers in March.

The organization has said that if nothing changes by July 1, it will have to end its service entirely in 90 to 120 days.

Multisystemic therapy is "the treatment of choice for youth with conduct disorder," said Sally Cooper, medical director for child and adolescent psychiatry at Spring Harbor Hospital in Westbrook, a division of Maine Behavioral Healthcare. But she couldn't remember the last time a clinician trained in the therapy was available to help a patient.

"Sometimes, we try to make the referral, and we hear, 'Yes, this is definitely a kid who would benefit, but we don't have anything available for six to eight months,'" she said.

-- At the start of this fiscal year, Tri-County Mental Health Services, based in Lewiston, had three multisystemic therapy teams: one in Androscoggin County, one in Oxford County, and one that served Cumberland and York counties. It shut down its Cumberland-York team this winter given year-after-year six-figure losses, "and we are going to need to consider whether we can sustain the remaining two teams," said Executive Director Catherine Ryder.

"We believe in the service and the mission, but at some point you have to decide whether you're going to keep your doors open or provide a service that continues to be a loss leader," she said.

-- Kennebec Behavioral Health, based in Waterville, had four teams 18 months ago but has since eliminated two, withdrawing the service from northern Penobscot, and parts of Franklin and Somerset counties, said Tom McAdam, chief executive officer. The organization previously served between 90 and 110 families a year; it's now seeing half the number of clients. As of June 6, it had a dozen youth on its waitlist, though it is also accepting fewer referrals, many of which come from the Maine Department of Corrections.

It will likely have to cut more teams if the Medicaid reimbursement rates don't change. "The net result financially is, we're all just hemorrhaging cash," McAdam said.

Malory Otteson Shaughnessy, executive director of Maine'sAlliance for Addiction and Mental Health Services, said she worries about the potential severe consequences of losing the intervention.

"Everyone has concerns about children's mental health and school shootings, and yet here's a service that truly works that we're losing. It's just horrifying," she said.

'I was still going to be bad'

More than a decade ago, the Division of Juvenile Services within the Maine Department of Corrections helped spread the use of multisystemic therapy and a similar program, functional family therapy, as part of a strategy to reduce reoffense rates and improve public safety. By contracting with local agencies across the state and financially supporting their work, it was able to offer alternatives to incarceration.

In 2011, Maine ranked third among the states for its number of family therapy teams per million people, according to the Association for the Advancement of Evidence-Based Practice.

The Department of Corrections still supports the treatment -- it helps the organizations cover uninsured clients and pays for some specialized staff training -- but the bulk of funding for multisystemic therapy comes from the agencies billing for reimbursement from MaineCare. For instance, in 2017, 89 percent of payments for Tri-County's multisystemic therapy program came from MaineCare, and 11 percent came from the Department of Corrections.

The current MaineCare rate is $31.07 per quarter hour. However it actually costs about $41 per quarter hour to deliver the care, according to the agencies. In Nebraska, the rate is $38.24; in Washington D.C. it is $51.96; and in Delaware it's $48.75.

"In spite of all [the Department of Corrections'] generosity and commitment to this program, we have not been able to sustain it because the standard reimbursement rate received from MaineCare is not adequate," said Ryder, who is also president of the Alliance for Addiction and Mental Health Services.

Though MaineCare rates don't cover providers' costs and lag national reimbursements, a consultant for the Maine Department of Health and Human Services in 2016 recommended cutting multisystemic therapy payments even further, to $25.07 per quarter hour. Payment for the therapy targeted to sexual offenders would have dropped to $25.62 per quarter hour from $38.73.

The reductions drew strong objections, prompting DHHS to keep the rates at their current levels "in the interest of continuing to support evidence-based treatments," the department said in a document summarizing its responses to public comments on the rate changes.

DHHS has declined to raise the rates, however. A spokeswoman didn't reply to a request for comment.

A bill, LD 1868, passed by lawmakers in April would have temporarily boosted the rate 20 percent while the state conducted a rate study to determine what MaineCare should be paying, but the bill awaits funding. What happens to the legislation will depend on whether lawmakers reconvene after they adjourned May 2 without finishing their work.

Multisystemic therapy is more expensive than other treatments because agencies have to pay to use the model, their specialists have to be trained in providing the therapy, and an expert consultant has to review cases every week.

But while the service is more expensive upfront, it's also more successful.

"The accomplishments are phenomenal," Ryder said. Between 2010 and 2016, 91 percent of youth who received multisystemic therapy from Tri-County lived at home at the end of the program; 87 percent were in school; and 87 percent had not been arrested. Without the treatment, it's likely many would have instead been at Long Creek Youth Development Center in South Portland, Maine's youth prison.

Research outside Maine has shown long-lasting results. A 22-year study in Missouri, for instance, showed that young people who received the therapy had 36 percent fewer felony arrests, and 75 percent fewer felony arrests for violent offenses, compared with those who received individual therapy that didn't involve family members. They also had 37 percent fewer divorce, paternity and child support suits as adults. Siblings benefited, too: They had 56 percent fewer felony arrests.

Studies have shown that the therapy saves money long-term by reducing incarceration costs. "The net result is that it helps to keep kids out of Long Creek. Not only is it the right thing to do, it saves an unbelievable amount of money," said McAdam, with Kennebec Behavioral Health.

"It's a proven, evidence-based treatment that the Department of Corrections spent significant resources on to bring to the state. It's proven throughout the country," McCorison, in Aroostook, said. But "family and community access to this service is going to be lost."

Functional family therapy is similar to multisystemic therapy. It's a family-based intervention for young people ages 11 to 18, though the treatment usually takes place over a shorter period, three months instead of up to six months, and focuses more on family dynamics.

There are two providers in Maine -- Catholic Charities Maine and Spurwink -- who are reimbursed at the rate of $28.74 per quarter hour, which is the lowest Medicaid reimbursement for the service in the nation, according to Helen Midouhas, a functional family therapy national trainer and consultant.

Because of the low rate, and a related challenge of finding qualified workers, Catholic Charities has reduced the geographic footprint that it serves: Several years ago it closed its Caribou office. It now provides functional family therapy in the areas around Bangor, Augusta, Fairfield, Waterville and Auburn, said Jeff Tiner, chief clinical officer.

The organization receives private funds from St. Michael's Center in Bangor to offset staff training costs, but it's the Department of Corrections that pays for the bulk of the program -- 65 percent -- with grant funds.

"Absent that we would be giving notice of closing the program," Tiner said.

Spurwink, based in Portland, hasn't reduced services, but it has struggled to provide the therapy, as other parts of the agency have to make up for the program's losses, said Eric Meyer, president and CEO. The program serves 70 to 80 youth per year, Meyer said.

Like Catholic Charities, Spurwink has also found it difficult to hire staff, who are often required to travel far, work evenings, and help families with complex needs, he said. The agency has budgeted for four clinicians and one supervisor, but currently has only one clinician and one supervisor.

Anderson's son said people have tried to help him in the past. A staff member follows him around at school, helps calm him down when he starts to get angry, and rewards him when he is well behaved and goes to classes. He likes the rewards, he said, such as getting to eat lunch with the staff member or play games. The BDN isn't naming him because of his age.

Before he acts out, "what's going through my head is, 'Hey, I'm getting pretty mad.' Hate school. People are making me so angry it makes me feel like I want to punch them in the face," he said. "I feel like people aren't listening."

He didn't like the person who came to help him get ready in the morning as part of MaineCare Section 28 services. But he did like another behavioral health professional under a separate program who took him out of the house, sometimes to get a Happy Meal or go to the park.

However, he acknowledged that his behavior didn't change. "I was still going to be bad at home," he said.

"Something about this side is good," he said, by way of explanation, pointing to his left side. "Something about this side is bad," he continued, pointing to his right side. "I hate using brutal force on [people], but that's what you get."

Maine Focus is a journalism and community engagement initiative at the Bangor Daily News. Questions? Write to mainefocus@bangordailynews.com.

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