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Alaska worked to bring kids home from Outside psychiatric institutions. Now, more are being sent away again.

Five years after the end of “Bring the Kids Home,” a successful state effort to bring children in Outside psychiatric institutions back to Alaska, the number being sent away is rising again.

Last year, for the first time since the program ended, more children were treated in the Lower 48 than in Alaska. In 2018, 254 kids received inpatient psychiatric treatment Outside, mostly in corporate-owned, for-profit facilities scattered across states including Texas, Utah, Montana and Colorado.

Most of those sent away are teenagers, state data shows. About a third are elementary school-aged. The youngest are just 6. Almost half are Alaska Native.

Totals and look for FY 2015-18 by demographics

Of the 143 children in out-of-state residential care on April 15, some 107 were in their parents’ custody, according to the state. The rest were in state custody through either the Office of Children’s Services or Division of Juvenile Justice.

Families who’ve been through the experience talk about kids who try to hurt family pets, stab themselves with knives, jump from windows or pummel their siblings to the point of serious injury. Some have diagnoses such as autism or fetal alcohol spectrum disorders. In a crisis, sometimes the promise of a locked facility with immediate professional help seems like a godsend, they say.

For decades, however, there have been questions about whether the expensive, state-funded care out of state helps or hurts children.

The state-funded "Bring the Kids Home” program, launched in 2004, was a recognition by policymakers that sending children to institutions thousands of miles from home and family causes damage, said Brita Bishop, the program’s former director with the Department of Health and Social Services.

Some of the problems identified by the initiative: It’s hard for far-away families to monitor living conditions or participate in their children’s treatment; kids regress when they return home; and children, especially Alaska Native youths, “experience cultural loss” by being separated from their home and family for years at a time.

There are questions about what happens to kids while they live in the facilities. Alaska teens have been paralyzed and committed suicide while in Outside residential treatment.

In February, the state cut ties with a Missouri facility it wouldn’t name for failing to follow federal rules on secluding and restraining children living there, according to the Division of Behavioral Health. A Montana facility that houses Alaska kids was recently accused of drugging children with injections.

What’s complicated, though, is how the treatment is paid for. Medicaid pays for virtually all out-of-state residential psychiatric care for minors. The state vets and approves a roster of facilities and pays the bills for most anyone who lives at one of the institutions for more than 30 days with a mix of federal and state money. Last year, the total cost spent by Alaska on care at Outside facilities was $18 million.

Long history

Alaska has probably sent troubled youths out of state since before statehood, said Steve Krall of the Division of Behavioral Health. But practitioners found that time spent Outside didn’t always lead to success when the kids eventually made it back to Alaska.

“Residential settings are good for getting control of kids’ behavior,” said Krall, who is the program coordinator for residential care for children. “It doesn’t necessarily prepare them for coming back into a complex setting like their own family or community.”

Many have questioned why state money and resources couldn’t be better used to build programs here.

A trailblazing 1980s effort known as the Alaska Youth Initiative aimed to add more services in Alaska to keep emotionally disturbed kids from being institutionalized. But between 1998 and 2004, the number of out-of-state placements for kids exploded, increasing by nearly 800 percent, according to research by the Alaska Justice Center.

At the peak in 2004, some 752 children were sent to locked institutions. Most stayed years. The state was paying upward of $40 million per year for the care.

The “Bring the Kids Home” effort again put money toward offering services to families in-state. Some services, like parenting classes, were designed to head off the need for hospitalization by intervening earlier, before a crisis. Other grants went to training therapeutic foster parents, so kids could stay in Alaska. The whole idea was to keep children close to home whenever possible, Krall and Bishop say.

“It’s not that nobody should go to a psychiatric setting,” Krall said. “You want to be careful about who you are sending, and why.”

By some measures, it worked: By 2009, the number of kids being sent out of state had declined to fewer than 100 per year. By 2011, the Medicaid expenditures were down to $11 million.

That trend continued through 2014, when the Bring the Kids Home program ended. The program was discontinued in part because it was seen as a success, according to Bishop.

“We reached a place where we had pretty stable improvement and needed to go on to other things that were high priority,” she said.

Since 2014, the numbers of kids going Outside have been creeping up. The reasons for the resurgence are complex, Krall and Bishop say. Some Alaska residential programs closed, reducing available bed space. Until recently, Medicaid payment rates for providers lagged so far behind the average cost of care in Alaska that running programs wasn’t always financially viable, Bishop said.

And there are some kids with a combination of issues that Alaska’s limited facilities just don’t have the capability to treat, said Paul Cornils, executive director of the Alaska Youth and Family Network, which helps families navigate the behavioral health system.

“We see lots of kids with autism going out. Complex trauma and mental health issues. Bipolar, schizophrenia, FASD. We don’t have the skilled facilities here.”

Reputations mixed

Parents must choose from a list of 17 state-approved psychiatric residential treatment facilities for Medicaid to pay. About half are owned by Universal Health Services -- the same psychiatric care giant that operates North Star and 300 other facilities nationwide. Several others are owned by another corporate chain, Acadia Healthcare.

A few offer specialized service, like treating eating disorders or “sexually maladaptive behaviors.”

Right now, there’s a need for facilities that can handle kids with developmental delays or autism as well as violent behavior, kids who’ve been sexually abused or severely traumatized and act out violently and sexually, said Terry Roth, Medicaid manager with the Division of Behavioral Health.

Officials won’t say how many Alaska kids are currently housed in each facility. State inspectors visit facilities annually, either with 48 hours notice or unannounced. Facilities aren’t supposed to use “chemical restraint,” except in emergencies, Roth said.

Their reputations are mixed: Some of the facilities have been the targets of lawsuits and criminal investigations.

Recently, a Montana newspaper reported that a facility in Butte, Acadia Montana, drew the ire of Oregon lawmakers after it was revealed that a 9-year-old resident from Oregon was being chemically restrained with shots of Benadryl to punish her for misbehavior.

The girl was also placed in locked seclusion. The same report asserts that investigators from Alaska’s Division of Behavioral Health who are supposed to do regular checks of the facilities found “intramuscular injections of (drugs used to manage psychotic behavior or agitation), holds and/or restraints were common.”

There were 15 Alaska kids in the facility, the report says, and all reported that they got shots that “made them sleep all day.”

It’s not clear whether the state is still placing kids at Acadia Montana. The Division of Behavioral Health said it has suspended new admissions of Alaska kids while it investigates two residential treatment centers and is looking at transferring kids out, but did not name the facilities.

Psychiatric treatment for children is a growing and profitable business, said Marcia Lowry, an attorney and executive director of A Better Childhood, a national nonprofit advocacy group that works on foster care issues.

States often justify sending kids away by saying their needs are so severe there’s nothing to serve them at home. But so much money is spent on payments to the facilities that the claim rings false, Lowry said.

“It is often a failure on the part of the state itself,” she said. “If you have that many kids being sent away, why hasn’t the state been able to develop programs for them?"

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