Earlywarning
Prompt treatment is key to improving mental illness, yet kids younger than 6who need mental health care are the age group least likely to receive it.
His nightmares weren’t the normal kind. At 3, Joshua Plunkett hallucinated about dog-headed men trying to attack and giant snakes about to swallow him. His mind, even then, brought him auditory hallucinations that would terrify an adult, let alone a preschooler. The “kids” in his head once told him to kill himself by jumping off the balcony.
His parents were there to stop him.
At 5, Joshua’s mother found him clutching a butcher knife in one hand and the family cat by the tail in the other. He was in a trance. Brenda Ralph snapped her son out of it by screaming his name.
“Iwas in another mind,” Joshua, now 17, explained recently.
Joshua’s mind has been different since he was born. He is among the 13 percent of children who have diagnosable mental illness, and an example of how early treatment can curb the impact of mental problems on school and growing up.
Early treatment is key to im- proving mental illness, yet kids younger than 6 are the age group least likely to receive mental health care if they need it. About half of adults with mental illness had problems as children, and three-quarters of adults with mental illness had symptoms by age 22.
A national study on adverse childhood experiences found that people who experienced childhood trauma — whether because of abuse, a one-time traumatic event or even divorce — were more likely to have mental illnesses as adults. For others, it’s hereditary.
More kids, shorter stays
The emergency room at Children’s Hospital Colorado has seen 10 percent to 30 percent increases year after year in the number of children arriving in mental health crisis — reaching 3,100 kids last year.
In 2014, the hospital is on pace to see more than 3,800 children in mental health crisis at the emergency department. Most of them are suicidal or aggressive and threatening to hurt someone else.
About half of the children end up needing hospitalization, said Dr. Douglas Novins, chairman of the department of psychiatry and behavioral sciences at Children’s.
“We are really in a behavioral health crisis in our state,” he said. “The number of children who are coming here in behavioral health crisis has really increased enormously.”
The hospital has 18 psychiatric overnight beds, plus others for patients with autism or eating disorders, and they are almost always full. Children’s sends kids who need hospitalization to other inpatient centers or hospitals when its psychiatric unit is full or the family’s insurance wants the child to go somewhere less expensive.
Behind the locked doors of the children’s psych unit, thewalls are a friendly turquoise and purple. The individual rooms have twin beds, private bathrooms, plastic chairs made heavy with sand, and electronic window shades sealed between panes of glass.
First names are written on the outside of children’s doors, and the stuffed animals they brought from home sit on their beds. There is also a gym, and rooms for yoga, dance and music therapies.
Two decades ago, the average length of stay for children in psychiatric hospitals was a month. Today, it is nine days, with a goal of treating children in the least-restrictive environment possible.
“Often the pressure for the shorter length of stay is from the insurance companies,” said Jim Myers, administrator of Children’s pediatric mental health institute.
Families can visit each day but must leave anything considered remotely dangerous — keys, nail files, cellphones and paper clips — in lockers outside the unit.
About 5 percent of children will experience a mental health crisis likely to require hospitalization. In Colorado, an estimated 89,000 children and teens are dealing with serious emotional disturbances, some of them so severe they cannot live with their families.
Problems started early
Joshua has been in mental health treatment since age 4, including a week-long stay at Children’s after a first psychotic episode that lasted two days and had him pulling his hair out. He was diagnosed with bipolar disorder at age 5 and autism at 7.
“From the beginning, we pretty much knew something was different,” Brenda said.
As an infant, Joshua was inconsolable much of the time. He wouldn’t sleep. Wouldn’t take a pacifier. His grandmother had to go to their house and hold him just so Brenda could take a shower. It didn’t get easier. Joshua was kicked out of two preschools for attacking other children. He “bombed out” of elementary school and spent a couple years at a state-funded day-treatment center, where he felt like he wasn’t a “weird alien outcast” for the first time in his life, and a year home-schooling.
Through a combination of medication and therapy, Joshua was ready to rejoin public school in seventh grade. Usually, he can contain his outbursts and emotional mood swings by “holding it in” until he gets home for the day, he said.
Even at 17, the Horizon High School junior still doesn’t like touching animals or people. Or loud noises. Or almost any food that is not noodles or fried chick- en or microwavable chimichangas. Or getting on anything with wheels, including bikes, scooters and skateboards. He definitely does not like change.
A school picnic in the park had him concerned. “I’m not going to handle that really well,” he said.
Joshua is polite and loves to talk about music, especially rap.
He realizes he has different obstacles than his classmates. They are talking about college; he is learning from his occupational therapist at Community Reach Center how to deal with the noises and smells of the crowded city bus, shop for groceries and cook his own dinner.
Joshua is in special-needs classes in high school and avoids the lunch crowd by eating with teachers and a few other students in a separate room. He finds it especially difficult when he is studying “depressing things.” A book about the Holocaust in English class and a video about Hurricane Katrina devastate him for days.
Advocating for Joshua has taken up much of his mother’s life.
School meetings about his behavior, where Brenda Ralph was once the lone outsider, now include a panel of advocates she brings with her into the room. She fought for special-needs classes, and she drives Joshua to weekly occupational therapy and psychi- atric appointments.
“I can’t have a job because of all the appointments he has; this is why I’m a stay-at-home mom,” she said.
Oneweek each summer, Brenda and her husband, Jason, get a break, and Joshua hangs out with other autistic children at an Easter Seals camp in Empire.
Genetics and environment
Many mental illnesses, including schizophrenia and bipolar disorder, are linked to genetics and environmental factors. What happens in childhood has a startling correlation with mental illness later in life.
Researchers have used Kaiser Permanente data gleaned from the questionnaires of thousands of patients who were asked about their childhoods, including whether their parents used drugs, were abusive, had mental illness, were imprisoned, divorced, died or committed domestic violence.
The more childhood traumas, the more likely adults are to have clinical depression and hallucinations. One study found that people with seven or more negative childhood experiences were five times more likely to have hallucinations.
Take, for example, William Gregor, who hasn’t belonged to anyone since he was 4.
That’s when he was taken from his family and put in foster care, except he didn’t live with foster families — he grew up in institutions, group homes and a ranch for boys with serious mental illnesses.
The list of prescription drugs he was given is long: Thorazine, Zyprexa, Lithium, Seroquel, Risperdal, Trazodone. “I’ve done it all,” said Gregor, 39.
He has been diagnosed with paranoid schizophrenia.
Now, he is a heroin addict. Gregor panhandles near the 16th Street Mall in downtown Denver until he gets $100, enough for 1 gram in the morning and another at night.
Without the heroin, he knows of only one other way to deal with the voices in his head.
“I beat my head against a wall. I punch myself,” he said. “I go into a dark place in my mind. I start hearing and seeing things. You got to beat your head to make it stop.”
Babies can get depressed
Diagnosis of mental illness in children has advanced significantly in the past 20 years, but what is lacking is “knowing what works and what helps,” said Lydia Prado, head of child and family services at the Mental Health Center of Denver.
It wasn’t until the late 1980s that the medical world definitively acknowledged that children could get depressed. Prior thinking was that children had not developed enough emotionally to suffer depression. The field of children’s psychiatry has evolved to recognize that depression looks different in children than it does in adults.
Even babies can become depressed, said Dr. Shannon Bekman, program manager for the infant mental health programat the Mental Health Center of Denver.
Babies are supposed to cry. It’s when they stop crying— often because of neglect — that they are considered clinically depressed.
Scientists have found that a huge portion of brain development happens in the first three years of life, so treatment then has lifelong impact, Bekman said. Therapy for depressed babies focuses on strengthening the parent-childhood relationship.
Some children develop a mental illness because of a one-time traumatic experience such as a car accident. One child treated at the Mental Health Center of Denver was riding in a Toyota Prius that was struck head-on by a tractortrailer rig. The preschooler became withdrawn, regressed in toilet training, and refused to set foot in a vehicle. He was diagnosed with post-traumatic stress disorder.
Another child would break down when it was time to clean up. It turned out that a caregiver had been telling the 4-year-old a goblin would get her if she was bad.
The symptoms of mental illness in younger children typically are setbacks in language or developmental skills, including walking or crawling. Mental illness in school-age children often looks like anger and aggression, although girls are more likely to internalize it and appear sad and shy.
The Mental Health Center of Denver has therapists in several Denver schools and public health clinics so that kids can get psychiatric care at the same place they see pediatricians. The center also sends therapists to day-care centers and runs a day-treatment program for kids whose mental illness is so severe that it keeps them from functioning in regular classrooms.
Denver Public Schools has infused its mental health services with $4.5 million of additional spending spread over three years, on top of the $12.2 million annual budget for psychological and socialwork. Every school in the district has either a psychologist, social worker or both, and mental health staffing has increased 30 percent in five years.
The boost in services targeted neighborhoods where children have suffered the most trauma and are more likely to have emotional problems at school, said Eldridge Greer, director of social emotional learning for Denver schools.
At 15 school-based clinics last year, more than 1,500 Denver students received 12,000 mental health therapy sessions.
“If we don’t look at it through the mental health lens, it may be seen as a discipline problem,” Greer said. “If we don’t address mental health, we are not going to get the results we want in academics.”
Relieving pressure
This is how Chazz Worrell, 10, explains his depression, anxiety, post-traumatic stress and intermittent explosive disorder:
“When people be mean to me, it makes me get really angry, so I have to let it all out somewhere,” he said. He feels like he wants to hit somebody. “But I don’t do that. What I do is hit wood. It helps keep the pressure on the inside instead of letting it all out on other people.”
He chops wood, builds fences, moves horses and bottle-feeds the calves at his older brother’s small ranch in Fort Collins.
The fourth-grader spends time at the ranch almost daily, and his mother says it helps him more than any other therapy. Without some release, his emotional outbursts are volatile.
“He can hit things, throw things, try to break things or even hit himself,” Liz-Worrell said. The anger gives way to sadness, especially if he hurt someone or broke something. He begins to yell, “I’m stupid! I shouldn’t be here.”
Chazz’s anxiety has him constantly worried in public that he will get lost and never see his parents again. They are buying-walkie-talkies. His post-traumatic stress developed after his grandmother passed away in front of him.
Liz has been through this before, with her now-23-year-old son, and this time, she is much more equipped to handle the school meetings that felt, the first time around, like board rooms where shewas on trial for her parenting skills. Now, she brings Chazz’s advocate from a community mental health clinic.
By now, she also has shunned medication, tired of seeing her older son playing the “guinea pig” as doctors adjusted medications that made him sit around all day like a zombie. Instead, she gives Chazz a quiet room, with his dog, to calm down. Afterward, they talk about howhe could have handled his outburst another way.
“By the time (my children) are done here, they are worn out,” said Liz, surrounded by calves, alpacas and horses. “The best therapy I can give them is this.”