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A budget-cutting Sophie’s Choice: Youth programs hit hard

In 2007, King County voters approved a one-tenth of 1 percent sales tax to support Mental Illness and Drug Dependency (MIDD) community treatment and diversion programs. These would not only improve care for ill individuals but also minimize the high costs of using corrections and emergency-medical personnel as the default responders to people caught in chemical-dependency or psychiatric crises.

Ten of the 37 strategies for new and expanded programs originally planned for MIDD funding were to address problems of children and youth, directly or indirectly. Such investments, according to economists such as Nobelist James Heckman, have a higher rate of return for society than investments in schools or even in highly-regarded stocks.

Medical research also confirms the prudence of providing systematic help to children who live with the trauma of family violence, drug addiction, alcohol abuse, and homelessness, because it reduces not only their emotional and social disorders in adulthood, but also their physical illnesses.

Despite such encouraging outcomes, a March 28 progress report from the MIDD Oversight Committee shows that new and expanded programs for youngsters in King County were disproportionately scaled back during 2009-2010.

Reductions in many planned MIDD services were necessary because revenue declined in the economic downturn, and 30 percent of available MIDD dollars were used to backfill cuts in the county's general fund, for existing services upon which MIDD programs are being built.

Even with cutbacks, says the report (online here), jail bookings and days in jail for people with psychiatric or addiction disorders were successfully reduced between fall 2009 and fall 2010 by more than 23 percent, while psychiatric crisis hospitalizations decreased 19 percent. These reductions correlate with increases in the number of people receiving thriftier, high-quality care from improved community treatment programs.

But cuts to programs for youngsters went deep, forcing the postponement of programs to improve the parenting skills of people with substance abuse issues; to prevent children of abusers from becoming addicted; to establish a reception center with coordinated services for youth (where police could bring kids in crisis); and to expand the Children's Crisis Outreach Center, which offers stabilization and in-home services to King County youngsters and families in dire straits.

In sum, MIDD suspended four of the 10 programs in its “Youth” category in 2009-2010. Put another way, four out of the six programs placed on hold were ones that had been designed to meet youngsters' needs.

The MIDD committee's reasoning, according to a September 2009 briefing by the council's Regional Policy Committee, was that the four programs were less developed than the adult programs. Amnon Shoenfeld, who directs the King County mental health services division and serves on the MIDD oversight group, said that it was more fiscally responsible to postpone programs that were only in initial stages, and that youth services have perennially lagged behind services for adults.

“We hated not starting the programs for parents who abuse drugs and the drug-prevention program for children,” he said. But these, like the youth reception center, were in an embryonic state. To deal with the money squeeze it was better to delay new programs than “cut existing programs and waste the money you used to set them up.”

Programs for children in crisis are one of society's best bargains, says University of Chicago professor Heckman, awarded the 2000 Nobel Prize in economics. He cites research demonstrating that expensive social problems such as crime, teen pregnancy, school dropout rates, and poor adult health are tied to levels of skill and ability that were stunted in early childhood. Stressing the importance not only of cognitive skills but of what he calls soft skills, Heckman says “perseverance, attention, motivation, and self-confidence contribute to the success of society at large.” And all skills suffer in the children of families in prolonged crisis.

Social policy must address adverse family environments if children are to become productive adults, Heckman argues. Children in healthy, materially secure families receive lots of early investment, but the damage of growing up in a chaotic, impoverished family can't even be repaired by good schools. The only thing that works is direct early intervention in such families, backed by public dollars as necessary.

Heckman calculates that the rate of return on these investments, “seen in a purely economic setting, range from 7-10 percent. As a benchmark, the historical return on the stock market is about 5.8 percent.” So there's a comparatively "very high social and economic return” on “fixing people, creating a base for future productivity and motivation for the society.”

The rate of return is “much better than for infrastructure, much better than building bridges, much better than fixing potholes,” he concludes. (Find links online to the summary of an almost-40-year study that followed the progress of disadvantaged children into mature adulthood — part of the data Heckman analyzed — and an abstract of his analysis.)

Research posted at the Centers for Disease Control (CDC) in Atlanta confirms similarly huge benefits to society in medical terms. The Adverse Childhood Experiences (ACE) study, led by San Diego's Kaiser HMO and analyzed by CDC epidemiologists, indicated that the bodies and brains of children who live with the trauma of family violence, addiction, alcohol abuse, or homelessness are neurochemically changed long-term.

The consequence is not just an increased likelihood of adult problems such as chronic anxiety, depression, and cognitive impairment, but physical disorders like cancer, heart disease, emphysema, obesity, chronic bronchitis, and diabetes. This is true even when an individual's diet, exercise regimen, and other lifestyle choices have been healthy. The ACE study was based on a questionnaire completed between 1994 and 1998 by more than 17,000 middle-class patients, asking them to describe their early experiences in 10 categories including parental abuse, alcoholism, mental illness, and divorce.

In correlations that the Atlanta researchers called “stunning,” writes Paul Tough in a New Yorker article called  “The Poverty Clinic” (March 21), it became clear that “the higher the ACE score, the worse the outcome, on almost every measure, from addictive behavior to chronic disease.” Lowering ACE scores in children's lives and countering their effects with healing interventions are steps as medically practical and smart as lowering cholesterol. Such steps are educationally beneficial, too, considering the studies showing that kids who experience prolonged early trauma can't sit still in school or follow directions like their more fortunate peers.

Tough's New Yorker piece quotes Jack P. Shonkoff, pediatrics professor at Harvard Medical School and director of the Center on the Developing Child, as having concluded from various studies that separate strategies aren't needed for developing cognition, physical health, and character, because “all have common roots. We now know that adversity early in life can not only disrupt brain circuits that lead to problems with literacy; it can also affect the development of the cardiovascular system and the immune system and metabolic regulatory systems, and lead to not only more problems learning in school but also greater risk for diabetes and hypertension and heart disease and cancer and depression and substance abuse.”

Improving the behavior of the parent or caregiver of children in high-risk situations actually changes their physical chemistry, according to the studies Tough cites, leading to fewer behavior problems and greater success in school, as well as measurably better health outcomes as years pass. So it's distressing to lose MIDD programs that would have steered children of drug users away from drugs and helped chemically dependent adults be better parents.

Such interventions fall under the general rubric of preventive services. These go unfunded by the state because Medicaid won't cover them. Of course, any program that would help youngsters simply because they live in traumatic situations could be labeled preventive; it's no wonder programs for kids in crisis have been only a small percentage of county services. Shoenfeld said that “MIDD was the way to start more prevention work” for King County youngsters.

King County Council member Bob Ferguson commented, “We had good reasons to put those programs into our original plan, and they’re still worth pursuing. I realize that revenues are down, and there's need for backfilling. But the need is for shared pain. We shouldn’t put it all on the backs of youth.”

The coming year could be brighter. Ferguson and County Executive Dow Constantine wrote to the MIDD oversight group in February, urging its members to make up for “disproportionate delay on strategies serving children, youth, and young adults” by prioritizing services for them when budgeting for 2012. And according to Shoenfeld, the MIDD outreach program for children in crisis — put on hold in 2009-2010 — is now on track for expansion.

Looking further into the future, Shoenfeld observed that “prevention is one of the evidence-based practices covered by the Affordable Care Act, which also integrates mental health and substance-abuse services into primary care. So in 2014, assuming (the new health care act) survives, we'll do a better job.”

He stressed that “we have to do prevention, get to kids earlier, and put more resources in that area” if we want to improve health care as a whole and drive down its costs. “It's not as if we don't know how to do it. And there's good evidence that it pays off.”

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