Noteworthy News Articles on Mental Health Topics, January 29-31, 2007

Unheeded Warnings (Number 2 of 3 special articles)
Ruby Bailey, Jack Kresnak & Tina Lam, Detroit Free Press- 1/29/2007

On paper and by reputation at the Lula Belle Stewart Center, Charlsie Adams-Rogers was a good foster parent who could provide a safe, nurturing home for 2-year-old Isaac Lethbridge and his 3-year-old sister.

Workers at the Detroit-based foster-care placement agency frequently complimented Adams-Rogers' child care skills and training in their reports. She was known among employees and other foster parents for her mentoring and advocacy work.

For a 2005 review, a Lula Belle worker simply cut and pasted Adams-Rogers' evaluation from her 2004 review. Her evaluations in 2003, 2004 and 2005 warned that she risked burnout from outside activities, but her license was still renewed.

Adams-Rogers, 59, also had a history of complaints alleging mistreatment of children in her home. Though Child Protective Services never substantiated any of the nine complaints, people familiar with the child welfare system say the allegations should have raised red flags about what was going on in the brick home on Greenlawn in northwest Detroit.

Critics say the number suggests a pattern of turmoil that should have triggered closer scrutiny of Adams-Rogers by officials at Lula Belle or licensing workers from the state Department of Human Services. The scrutiny was critical, experts say, because young, fragile children were involved.

Adams-Rogers calls Isaac's death a "horrible, horrible accident."

"I've been helping kids all my life," Adams-Rogers said. "I got into foster care to help children."

Rules bent for foster mom
Adams-Rogers' foster-care career began in January 1999, about two years after she retired as an inspector at the Chrysler Sterling Stamping Plant. Lula Belle licensed her shortly after she took in 10 nieces and nephews whose parents had neglected them.

Her provisional license allowed her to receive state funds for the large brood.

Because Adams-Rogers' home had only three bedrooms, the state Department of Human Services gave her an exemption to rules that generally don't allow five children to sleep in one bedroom.

By that April, the 10 children had returned to their parents, and Lula Belle sent four other foster children -- all boys -- to Adams-Rogers' home. Two months later, she asked that they be removed because she was leaving town for a while.

By the end of July, Adams-Rogers was back in the foster-care business. That's when Lula Belle gave her a regular license for as many as four children up to age 17.

Over the years, she received exemptions to care for up to eight children at a time. She estimates she took in 50 foster children.

When Isaac and his sister arrived on June 29, 2006, Adams-Rogers had three adopted children -- ages 18, 12 and 1 -- and two foster children ages 17 and 16 living with her.

All had "significant histories as child victims of physical, sexual and/or emotional abuse, as well as neglect," the DHS said in court records.

Lula Belle workers apparently didn't think twice about sending the two Lethbridge children into a crowded setting with unstable teens and a disturbed adolescent.

Later, a judge noted: "All the flags were up. All the signs were there." Except everyone ignored them.

A house full of trouble
In interviews with the Free Press, Adams-Rogers acknowledged that she had a big family and a busy household. In addition to her adopted and foster children, she had three adult biological children, 12 grandsons and three great-grandchildren.

One of her sons had a troubled past. Terrance Rogers, 29, was sentenced to 3 months in a state boot camp in 1995 for receiving and concealing stolen property. He also pleaded guilty to domestic-violence charges involving a girlfriend in 2001 and 2002, and served several months in jail for violating probation in those cases. That should have raised eyebrows at Lula Belle during licensing reviews because, in court records as recent as 2003, Terrance listed his mother's address as his own.

Adams-Rogers insists that Terrance didn't live with her, but the DHS noted in an Aug. 24 Wayne County Family Court filing that adults, including Terrance, secretly lived in the house.

The home was "family headquarters," Adams-Rogers said, where relatives often dropped by during the week, came for Sunday dinner and sometimes stayed a few days.

"It does not mean the house was out of control," she said.

Adams-Rogers' adopted 12-year-old daughter was often seen in charge of Isaac and his sister. Court records say she struggled with inappropriate sexual behavior and was physically and verbally aggressive.

"She needs to be constantly monitored on a daily basis," a Lula Belle worker wrote of the girl, who told investigators after Isaac died that she might have accidentally injured him.

One of Adams-Rogers' foster children, a teen with cerebral palsy who had been sexually abused, was in therapy and took prescription medicines, the DHS said.

Before putting Isaac and his sister in Adams-Rogers' home, Lula Belle had removed them from a Detroit foster home where Isaac's sister was diagnosed with hepatitis B, a serious liver disease that can be transmitted sexually as well as other ways. Their social worker noted that they were dirty and bruised while living at that home. Now, they were in a home with young children with serious problems.

Neighbors speak up
Over the years, some of Adams-Rogers' neighbors called Child Protective Services to complain about crying children and yelling and cursing at her house. She admitted that nine complaints against her, including allegations of physical neglect and improper supervision of kids, were investigated, but she said none was substantiated.

She called the claims "trumped-up lies."

Details about the investigations could not be confirmed because protective services records are confidential.

After one investigation, Adams-Rogers wrote letters and had her children put them in neighbors' mailboxes, saying: "When you can open your home and heart, then you can tell me how many kids I can have in my home."

After that, neighbor Victoria Griffin said, people didn't want to get involved. "People would leave off the porch in the summer because they didn't want to witness anything," she said.

Neighbors said they were troubled because the 12-year-old often seemed to be in charge of Isaac and his sister, even though Adams-Rogers had a live-in caregiver.

One neighbor recalled seeing the girl walking with the kids, Isaac struggling to keep up. The girl yelled and cursed at him, the neighbor said.

Griffin and others noticed the kids were dirty. Once, Griffin saw that Isaac's sister's leg was bleeding. "I should have said more," she said.

Bruises raise suspicions
On Aug. 4, a little over a month after she took in the Lethbridge kids, Adams-Rogers took Isaac to University Family Physicians on West McNichols in Detroit. He was tugging at his ear, but the doctor noticed something else: bruises on his forehead and back. The doctor called in an associate, Dr. Pierre Morris.

Morris testified in court that he saw multiple bruises in various stages of healing and told Adams-Rogers they looked suspicious. He said she told him Isaac had fallen on a slide at McDonald's during a July 21 visit with his parents, and that another doctor had told her the boy bruised easily.

Morris testified that he planned to report his suspicions of abuse but never reached Child Protective Services by phone. He said he filed the required state form. He wasn't questioned further in court and he did not respond to the Free Press' requests for an interview.

After seeing the doctor on Aug. 4, Adams-Rogers took Isaac to Lula Belle, where she showed the bruises to Karl Troy, his foster-care worker, and said they must have occurred during Isaac's parental visit two weeks earlier. She said she hadn't reported the marks because she thought they'd clear up.

The DHS said Troy noted in Isaac's file that the boy's forehead, cheeks and chin had greenish-blue bruises and his eyes were blackened. But he allowed Isaac to go home with Adams-Rogers. Troy declined to speak with the Free Press. State investigators later faulted him for failing to assess the child's safety or report the injuries to protective services.

The DHS said Troy did not speak with Adams-Rogers again until Aug. 16, when she called to report Isaac's death.

A Lula Belle licensing worker learned of the bruising Aug. 7, but it was two more days before she visited Adams-Rogers' home, where she reported seeing only a light bruise on Isaac's forehead, the DHS said. The department criticized the licensing worker for only interviewing Adams-Rogers.

The state said there was no indication that anyone at Lula Belle ever notified protective services as required. Ken Merritt, an attorney for Lula Belle, disputes that. He said the agency called protective services Aug. 4. "CPS is the one that's supposed to do something about it," Merritt said.

When Adams-Rogers took Isaac back to Morris on Aug. 14, the doctor said the bruises were healing. Soon, there would be many more.

A mysterious death
Aug. 16 started out like many other days at Adams-Rogers' home. Deborah Roberts, the live-in caregiver, said she fixed Isaac breakfast around 9:30.

His sister, who had turned 4 just two days earlier, came downstairs about an hour later with Adams-Rogers' 12-year-old daughter, Roberts said. It was hot and, after breakfast, the kids went out to the back porch and played with a stray kitten.

At least nine, and perhaps as many as a dozen, people were in and out of the house that day. Around lunchtime, two of Adams-Rogers' grandchildren stopped by. Another relative came by in the afternoon. Around 1:30, Roberts recalled seeing Adams-Rogers in the den as Roberts headed to her basement bedroom.

Kids were watching televisions upstairs and downstairs, Adams-Rogers said. She recalled that her 12-year-old daughter told her Isaac was napping.

A 16-year-old foster daughter testified that around 3:30 p.m., she came in from the library and headed upstairs to her room. Before long, she heard screaming and ran out to the hallway to find Adams-Rogers' 18-year-old adopted daughter holding Isaac's limp body and screaming for help. The 16-year-old said Adams-Rogers came upstairs, then ran back down and called 911.

According to court records, the 18-year-old told investigators she spotted Isaac lying under a blanket in his bed and thought it was odd on a hot day. When she took off the blanket, she saw he wasn't breathing.

Roberts, the caregiver, testified that Isaac's fingertips were blue, and he had a knot on the right side of his forehead. She said she got a cold towel and put it on his head as the 18-year-old pumped his chest. Roberts searched for a pulse and thought she found one.

When EMS workers arrived, they labored in vain over Isaac for about 25 minutes. He was pronounced dead at Children's Hospital of Michigan shortly after 5 p.m.

Back at the house, Detroit police found seven children in the living room, including a little girl with light-purple bruises on her arms and legs -- presumably Isaac's sister.

"I didn't see any tears from anybody," Officer David Kline said in court.

Protective services workers took the three surviving foster children and Adams-Rogers' two youngest daughters to other foster homes. Adams-Rogers said she turned in her foster-care license; the state moved to cut off her parental rights to her adopted 12- and 1-year-old daughters.

On Jan. 9, Adams-Rogers was charged with involuntary manslaughter for the death of a minor in her custody. She was also charged with two counts of second-degree child abuse.

In court hearings on terminating Adams-Rogers' parental rights, it was revealed that her 12-year-old daughter told investigators she'd been playing with Isaac, tossing him on a mattress, but she missed and he hit the floor. Medical experts testified that it was unlikely the fall could have caused the fatal injuries.

Isaac had brain hemorrhaging, according to an autopsy. His right collarbone was broken. He had second-degree burns on his chest and abdomen and behind one ear. One burn was 4 inches wide. There were old bruises on his lower legs, left arm and left buttock. There were new bruises on his forehead and upper back, and abrasions on his lower back, forehead and eyebrow.

Adams-Rogers maintains that Isaac's death was an accident. As she was arrested, she denied any role in harming him, blaming her 12-year-old daughter. Prosecutors have not ruled out other charges.

Warren Harris, Adams-Rogers' attorney, said his client took Isaac to a doctor because of the bruises and told Lula Belle workers about it.

"We know that a tragic event occurred; a child lost his life," Harris said. "I think that the problem is people automatically attribute that to Mrs. Rogers. ... All I'm saying to the public is, when you have a person who has no history of abuse, who for all intents and purposes is a very good mom, let's not be so quick to judge."

But as she terminated Adams-Rogers' parental rights on Nov. 13, a Wayne County judge noted that Isaac died in a houseful of people, and no one could say they heard a scream.

"Isaac should have been attached to the hip of Ms. Rogers," Family Court Judge Sheila Ann Gibson said. "If something's happening to Isaac, she should have known about it. All the flags were up. All the signs were there."

Hope for his sister
Isaac almost made it. A few weeks before his death, a Washtenaw County foster mother who was caring for the ninth and youngest Lethbridge child -- a girl born in April 2006 -- said she could take Isaac and his older sister. But moving the kids would require a change in court jurisdiction from Wayne County.

Officials in the two counties were discussing the change when Isaac was killed. Afterward, Wayne County allowed Washtenaw to take charge of his sister's case, and she was placed with the family there.

When her court-appointed lawyer visited the 4-year-old girl on Aug. 30, she was struck by the child's need for affection. Shirley Anderson-Titus said she rocked the little girl to sleep after she climbed crying on her lap.

Two days later, Isaac's funeral was held in Ann Arbor. It was private, attended by only a few family members and friends. Isaac was cremated. His parents have his remains.

In some cases, they say, this has forced doctors to release patients regardless of their mental state, sometimes only to have them involuntarily committed again with no guarantee that they will be placed promptly at a psychiatric facility.

The bottleneck of mental health patients in emergency rooms has been in the making for years, as the number of psychiatric beds in public and private hospitals has decreased. The long delays are worrisome to health care officials and patient advocates because they say the waits often worsen patients' conditions and overburden already-busy emergency departments.

"This is a national problem," said Patricia Petralia, vice president and chief operating officer at Potomac Ridge Behavioral Health Center in Rockville. "They're not receiving active treatment."

State officials acknowledge the problem, but they say cases of patients who are not referred to inpatient psychiatric facilities within 30 hours are not widespread. They say they are trying to address the issue by quickening the referral process and monitoring patients more closely to make sure they get access to the type of treatment they need.

"The number of beds available has not kept up with the demand," said Brian Hepburn, the executive director of the Maryland Mental Hygiene Administration. "Anytime you have someone released on a technicality means they're not getting their needs met."

Elsewhere in the region, Virginia has no time limit prescribed by state law, but also often faces problems placing involuntarily committed patients into facilities.

"We hear anecdotal complaints of people waiting in emergency rooms for extended periods of time," said James Reinhard, commissioner of the Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services.

In contrast, the District's St. Elizabeths Hospital has 420 beds for psychiatric patients, more than enough to meet demand in the city. "We're not experiencing a crunch," said Linda Grant, spokeswoman for the D.C. Department of Mental Health. "Traditionally, we have not had a problem with placement."

The number of beds at Maryland state psychiatric hospitals declined by 72 percent between 1982 and 2005, according to a report released last month by the Maryland Health Care Commission. The drop from 4,390 to 1,235 beds during that period came as three hospitals closed and others downsized. The number of beds at private licensed psychiatric hospitals fell by 36 percent during that period, dropping from 830 to 519.

The number at state and private psychiatric hospitals in Virginia also has dropped sharply in the past 30 years. The reasons for the decreases, health experts say, include the deinstitutionalization of many patients and the difficulty of making psychiatric hospitals financially solvent.

Neither Maryland officials nor the patient advocates could provide specific numbers of people affected by the delays caused by the shortage of beds. But they agree they are increasing.



Military Creates Mental Health Hotline
Associated Press, 1/29/2007

WASHINGTON -- U.S. troops who have been reluctant to seek help for mental health problems may soon be able to find it with a phone call.

A new automated phone-in assessment program is the latest effort by the military to reach out to soldiers and family members who might not otherwise seek help for post-traumatic stress or other psychological issues.

The program is similar to an anonymous mental health screening effort begun online last year. About 40,000 troops or their family members -- roughly 7 percent of them in Iraq -- have participated.

There's much concern among those in the military that seeking help will affect someone's career, so it's good to have more anonymous options, said Dr. Jay Weiss, a former Air Force psychiatrist in private practice in Louisiana who has treated Iraq veterans.

While seeking help via telephone and Internet is not ideal, it's ''certainly better than nothing,'' he said.

The new efforts are extensions of counseling programs the military has implemented in recent years. Defense officials are hoping that the phone screening will attract National Guard and Reserve troops and families who are far from a military base and may not have easy access to in-person counseling or to the Internet.

The phone-in program was introduced Monday at the Military Health System annual conference in Washington. It is expected to begin taking calls by Feb. 12. The calls will be conducted in English and Spanish and will operate 24 hours a day.

''People respond in different ways. Some people will go to the Internet. Some will talk on the phone. Some people, they need someone ... who is in the same situation, the chaplain. Some people respond to religion, some will not,'' said Lt. Col. Bruce Farrell, full-time support chaplain for the Pennsylvania National Guard.

Participants in telephone screening are transferred to a counselor if they indicate they might be suicidal or if they wish to speak to a live person. Callers are given an immediate result from their assessment and phone numbers for treatment or educational resources.

The military already has phone-in counseling resources available, but the new program is the military's first to have automated interactive mental health screening.

Army Surgeon General Kevin Kiley testified recently on Capitol Hill that an estimated 17 percent of troops return from Iraq with post-traumatic stress disorder, severe anxiety or depression. Symptoms of PTSD include hypervigilance, irritability and nightmares.

Since the 2003 invasion of Iraq, 96 troops have committed suicide in Iraq, according to the Department of Defense. Another 15 committed suicide in Afghanistan.

Those who have participated in the assessments online in the last year have primarily filled out questionnaires on depression and alcohol abuse, said Col. Joyce Adkins, program director for the Defense Department's combat and operational stress control program. Those who participate online can print out their assessment and take it with them to see a counselor.

Although troops who have not deployed are encouraged to participate, about 60 percent who have participated in the online program have indicated they or a family member has been deployed to combat.

Like the Internet program, the phone-in system is focused on educating people about issues such as depression, alcohol abuse and post-traumatic stress disorder, Adkins said. She said the programs aim to get the word out that problems like post-traumatic stress disorder are ''not a life sentence.''

''PTSD and other mental health concerns are treatable,'' Adkins said. ''You can get treatment and recover fully.'' The toll-free number for the Telephone Self-Assessment will be (877) 877-3647.

On the Net:
Mental Health Assessment Program: https://www.militarymentalhealth.org/welcome.asp
Pennsylvania Dept. of Military and Veterans Affairs: http://sites.state.pa.us/PA--Exec/Military--Affairs/DMVA/

Child Welfare System Overhaul May Be Only Hope
Jack Kresnak, Ruby Bailey & Tina Lam, Detroit Free Press- 1/30/2007

Despite previous attempts at reform, the death of 2-year-old Isaac Lethbridge in foster care exposes a stubbornly persistent pattern of failures in Michigan's child welfare system. The overburdened system has seen the number of children in foster care rise steadily since the mid-1990s, even as the state's resources to handle them shrank. Isaac was the third young child to die under the state's watch in the last 18 months."This is a system at risk, there is no question," Department of Human Services Director Marianne Udow said.

Gov. Jennifer Granholm will address issues raised by Isaac's death next Tuesday during her State of the State address, spokeswoman Liz Boyd said Monday.

Boyd said changes in foster care already implemented by the state are "the first step to ensuring the protection of children." "Do we need to do more? Certainly," Boyd said.

Marcia Robinson Lowry, executive director of Children's Rights, a New York-based advocacy group that sued the state over foster care in August, said Michigan needs to ensure greater accountability and lower caseloads for workers, move children into adoptive homes more quickly and license more relatives as foster parents so children can stay with their families and still get help.

"This system really needs a very, very thorough overhaul," Lowry said. "Keeping kids alive and safe from abuse and psychological trauma seems like it ought to be high on the list of things the state would pay for."

A few years ago, Michigan's system was considered a model because of its high-quality family-preservation programs. But funds for preventing maltreatment, including programs to teach parenting skills, have been cut, and that may send more kids into an already stressed-out system.

With a budget deficit projected at more than $800 million for the current fiscal year, the state is in no position to pour millions more into child welfare, though experts say it is possible to improve conditions for foster kids without adding costs.

"Running a child welfare system right will always cost you less than letting a runaway child welfare system run up the tab," said Jess McDonald, former director of the Illinois Department of Children and Family Services. During the past decade, McDonald took a system bursting with more than 50,000 foster children to one with fewer than 17,000.

How one state improved
The turnaround in Illinois came by setting high goals and devising strategies to reach each one, McDonald said. A major one was getting all public and private agencies in the system accredited through the Council of Accreditation for Services to Children and Families of New York. Without accreditation, agencies are no longer eligible to manage foster children in Illinois. Fewer than half of the 500 licensed child-placing agencies in Michigan are accredited. "Your basic operation has to be functioning in a certain way," McDonald said, explaining why he likes the standards enforced by accreditation. "It's a good blueprint." Among the widely accepted standards: visiting children every month and worker caseloads of 15 or fewer children. Michigan foster-care workers typically handle caseloads of 20 children or more.

In the mid-1990s, Illinois also began using performance-based contracting with private foster-care agencies, using a system of rewards and punishments to ensure that agencies work toward positive outcomes for children. It also changed the jobs of hundreds of state employees who monitor foster-care cases assigned to various private agencies because, McDonald said, they represented a redundant layer of supervision for foster children already under an agency's care. In Michigan, there are 121 such workers.

Hundreds of those employees in Illinois got new assignments. Many became foster-care case managers, helping to reduce workers' caseloads from 25 or more foster children to 14 or 15. Other employees were assigned to licensing, and still others provided closer monitoring of struggling private agencies as part of performance teams.

"Redeploying those staffers gave us the opportunity to improve accountability of private agencies," McDonald said.

As in Michigan, Illinois' caseworker turnover rates were high -- 50% a year or more. McDonald said Illinois' caseworker turnover rate dropped to less than 10% with the reforms.

"The first thing you have to do is stop the bleeding," McDonald said, by hiring and promoting people who are qualified and giving them time to do the job right.

"You want to protect the workforce but set expectations for quality," he said. "It's who you hire, how you train them and how you supervise them."

Illinois also changed licensing rules to rule out placing more than six children in a foster home, except in rare cases. In Michigan, it's not uncommon for foster homes to have as many as eight foster children.

Tough choices for Michigan
Stresses on Michigan's child welfare system intensified in the last 15 years as tax reforms led to downsizing the state workforce. Udow said early retirements and staff reductions at DHS since the late 1990s resulted in the loss of 4,000 workers -- many of whom were the most-seasoned and best-trained staffers. Today, the department has fewer than 10,000 workers. Training funds also have been cut.

Meanwhile, new laws that shorten the process of terminating parental rights sent more children into the system. There are 18,600 kids in foster care today, compared with about 16,000 in the mid-1990s. And Child Protective Services is substantiating more complaints of abuse and neglect, from around 12,000 in 1995 to more than 17,500 in 2006.

Child advocates attribute the increase to greater public awareness and willingness to report suspected abuse, coupled with heightened economic pressure that leads to more maltreatment of children.

With a worsening state revenue outlook, tough choices are ahead for the governor, Legislature and Department of Human Services.

Melvin Haga, executive director of the Michigan County Social Services Association, which makes suggestions to the state on behalf of county DHS boards, said Michigan can't cut its way out of its predicament.

"If you expect people to do 100% of the work, you should give them 100% of the resources," Haga said. "If we're staffed at 81% -- and I think that's pretty close -- then there's 19% of the work that you can't expect them to do."

Udow said DHS has limited options and faces "horrible" choices.

Ruth Mutchler, a UAW Local 6000 area representative for DHS child welfare workers, said the state can create different programs, but "the bottom line is, if you don't staff the program, you're not going to see the results you need."

Arguments for an overhaul
Tapping into federal foster-care money is one way to bolster funding, which has lagged in Michigan because fewer children are being placed with licensed foster parents -- a requirement to receive federal funding. Lowry of Children's Rights said licensing more relatives who can care for children will expand the services that can be provided.

But even federal foster-care reimbursements to counties have fallen by about half in the decade since Congress froze family income-eligibility standards at 1996 levels. Before those changes were made, about 75% of Michigan kids in foster care were eligible for certain federal funding based on their families' income, Udow said. Now, it's less than 60%.

In Wayne County, which handles about one-third of all of the children in foster care in the state, reimbursement drop-offs have resulted in the county paying an extra $40 million a year for foster kids.

Some experts argue that a more integrated foster-care system would help contain costs and produce better results for children.

Six years ago, for example, Wayne County created a managed-care approach for juvenile delinquents that helped lower juvenile crime rates and cost less because it provided intensive services while keeping children in their homes instead of in more expensive institutional care.

Dan Chaney, director of juvenile services for the Wayne County Department of Children and Family Services, said a similar approach would improve foster care. Now, he said, too much effort is spent trying to qualify foster children for funding for care instead of taking a more comprehensive approach toward solving a family's problems. In such a system, agencies would be required to adequately care for foster children or lose funding.

Now, the foster-care system "is too categorical," Chaney said. "They have these little niches they try to fit these kids into, unlike our system of care where we give a child to a provider and they have unconditional and complete responsibility."

Preventing problems
Nearly every child advocate and expert said Michigan's system needs more accountability, something difficult or impossible to achieve at current staffing levels without reducing the number of children in the system.

"The DHS has plenty of rules and regulations in place, they just don't follow them consistently," said Judge Judy Hartsfield, presiding judge of Wayne County Family Court. "I find that the checks and balances often don't work until you push past maybe the first level of supervision, and sometimes the second level of supervision."

Some states have cut the number of children in foster care by intensifying services such as family-preservation programs to keep families intact. Illinois had 51,000 kids in foster or institutional care in 1991. Last year, the number was 16,600 -- 2,000 fewer than Michigan, which has 2.5 million fewer residents.

"We realized that taking a lot of kids from their parents didn't make the kids any safer," said Benjamin Wolf of the American Civil Liberties Union of Illinois, which sued the state in 1988. "We just need to make more sophisticated, more thoughtful decisions."

Udow said the state is working to keep kids out of foster care through its Family to Family program that brings struggling parents together with extended families, DHS workers, teachers and others to find ways to help them through crises. Child Protective Services uses a similar program, Families First, to try to keep families intact.

More than 3 in 4 children entering foster care in Michigan do so because of parental neglect, not abuse. Each child in foster care costs the state an average of $18,500 a year. Experts say redirecting funding into family-preservation and prevention programs can reduce foster-care costs and is a better use of limited resources.

"If we in the state of Michigan, and even nationally, put more emphasis on spending dollars up front, we would keep families intact," said Bill Newhouse, executive director of Children's Charter, a Michigan nonprofit that provides technical assistance and training for social service workers. "I'm not necessarily advocating just throwing more money into the system. But prevention is something I believe would work."

Left-Behind Children Choosing Suicide
Chris Kraul, Los Angeles Times- 1/30/2007

GIRON, Ecuador -- His seventh-grade teacher was discussing family values last month when Jaime Castillo startled his classmates by bursting into tears. They knew that the 13-year-old hadn't seen his father since he left for the United States three years ago and that he was depressed.

The next day, his friends' surprise turned to shock when they learned he had gone home and swallowed a packet of rat poison. Only quick action by his mother and doctors at a clinic saved his life.

"His mother takes good care of him, but his father is in another part of the world," said friend Jose Abel Avila, 14, who also lives in this town surrounded by lush, steep mountains that bring to mind Switzerland in the summertime. "He sends money, but it can't take the place of affection."

The province of Azuay has sent more emigrants to the United States and Europe than any other region in Ecuador. The exodus of young parents has had devastating consequences for the youths they leave behind.

A sharp increase in adolescent suicides as well as teenage pregnancies, alcoholism, car wrecks and declining school performance represent the dark side of Ecuador's migration phenomenon. Although the flight of as many as 20 percent of its citizens over the past few decades has created an economic windfall totaling $2 billion a year in remittances, the social costs have been high.

"Fifteen years ago, youth suicides were unheard of," said Guido Pinos, a psychiatry professor at the university in Cuenca, the provincial capital. "Now they have become a kind of fashion, or what we in psychiatry term a `model,' to follow to escape from conflict, from being uncared for or feeling abandoned."

Pinos said that in 2006, youth suicides in Azuay rose 20 percent from the previous year, and he estimated that the province's overall suicide rate was at least twice the world average of about 12 per 100,000. In towns such as Giron and neighboring Santa Isabel, which have seen an exodus of men, the rate is eight times the global norm as calculated by the World Health Organization, health officials say.

"Sixty percent of adult males have left this municipality. As a result, families fall apart," said Claudia Romero, a social worker in Santa Isabel. Suicides in her town last year included those of a 10-year-old boy and a 9-year-old girl, she said.

Miguel Penafiel, director of Vicente Corral Moscoso Hospital in Cuenca, said that although other countries with a pattern of emigration to the United States and Europe also see suicides, he thinks Ecuador's rate is higher because social disintegration is more pronounced here.

"There are many destroyed families here, as many as 20 percent in some towns, by which I mean you have children living without either parent," Penafiel said.

Elizabeth Jimenez, a psychologist with the Waaponi Foundation of Cuenca, a youth counseling group, said suicides might be high because Ecuador is one of the world's "saddest countries."

"When people get depressed in the country, they listen to sad music and consume alcohol. It's a lamentable social characteristic," she said.

The suicides cut across class lines, affecting children who receive significant amounts of money from their absent parents and those who do not.

"Despite the resources they may be getting from their parents, the youths are missing someone and something," said Jose Manuel Usca, a Roman Catholic priest in Giron.

These phobias, Mr. Shawn goes on, have meant that he ends up “missing things and harming, or losing relationships.” They have circumscribed his life, and turned ordinary undertakings — going on a trip, visiting friends, doing errands — into a daunting obstacle course. The prospect of a trip makes him “almost frozen with anticipatory anxiety for weeks or months in advance,” and even small jaunts, like a walk down a road, require him to equip himself with “safety items,” like a supply of Xanax, a bottle of ginger ale, a cellphone and a paper bag “of the type I breathed into once, many years ago, to calm myself when I suffered a concussion.”

In probing the consequences and possible causes of his phobias, Mr. Shawn has written a brave, eccentric and utterly compelling book that’s as revelatory and candid as anything ever written by Joan Didion, and as humane and scientifically fascinating as any one of Oliver Sacks’s case studies.

Mr. Shawn is unsparing in his dissection of his phobias and the self-preoccupation they entail, and he intercuts his research into the psychology of his affliction with some painfully recalled childhood memories that unfold into a thoughtful, philosophical meditation on Freud and families and identity.

The son of the famed New Yorker editor William Shawn, Allen Shawn has an older brother, Wallace, the playwright and actor; and a twin sister, Mary, who is autistic and lives in an institution in Delaware. The diagnosis of his sister’s condition and her departure, when she was 8, for a special school on Cape Cod seem to have triggered a severe case of separation anxiety in Allen, as well as fears that “one could be turned out of the house for being too difficult to handle,” for “being too inefficient mentally, or for being too wild.”

These fears amplified his own “terror of mental illness” — the fear that, being Mary’s twin, he too was somehow damaged or different.

Mary had been Allen’s closest companion when they were small children, and he says that his parents’ desire that he simply move on with his own life backfired: he had remained Mary’s twin, “finding ways to make my life parallel to hers.”

“I can’t help noticing that she, like me, is subject to ‘attacks,’ ” Mr. Shawn writes, “lives within a fixed routine, resists even minute changes from what she expects, is extremely limited in her ability to travel. She is institutionalized, I am out here, ‘free’ and ‘functioning,’ yet I have managed to build some invisible walls around myself.”

There were other factors that fed Allen’s phobic inclinations as well: a hereditary predisposition toward phobias; a childhood desire to emulate his father (who suffered from an array of phobias, including a distaste for airplanes, bridges and elevators); and a tendency to internalize his overprotective mother’s warnings about the perils of the world. Mr. Shawn recalls that she kept a watchful eye on him as a child, “delaying seemingly forever the moment when I would be allowed to cross the street by myself, and cultivating a sense that I wasn’t ready to ‘handle’ this or that activity, this or that scary scene in a movie.”

In addition, the Shawn household, with its emphasis on discretion and denial, seems to have been an “incubating environment” for future phobias, a petri dish of unspoken emotions. The author’s father carried on a four-decade extramarital affair, and his reticence about his complicated double life (“it wasn’t uncommon for him to eat, or at least, attend four or even five meals a day to accommodate all the important people in his life”) created an atmosphere in which secrecy and repression flourished.

“Beneath my sunniness,” Mr. Shawn writes of his younger self, “there was also rage that my family was somehow a sham, that I was a twin who wasn’t supposed to feel like one, that we were Jews with an Irish name. I felt that huge passions and angers that somehow couldn’t be mentioned were seething within me and within the house and that the world was raw and crude but had to be referred to politely in perfect sentences. There were blinding hatreds in the air that couldn’t be named; there was sex that couldn’t be spoken of; there were deep mysteries that had to be sanitized and secularized; there was deep competitiveness and there were deep character flaws that couldn’t be acknowledged.”

Mr. Shawn says he “held in my feelings and my problems, and they grew without my even knowing it.” Although he wasn’t agoraphobic as a child, he began, after college, to build his “life around the experiences in which I felt calm.” Since then, he now realizes, he has been dragging his childhood along with him like a giant, melancholy shadow.

With phobias, of course, it’s impossible to point to one precipitating cause, one formative event, and in Mr. Shawn’s case, a constellation of events, experiences and environmental influences helped reinforce any existing tendency to bury his difficulties inside. In “Wish I Could Be There,” his inquiry into his affliction becomes an inquiry into his own past, and that inquiry, in turn, becomes an eloquent meditation upon the mysteries of personality and family, and the ingenious, often debilitating ways in which the human mind can try to cope with the exigencies of the world.

“In a way,” Mr. Shawn writes, “I had been raised to feel that the world was a kind of Pandora’s box that was simply too frightening to ever fully open. As an adult I found a way to open it a bit, while sitting on top of it too.”