Mentally ill children to get help at home

A federal judge has accepted the state's plan to fix its system of care for poor mentally ill children, with Massachusetts authorities promising comprehensive services at youngsters' homes, rather than stranding them in institutions or ignoring them altogether.

US District Judge Michael A. Ponsor ruled late Thursday that the state's proposal offered the best hope for children in desperate need of treatment for psychiatric and emotional conditions and would end years of legal wrangling.

"If implemented and successful, the plan will represent a new day for this population of underserved, disabled children," the judge wrote in his nine-page opinion. "It holds the potential to be an enormous step forward."

Massachusetts had endured withering criticism from Ponsor in an earlier ruling for keeping children too long in psychiatric wards, group homes, and foster care, rather than providing services in their homes. Advocates even coined a term for such patients, "stuck kids."

It is estimated that 15,000 Massachusetts children whose care is paid for by the government could be affected by the decision, at a cost to the state of up to $459 million, according to Ponsor's ruling. Some provisions of the reform plan must be implemented as soon as the end of this year, and it needs to be fully in effect by June 2009.

Brigitte Walsh, a spokeswoman for the state Executive Office of Health and Human Services, said last night that Massachusetts officials are examining Ponsor's decision and would have no further comment until their review is complete.

Advocates hailed the ruling as a crucial turning point in the state's often-sullied history of guaranteeing uniform, coordinated services for poor children suffering from conditions that range from attention deficit disorder to schizophrenia.

"It's going to make a tremendous difference," said Lisa Lambert, assistant director of the Parent/Professional Advocacy League, an association representing about 4,000 families with mentally ill children. "There has been a real focus up until now on a crisis response. This will be much more of a response at an earlier time, and it's definitely the way we really need to go."

The judge's ruling appeared to be a Solomonic decision. A year ago, Ponsor sided with the eight families who brought the case, ruling that the state had illegally forced thousands of mentally ill children "to endure unnecessary confinement in residential facilities." But on Thursday, he adopted the state's plan for fixing the system, rather than the more expansive plan proposed by children's advocates. In effect, the judge said to state authorities: You will have no one but yourselves to blame if you don't like the way the new system turns out.

Ponsor said that he embraced the state's plan "as a practical matter."

"There is some force in being able to say to defendants: You have endorsed this plan, now implement it; prove to the court that it will work," Ponsor wrote.

Thursday's ruling entitles children to extensive services where they live. That means there will be specialists to help manage their care and crisis teams available during severe bouts of mental illness. And instead of having the care of a child overseen by a number of sometimes-conflicting specialists, each child will be assigned to a single case manager.

"You get one person who's in charge of the show," said Steven J. Schwartz, executive director of the Center for Public Representation, the nonprofit law firm that handled the case for the families. "All of these services are delivered in the community and either literally in the home or on the playground or at the school."

The litigation was known as the Rosie D. case, named for the lead plaintiff, who remains unidentified. After Ponsor's January 2006 ruling siding with the families, representatives of the state and the families attempted to reach an agreement on how to repair the mental health system. When they failed, Ponsor ordered each side to submit a plan.

The proposal from the families, Schwartz said, was more detailed and advocated more extensive care for children and their families, including specific services after school and training for parents.

The heart of the state's 35-page plan is the substantial expansion of home-based services and the creation of crisis teams capable of intervening in the community. Additionally, the state vows it will do a better job of letting poor families know that mental health services exist and perform more rigorous assessment of children to make sure all youngsters who need help receive appropriate care.

The financial implications of the ruling for the cash-strapped state remained murky last night. The cost quoted by Ponsor was the figure state lawyers used, and Schwartz described it as an amount "intended to impress the court." He suggested it might have been overstated, failing, for example, to take into account substantial savings by eliminating expensive hospital stays.

Walsh, the state spokeswoman, said health agency authorities had no comment on the plan's economic implications.

David Matteodo, leader of a trade organization of mental health hospitals, agreed that offering more services at home is laudable. But he cautioned that the reform plan should not be regarded as a panacea, saying that some conditions are so severe they will continue to need hospital services.

"I do think this is going to help -- I don't want to be negative," said Matteodo, executive director of the Massachusetts Association of Behavioral Health Systems. But, he said, "the problems are so severe, not only with the kids but with their families, that it's probably not going to solve everything."

Stephen Smith can be reached at stsmith@globe.com.