By Mary Otto
Washington Post Staff Writer
Wednesday, March 30, 2005
Dawn Rieck sat at the dining room table in her split-level house at Andrews Air Force Base, chain-smoking. She wore a distant yet acute expression, as if she were trying to read the wind.
She was listening to her daughter play.
At that moment, her middle child, Jessica Marie Caughlin, 11, was not beating her 4-year-old brother or killing her big sister's hamster or cutting the goldfish in two. She was not threatening to stab her mother. The knives were all locked in the garage.
With this child, however, her mother is always anticipating the next disaster.
It's like this for many parents who are raising children with serious mental illness.
With nerves and budgets, jobs and marriages regularly strained, they are consumed in the struggle to care for their children. Some say they need help that neither private insurance nor the public health system comes close to covering.
Yet this day, Jessica was simply playing with her two dolls. There was a bad doll named Dana Marie Caughlin. And there was a good doll named Princess Angel.
"Give me one feather from your wing," Jessica commanded Princess Angel.
With the feather, Jessica blessed Dana Marie -- who rose up from the floor and flew briefly, happily -- only to crash again.
It was like a small vignette from Jessica's own childhood: the powerful medications that steady her and then let her down, the sojourns through altered states and locked wards, only to return to a mother who is resigned to send her away again, even abandon her again, in an attempt to get her the care she needs.
What she really needs, the mother said, are intensive home- and community-based services: counseling, case management, respite care, psychiatric rehabilitation. They are called wraparound services for the way they are supposed to enfold the family and child.
Without wraparound, an institution can become the only option for parents such as Rieck, she said. "We're not giving up our kids because we want to," said Rieck, 37. "We can't do anything else for them. They are hurting other people. They are hurting themselves. There is nothing we can do anymore."
Maryland officials have recognized this desperation. They say the institutionalization of mentally ill and emotionally disturbed children is in many ways a failure -- bad for families and children and very expensive for the state.
In fiscal year 2004, Maryland spent more than $100 million placing about 3,000 mentally ill and emotionally disturbed children in hospitals and residential treatment centers, according to the state Mental Hygiene Administration.
Yet every dollar spent on services to help keep children with their families saves $10 in out-of-home placement costs, according to a report by the Governor's Office of Children, Youth and Families.
The District began offering a version of wraparound services in 2002. The Virginia General Assembly recently appropriated $1 million for a demonstration project providing wraparound-type services for 150 to 200 children.
And the budget proposal of Maryland Gov. Robert L. Ehrlich Jr. (R) included $1 million for two pilot wraparound programs expected to serve at least 200 children -- a minimum of 100 each in Montgomery County and Baltimore.
Some Maryland mental health advocates remain wary. The administration has cut about $15 million from a $42 million Medicaid program that was providing home- and community-based psychiatric rehabilitation and mentoring to more than 10,000 children, including Jessica. "The closest thing we had to wraparound they took away," said Cathy Surace of the Maryland Disability Law Center.
The impact of the cuts is a matter of debate, with an analysis expected next month. State officials have defended their decision, citing the program's ballooning costs and noting that spending on a broader array of therapy and rehabilitation services to mentally ill children held relatively stable last year.
For Jessica, the cuts meant losing a mentor who came to her home, usually twice weekly, in the afternoons. The mentor took her on outings to the library, shops and the recreation center -- places she enjoyed but had difficulty visiting without supervision. The visits helped, Rieck said, though they alone were not enough to save Jessica from her latest crisis.
Even as a baby, Jessica screamed in a way that scared her mother. By the time she was 3, she was lashing out. At 5, the girl was hearing voices, Rieck said. A variety of diagnoses followed, with doctors settling on bipolar disorder. Yet there was a time when her mother did not feel so alone.
When the Navy family was living in Philadelphia, wraparound services were available for Jessica, provided by the state of Pennsylvania. Support was there every day: a team of professionals counseling, accompanying Jessica to school, coaching her family at home.
When the Navy transferred the family to Maryland in 2001, the real nightmare began, Rieck said. Last year alone, Jessica was hospitalized four times for a total of six weeks. In November, Rieck was charged with abandonment because she would not take Jessica home without support. Rieck said she didn't feel safe.
"She's got too much rage, too much anger," she recalled telling the staff at Children's National Medical Center.
After many desperate phone calls, Rieck got Jessica a two-week respite placement in a therapeutic foster home in St. Mary's County. Then on Dec. 1, her 11th birthday, Jessica came home.
"A ticking time bomb," her mother said, watching her play with dolls the day after Christmas.
Eight days later, the military police were in the house, physically restraining Jessica.
The call came when Rieck was at work at her office manager's job. She had left 18-year-old Jennifer in charge of Jessica and Anthony, who was sick in bed. Jessica got home from school and asked to go outside. But Jennifer, who had to mind Anthony, said no.
Jessica lost control. Jennifer called her mother, terrified. "Call the MPs," Rieck told Jennifer, already halfway out her office door.
By early the next morning, Jessica was locked in the children's unit at Sheppard and Enoch Pratt Hospital in Towson, Md., without her dolls or her family.
Rieck called her daughter every day at the vast, turreted stone and brick hospital and took off work for family counseling.
One day in January, she drove past the Gothic gatehouse, up a winding lane through old trees shrouded in fog. Into the gray carpeted emergency entrance where Jessica arrived by ambulance, her mother carried Jessica's Christmas sweat suit, the one with "Angel" printed across the front, and her favorite pillow.
After the counseling session, sitting in her car in the rain, Rieck was shaken. "She needs more help than I can give her. I need somebody who can work with her all day and not worry about her stabbing them in their sleep," she said.
That January weekend, Rieck's marriage, already in trouble, broke up. Rieck gathered her other children and three heavy notebooks containing Jessica's 1,000-page medical history and found a house to rent. She knew Jessica's time at the hospital was running out.
On Jan. 18, a bitterly cold day two weeks after Jessica's admission, the hospital called. And Rieck was back where she was in November -- being charged with abandonment for refusing to take her daughter home.
Sheppard Pratt spokeswoman Bonnie Katz said she understands the dilemma families face. But, she added, "we have a legal, ethical and medical obligation to the children to enable them to leave."
Once again, after many desperate calls, Rieck found a solution. She worked with the Prince George's County school system to arrange a placement for Jessica in a residential treatment center in Leesburg. Her insurance would cover 120 days there.
If Jessica needs more time there, her mother plans to ask for a voluntary placement agreement, in effect sharing custody with the state of Maryland and letting Medicaid and a judge have a say in Jessica's treatment.
One recent weekend, Rieck loaded Jennifer and Jennifer's boyfriend and little Anthony into her battered red Ford Explorer. She stopped for gas and cigarettes and red licorice and nosed southward through a tangle of highways, down to where a parkway gave way to a suburban Virginia thoroughfare and then a country road.
She passed through a stone gate and turned up a long drive winding through old trees to a stately old house with a mansard roof and fenced-in modern wings.
Inside, her blue-eyed middle child was waiting.
"I'm going to come home. I'm going to do better, Mom," Jessica promised, her mother recalled. "Then I can be like a normal kid."
Jessica Caughlin, 11, is in need of mental health services.
Dawn Rieck worries about money on the way to visit her daughter Jessica at a facility in Leesburg. Son Anthony, 4, is in the back seat.
Dawn Rieck dresses her son, Anthony, 4. Her mentally ill daughter, Jessica, used to be visited by a mentor until Maryland cut the program's budget.
In the family's SUV, which has a cracked windshield, Jessica's siblings, Jennifer and Anthony, head to Leesburg to visit their sister.