By PAUL von ZIELBAUER


It was early February 2000, and Judge Paula J. Hepner said she could
hardly believe what a doctor in the city's juvenile justice system had
done to the girl standing before her in Brooklyn Family Court.
The girl, Tiffany S., was 14, with a history of suicide threats and a set
of serious psychological problems well documented by doctors at a
psychiatric hospital for children. They had treated her bipolar disorder
with powerful medicines and, knowing that she was facing detention, had
recommended that she keep receiving them when the Department of Juvenile
Justice took her into custody.

But soon after Tiffany entered the system, Dr. Ralph L. Williams -- an
employee of Prison Health Services and the only full-time doctor for 19
juvenile centers across the city -- stopped her medications. Instead, he
placed her on Ritalin, a drug meant to treat attention deficit
hyperactivity disorder.

It took only days for Tiffany to deteriorate. Soon, she said in an
interview, she was hallucinating, fighting with other girls and spending
hours staring at a wall. As an additional measure, she said, a Prison
Health employee asked her to sign a pledge not to kill herself.
Judge Hepner ordered Tiffany back to the hospital, records show, and
moved to hold Dr. Williams in criminal contempt. In doing so, Judge Hepner
joined at least five other judges who would order more vigorous treatment
by Prison Health, a company that cares for hundreds of thousands of
prisoners in New York State and across the country.

That May, for instance, Judge Philip C. Segal of Brooklyn Family Court
held the juvenile justice commissioner -- whose agency represented Prison
Health in court -- in contempt after the company staff neglected to give a
13-year-old boy his H.I.V. medication. Later that month, Harold J. Lynch,
a judge in the Bronx, ordered a 13-year-old girl in the agency's custody
returned to the Bronx Children's Psychiatric Center. The girl, court
records show, had tried to kill herself after a Prison Health doctor
discarded her psychiatric medications and gave her Ritalin instead.

This is not just a single case," Judge Lynch told city lawyers. It's
many cases.

But those cases are only one distressing facet of what would be a four-
year effort by Prison Health to provide care to young people in the city's
network of juvenile detention centers and group homes -- a job that made
the company about $15 million in revenue before it was replaced in 2003.
Independent investigations have criticized the quality of that care.
Questions have also been raised by some city officials about whether the
company was forthright with various other city agencies about its work at
Juvenile Justice.

Of the roughly 500 youngsters, ages 7 through 16, who were in custody on
any given day, some had committed serious crimes. Others had been turned
over by parents who could not or would not care for them. Still others
were there simply because there was nowhere else to go. One thing is clear
about most of them: they were sick and in need of help.

Prison Health, a profit-making corporation with a troubling record in
many states, appears to have poorly served many of those youngsters,
according to a review of its work, based on court records and audits, as
well as interviews with children, judges, Legal Aid Society lawyers and
current and former Juvenile Justice employees. The results, those
documents and interviews make clear, were often confusion and mistreatment
throughout the company's time in the juvenile justice system, from January
1999 to April 2003.

For the 5,000 youngsters who passed through each year, the one full-time
doctor Prison Health employed oversaw a staff composed mostly of part-time
physician assistants, social workers and nurses. Sometimes, current and
former counselors who worked at Juvenile Justice said, the medical staff
mistakenly gave children medication that had not been prescribed to them.
One counselor said that to avoid further errors, Polaroid photos were
stapled to medical files to help nurses match names with faces.
The only independent audit of the company's medical care, commissioned by
the Juvenile Justice Department in 2003, six months after Prison Health
had already left, found that patient records had been in disarray, and
that no doctor had appeared to consult them anyway. Many children with
serious illnesses received no follow-up care, the audit said, and most
teenagers were not tested for sexually transmitted diseases. The audit was
never made public.

The work was poor and put young people at risk," the city comptroller,
William C. Thompson Jr., said in an interview. I'd almost say
deplorable."

Juvenile Justice officials have said they were generally satisfied" with
the company. The agency declined interview requests for this article for
five months, until aides to Mayor Michael R. Bloomberg ordered the
department's spokesman to answer questions about Prison Health's tenure.
Even then, in two interviews, department officials would not discuss the
company's record.

Richard D. Wright, the president and chief executive of Prison Health,
defended its work and the services it offered youngsters in
custody. There were a lot of professional people dedicated to that
contract," he said in an interview. We thought that they were sufficient
to deal with the workload.

Prison Health's performance at Juvenile Justice is the least known aspect
of its long and lucrative work in New York. The care the company provided
in upstate county jails in recent years has been assailed by state
investigators. And its work at the jail complex on Rikers Island has been
consistently, if not always diligently monitored by New York City, which
awarded the company a new $300 million contract in January.

But the care Prison Health provided children in the juvenile system, the
city comptroller now says, should have been examined by the city when the
company was seeking the Rikers contract in 2000.

Prison Health took over care at Juvenile Justice in 1999 when it bought
EMSA Correctional Care, a smaller competitor that had been doing the job
for three years. When it was vying for the Rikers contract, though, Prison
Health listed EMSA in disclosure statements as an affiliate and indicated
that EMSA was still working at Juvenile Justice.

The city comptroller now says that Prison Health was in charge of
providing juvenile care from the time it bought EMSA, and that EMSA
existed only on paper. The comptroller says that the company misled the
city, and that as a result, the city missed an opportunity to get a hard
look at Prison Health's work in its own backyard before it hired the
company for its adult jails.

Prison Health says that its filings properly listed EMSA as a separate
concern in 2000. The city agencies in charge of awarding the Rikers
contract, the Health and Hospitals Corporation and the Mayor's Office of
Contract Services, say they found no problem with Prison Health's
disclosures.

Over the years, as Prison Health has expanded nationally, followed by
accusations of flawed care by regulators, many of its critics have
wondered how it kept winning new contracts, sometimes in a county or state
next to one it had left under a cloud. In New York City, anger among
judges and lawyers in the juvenile justice system did not prevent the
company from landing a huge jail contract across town.

Of course, caring for youngsters inside the city's three jail-like
detention centers and 16 less restrictive group homes can be as dangerous
and frustrating as caring for adult prisoners. Few young people entering
the system have received consistent health care and, as a result, lack any
medical record to guide doctors. Often, there are not even family members
to question.

For many of them, as a result, detention offers the only opportunity to
get a physical or dental examination, or even talk to an adult willing to
listen. Proper medical and mental health care, say experts and the
department's own employees, is vital in helping them become productive
adults.

That care has improved under the two companies hired to replace Prison
Health, say city officials and lawyers working in the Family Court system.
It could hardly have gotten worse, said Jennifer Baum, a Legal Aid lawyer
who represented many youngsters during Prison Health's tenure.
I saw troubled and needy children being mistreated by shabby medical
care," she said.

Checkups and Warnings

By the time Prison Health Services acquired it, EMSA had been treating
the city's incarcerated children since 1996. EMSA had more experience with
children than Prison Health, but it had problems, too.

In Westchester County, EMSA had paid $750,000 to settle a lawsuit by the
parents of a 17-year-old girl who hanged herself at the jail there in
1996, after a psychiatrist stopped her antidepressant medication. The
doctor, Harvey N. Lothringer, had pleaded guilty to second-degree
manslaughter three decades before, admitting that he dismembered the body
of a young woman who had died during an illegal abortion he performed, and
then flushed her remains down a toilet. He spent four years in prison, but
in 1973, the State Board of Regents declared the doctor rehabilitated"
and restored his medical license. He began working for EMSA in 1996.
At Juvenile Justice, counselors and Legal Aid lawyers said they had found
EMSA's medical staff too small to properly treat all the children who
needed help. But a little less than a year after Prison Health arrived,
taking responsibility for the care, that private grumbling turned public.
Prompted by complaints from Ms. Baum, a half-dozen Family Court judges
filed at least 12 court orders or contempt motions in 2000 to force
Juvenile Justice to fix mistakes in care. In one instance, Dr. Joseph K.
Youngerman of the Bronx Children's Psychiatric Center pleaded with Judge
Lynch to help the suicidal 13-year-old girl who had been taken off her
medication; if he could not, the doctor wrote, the center would take her
back -- to spare her (and us all) any repeat" of her breakdown.
For nearly two years, though, those concerns remained buried in court
files. Then, in 2002, the city comptroller, during a routine review,
uncovered several problems.

He urged Prison Health to re-examine its staffing, which provided only
one full-time psychiatrist and one part-time physician for all medical
services. The company, the comptroller's office found, did not provide the
group counseling required in its contract. There was no system, the
comptroller said, to ensure that children taking psychiatric drugs
received them on days they were sent to court; unmedicated, they sometimes
broke down in front of a judge.

Indeed, several employees said that they sometimes were told that drugs
for some of the children were unavailable or simply unnecessary, leaving
them to handle the untreated patients.

If they get disruptive," said one longtime counselor at a group
home, the staff has to put them in a restraining position, and then you
end up with a child-abuse charge.

For reasons that its spokesman declined to disclose, the Department of
Juvenile Justice commissioned its own review in 2003. It was a rare move,
and it came only after Prison Health had left.

This would be the only outside medical audit. Done by IPRO, a well-known
nonprofit health-care auditing firm, it found serious deficiencies,
showing that things had been even worse than the comptroller's office had
thought.

Medical charts had been badly disorganized, the audit said, and there
was little evidence of an oversight physician" reviewing them. Young
people who developed medical problems were almost never" seen by a
doctor, but typically examined instead by a nurse, the audit said.
About one in six youngsters with chronic health problems like epilepsy,
sickle cell anemia and kidney disease never received follow-up treatment
while in custody. Tests critical to running an institution full of
troubled young people were so haphazardly administered that fewer than one-
third of the eligible girls received a Pap test, and only about 1 in 5
eligible youngsters were tested for gonorrhea, chlamydia and syphilis.
But Prison Health was by now largely beyond accountability. It had left
the previous April, when the Department of Juvenile Justice replaced it
with two other companies: Health Star Plus, which now provides medical
care, and Forensic Health Services, which handles mental health services.
Department officials, who had given Prison Health mostly satisfactory
evaluations during its four years, would not discuss the problems raised
by the audit.

At this point, we have new providers," said Scott Trent, a department
spokesman. It's a new contract. It's entirely irrelevant.

One Girl's Tale

Tiffany grew up in Brownsville, Brooklyn, and her early life was a
painful one. She was put in her grandmother's care by city child-welfare
workers when she was 3 to escape the abuse of two drug-addicted parents.
But that did not last long. After her brother sexually abused her sister,
Tiffany was moved yet again. When she was 13, she ran away.
On the streets, she was beaten, and she began to hear voices. She found
herself telling people, I'm not crazy!"

Tiffany ended up in the custody of the juvenile justice system after she
was accused of a minor nonviolent crime in 1999; she agreed to be
interviewed on the condition that the charge not be disclosed. But before
she got there, she spent a month in the adolescent psychiatry unit at
Kings County Hospital Center in Brooklyn.

The conclusion of doctors there was precise: Tiffany suffered from
bipolar disorder and behavioral problems and required psychiatric
medication and individual psychotherapy. Without them, her doctors
wrote, Tiffany is at risk for harming herself."

Once in custody, Tiffany was placed in a holding center in Manhattan on
Jan. 5, 2000. She was taking Depakote to control her mood swings, and
Risperidone, an antipsychotic. The next day, records show, she was
examined by Dr. Williams.

Prison Health had hired the doctor several weeks earlier. But Dr.
Williams had already made a mostly negative impression on some lawyers
working with the youngsters in custody. In interviews, the lawyers said he
replaced psychiatric medication with cheaper, less appropriate drugs.
Mr. Wright, the president of Prison Health, said Dr. Williams felt that
black children were too frequently put on psychiatric medications they did
not need. But Mr. Wright said that the doctor's decisions to withdraw
those medications were inappropriate, and that Prison Health forced the
doctor to resign in August 2001. Dr. Williams did not return messages left
with his lawyer seeking comment for this article.

Records show that Dr. Williams, after one 80-minute exam, concluded that
Tiffany suffered from attention deficit hyperactivity disorder, and
despite three court orders discontinued her psychiatric medications in
late January. Soon the hallucinations started again, she said in an
interview, and her antisocial behavior came roaring back.

I'd see stuff, shadows, people's faces," Tiffany recalled. I'll be
scared. I'll be crying. I always think people are out to get me.

She eventually threatened to kill herself, she said, setting in motion
her return to Judge Hepner's courtroom, and ultimately the psychiatric
hospital, where doctors put her back on her previous medication.

When you have medicine that is working, it seems really irresponsible to
alter it," Judge Hepner, in an interview, recalled saying in court. She
ordered Dr. Williams to pay a $1,000 fine.

The kind of treatment Tiffany received, records and interviews show,
began before Prison Health took over EMSA, but judges and lawyers said the
pattern grew increasingly familiar afterward.

In July 2000, a suicidal 15-year-old girl was taken off Depakote --
prescribed by doctors at Craig House, an upstate psychiatric clinic -- and
placed on Ritalin, according to court filings and lawyers and judges
involved in her case. It would take five weeks to have her medication
restored.

In March of that year, a 15-year-old boy at Bridges Juvenile Center, a
secure center in the Bronx, went days without his psychiatric medications
because Dr. Williams visited the center only twice a week. Prison Health's
policy, according to court transcripts and interviews, was to discontinue
youngsters' medications until a company doctor could complete his own
evaluation.

But rather than wait for Dr. Williams to show up days later at Bridges, a
Manhattan Family Court judge, alerted by the boy's lawyer, ordered the boy
sent to Bellevue Hospital Center. They can't say there's no psychiatrist
on staff at the hospital," the judge, Sheldon M. Rand, said in a hearing.

The company's strategy for treatment, when it went beyond drugs, included
the unusual approach of asking a youngster to write up and sign a pledge
not to commit suicide. Such pledges, experts in mental health treatment
say, accomplish little.

It's an awful tool," said a former Prison Health mental health
supervisor in the juvenile system. It's designed to make the clinician go
home and sleep better at night.

Tiffany said the whole exercise was stupid. I just wrote it so they
would stop following me," she said.

[This article originally appeared in the New York Times. Reprinted with
permission.]

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