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 inmates 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 inmates. 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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