Pew Charitable Trusts

The opioid epidemic has killed tens of thousands over the past two years and driven major reforms in state and local law enforcement and public health policies for people with addiction.

But another deadly but popular drug, methamphetamine, also has been surging in many parts of the country. And federal officials say that, based on what they learned as opioids swept the U.S., methamphetamine is likely to spread even further.

“The beginning of the opioid epidemic was 2000 and we thought it was just localized,” said Kimberly Johnson, director of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration, or SAMHSA. “Now we know that drug outbreaks aren’t likely to stay localized so we can start addressing them sooner and letting other states know of the potential for it spreading.”

From Arizona, New Mexico and Oklahoma to Montana, Wisconsin and Minnesota and all across the South, inexpensive methamphetamine is flowing in from Mexico, fueling what police and epidemiologists say is an alarming increase in the number of people using the drug, and dying from it.

Nationwide, regular use of the inexpensive and widely available illicit stimulant increased from 3 percent to 4 percent of the population between 2010 and 2015, according to SAMHSA. At the same time, heroin use shot from 1 percent to 2 percent of the population.

The number of people using methamphetamine, also known as meth, crystal meth, crystal, crank, ice and speed, has been among the highest of any illicit substance for decades. But despite the stimulant’s harmful long-term effects on the body — including rotting teeth, heart and kidney failure, and skin lesions — its overdose potential is much lower than prescription painkillers and other opioids.

Still, overdose deaths from methamphetamine have spiked recently.

In 2014, roughly 3,700 Americans died from drug overdoses involving methamphetamine, more than double the 2010 number, according to the Centers for Disease Control and Prevention. In 2015, the most recent year for which federal data are available, nearly 4,900 meth users died of an overdose, a 30 percent jump in one year.

Early warnings

In Oklahoma, methamphetamine was involved in 328 overdose deaths last year, a sharp climb from 271 in 2015, and more than the combined deaths from prescription painkillers hydrocodone and oxycodone, according to Mark Woodward, a spokesman for the Oklahoma Narcotics Bureau.

In contrast to the last epidemic, which began in the 1990s, rural meth labs are now a rarity and the fires and explosions that captured headlines back then are practically nonexistent today, Woodward said. “A lot of people thought if meth labs are down, meth use is down.”

“But so much is coming in from Mexico, and it’s just as good as the domestic cooked product,” he said. “Why risk leaving a paper trail at a pharmacy when you have a buddy coming up from El Paso tonight with a cheap supply?”

The majority of methamphetamine now is smuggled across the Southwest border, according to the Drug Enforcement Administration’s 2016 National Drug Threat Assessment Summary.

Its purity is high and its street price is relatively low, much cheaper than heroin.

“While the current opioid crisis has deservedly garnered significant attention, the methamphetamine threat has remained prevalent,” the report warns.

Minnesota, a hot spot during the last methamphetamine epidemic, is experiencing a surge in admissions for treatment of methamphetamine addiction, according to the state Human Services Department.

In the upper Midwest and much of the rest of the country, 2005 was the peak year for methamphetamine use. After that, federal and state laws restricting the sale of an essential ingredient in methamphetamine, the over-the-counter cold medicine pseudoephedrine, led to a sharp decrease in U.S. meth labs.

As more meth started coming in from Mexico, the number of people seeking treatment began creeping up again and began to surge in many places in 2015. Last year, nearly 11,600 meth users were admitted for treatment in Minnesota, according to state data — a significant increase over the 6,700 who sought treatment for methamphetamine addiction in 2005.

Methamphetamine also is showing up in places that never experienced an earlier epidemic.

“What we’re seeing is that the use of methamphetamines has recently moved out of trailer parks and rural areas and into inner cities,” said Ken Roy, medical director of a major treatment facility, Addiction Recovery Resources, in New Orleans. “We’re seeing a lot of heroin addicts that also use methamphetamines. It used to be the only way we got meth patients was when they came to the hospital from rural areas.”

Different drugs

Opioid users experience a dreamlike state and typically nod off. But methamphetamine produces an entirely different high. Users experience a sense of elation and hypervigilance, and often become paranoid and aggressive.

“They may binge on meth for days without eating or sleeping, and they often start seeing things that aren’t there,” said Carol Falkowski, an addiction expert in Minnesota.

Death from a methamphetamine overdose also is very different from an opioid death. With opioids, which affect the part of the brain that controls breathing, high enough doses can shut down respiratory functions, quickly causing death.

With methamphetamine, death is typically caused by a stroke or heart attack, and is characterized by extreme sweating as the body overheats prior to death. Because methamphetamine represents a lower risk of overdose, many use it for decades, which often results in gradual organ failure and death. Those deaths are typically not counted in the overdose statistics.

Likewise, treatment for addiction to methamphetamine is different than for opioids. No FDA-approved medications exist to stop the cravings for methamphetamine, whereas three effective drugs are available to help people recover from opioid addiction.

As a result, methamphetamine treatment primarily consists of outpatient therapy, often after a brief stay in a residential facility.

People who stop using methamphetamine do not suffer the severe withdrawal symptoms such as the vomiting, muscle pain and other flu-like symptoms suffered by opioid users. But they do tend to become immobilized, sleeping a lot and binge eating, as well as suffering from severe depression, anxiety and drug cravings.

Falkowski said that during the last methamphetamine epidemic, there was more emphasis on the way people behaved when using meth for long periods of time, and the threat they posed to public safety.

Health officials in places like Minnesota and Oklahoma say the health care providers who helped legions of people overcome methamphetamine addiction during the last epidemic are prepared for a new onslaught. But Johnson, the SAMHSA director, cautioned that the addiction treatment workforce has not grown in proportion to the growth in overall drug use since then.

Tackling a new meth addiction wave on top of an opioid epidemic could strain the nation’s health care system, she said. “I don’t think what we’ve done to scale up access to treatme nt for opioid disorders is going to be that helpful for methamphetamines.”

On the Spokane Indian Reservation, in eastern Washington, a group of about 40 public school teachers gathered last month, in a field of reeds that stretched as high as their heads.

Before harvesting the reeds, or tules, to make mats, they prayed. Later, they left tobacco as a gift. By learning the rituals of the Spokane tribe, the teachers of the Wellpinit School District hope to connect the culture to their lessons to get their students — almost all of whom are indigenous — to be more engaged.

In Washington and across the U.S., Native American students struggle more than any other student group to attend school consistently and graduate on time.

But this year more states — especially those with large Native American populations such as South Dakota and Washington — are trying to help by training teachers, working with tribes to create policies and programs, embedding culture in lessons, and giving more money to schools with many Native American students.

At the same time, a new federal law has incited conversation about how states and school districts should involve tribes in education.

The Every Student Succeeds Act, which last year replaced No Child Left Behind, places new requirements on all states and some school districts. For the first time, they must engage in “timely and meaningful consultation” with tribes when making annual plans. If they don’t, they could lose federal aid through programs such as Title I, for schools that serve mainly low-income families.

The new law also funds programs related to Native American education, such as Native American language immersion programs.

Separate from the federal efforts, Minnesota last year and South Dakota this year passed bills that increased funding for some schools with large Native American populations. The extra money will allow schools to update their curriculum with more references to indigenous culture and history.

Washington last year began requiring school districts to put Native American culture, government and history into lessons when updating their curriculum.

This year, a new University of Washington training program gives teachers certificates in teaching the culture. California created a similar program last year.

Cultural Differences

Native American teens are more likely than teens from any other racial group to not be in school and not be working, according to a 2016 report.

The disparities start when the children are young: More than half of 3- and 4-year-old Native American children are not enrolled in preschool, the report found.

The report also outlines problems at home. Native American students are the most likely to have parents who lack secure employment. Thirty-six percent live in poverty, compared to the national average of 22 percent.

Students attending Wellpinit schools in Washington often don’t have internet at home or a reliable way of getting to school, educators say. They face domestic violence, homelessness and the loss of close family members.

Also, schools on or near reservations are run in many different ways, making it hard for students to get a consistent education, said Ahniwake Rose, executive director of the National Indian Education Association, a nonprofit that advocates for Native American, Alaskan Native and Native Hawaiian students.

The vast majority of indigenous students — about 93 percent — attend public schools, on or off reservations. The rest attend schools either run by the federal Bureau of Indian Education or run by a tribe.

All those schools are run differently, and yet a student could end up going back and forth between them, Rose said.

Some states are giving tribes more control over education and that will help, Rose said.

“We know if we are more engaged in our kids’ education, they are going to do better,” Rose said. “Just give us a seat at that table.”

New Mexico passed a law, in 2009, requiring all state agencies to collaborate with tribes when making policies and programs that affect Native Americans or Alaska Natives. The governor now meets with Indian nation, tribe and pueblo leaders once a year to talk through issues.

But many Native American students’ performance in school has since worsened. Reading, math and science test scores were mostly down from 2010 to 2014, according to a state report.

And the students still have the worst attendance and the lowest four-year graduation rate.

Cultural Lessons

Part of the reason why Native American students struggle in school is that they are taught from a “white-privileged point-of-view,” said Washington state Democratic Sen. John McCoy, a member of the Tulalip tribe who supported the new law there that requires districts to add Native American culture to their curriculum.

“That has to stop,” he said. “We have to teach history, the good, bad and ugly, but it has to be taught correctly. By giving the true history, Native students in school can start feeling better about themselves.”

Strong Native American language and culture programs have been found to lower attrition, enhance student-teacher and school-community relations, and improve attendance and the rate of students who go to college, according to a 2011 report by Arizona State University.

Cultural programs can only go so far, however, as a 2003 study indicates.

The study found that cultural programming moderately improved student outcomes — but students also needed to see strong parental involvement, solid instruction, supportive, caring teachers, and a safe and drug-free environment in order to improve.

Education sometimes isn’t valued highly enough on reservations in South Dakota, where 11.5 percent of students are Native Americans or Alaskan Natives, said Democratic state Sen. Troy Heinert, a member of the Rosebud Sioux tribe. He used to teach at a school on his reservation, and one of his sons still goes there.

Transportation is a big issue, he said. Some students have to take a bus more than 30 miles, one way, to get to school. If they miss the bus, they miss school.

The rural nature of the community means educators need to tailor lessons to what children know and understand, he said. Teachers shouldn’t use the example of a skyscraper to teach geometry, “when our kids have only seen them on the internet,” he said. “But we can use teepees. We have those here.”

More Funding

South Dakota will try to improve outcomes for Native American students a few schools at a time. A law that passed this year provides $1.7 million for a specialist to work with up to three schools for three years to redesign their approaches to teaching, including embedding culture in the curriculum. The program is modeled after a public charter school in New Mexico.

Another law, passed this year, aims to improve teacher recruitment and retention for schools with large Native American populations. The state struggles with that in rural areas, because there’s not enough housing, too much crime and too much poverty, Heinert said.

Under the law, the state will pay the tuition and fees for “para-educators,” or teaching assistants, who go to college to become teachers. Many para-educators now live on reservations but don’t have the qualifications to teach, said Mato Standing High, the state’s director of Native American education.

Minnesota also will give more funding to schools with large Native American populations this year, said Dennis Olson, the state’s director of Native American education.

The state used to spend about $2.1 million a year on this effort in 32 school districts that were selected based on need. It now spends $9 million a year on all school districts with more than 20 Native American students, or about 138 districts.

Schools will use the money for whatever they see fit — from tweaks to the curriculum to supports for students to training for teachers.

In Washington, the Wellpinit teachers learning how to make tule mats were the first to participate in the new certification program at the University of Washington.

The teachers are learning how to better acknowledge their students’ culture in lessons, to help them connect to what they are taught, said Kim Ewing, principal of Wellpinit Elementary School.

Since storytelling is a Native tradition, a language arts teacher could have one student tell a story while another writes it down. A math teacher could teach students how to use algebra to count the tules in a field.

If the richness of the community can be applied in the classroom, Ewing said, “that makes a huge difference in learning.”

The U.S. Department of Transportation has given Oregon $2.1 million to expand its “pay-by-the-mile” experiment as an alternative to the gasoline tax, buying into the idea that the current method of paying for highway repair and maintenance may be outdated.

Under Oregon’s pilot program, “OreGO,” people sign up to put a small reporting device in their cars that measures the number of miles they drive on Oregon roads. Oregon collects 1.5 cents a mile on the distance participants drive and issues a refund of the gasoline taxes they pay at the pump.

The goal is to see whether taxing by the miles driven is a better way to raise revenue than taxing at the pump now that fuel-efficient cars and inflation have eroded federal and state gasoline tax revenue.

Drivers of gas-guzzlers generally pay less under the mileage program, while drivers of fuel-efficient cars pay more. But the program is designed to be revenue-neutral to the state.

The pilot program was designed for 5,000 participants, but the state has had trouble attracting people over worries they might get charged more or that their activities might be subject to monitoring with the GPS-like device that tracks the miles driven. So far, only 1,263 vehicles have been enrolled in the program, according to the Oregon Department of Transportation.

“Inviting Oregonians to volunteer to pay a new tax is a daunting communications task, especially given concerns over privacy and fairness,” said Tom Fuller, spokesman for the Oregon department. “What we’ve found is that the more people know about road usage charging, the more they support it. So this grant will help us do just that — educate Oregonians about the why and the how of this idea. We think it will lead to more folks signing up.”

Interestingly, he said, owners of fuel-efficient cars like the hybrid Toyota Prius have signed up in greater numbers, although they might pay more, indicating that transportation-conscious residents understand the program.

Statistics show that in Oregon and across the country, the gasoline tax has not kept up with inflation, even as demands for transportation infrastructure repair and construction have skyrocketed.

“One of our nation’s biggest challenges is how to meet the funding needs of our nation’s crumbling surface transportation infrastructure in a long-term, sustainable way,” said U.S. Rep. Peter DeFazio, Democrat from Oregon. “I’ve long said that we must consider all viable options to meet this pressing need.”

California and Washington are studying the Oregon program with an eye toward setting up pilot programs of their own.

What if lowering student debt was as easy as sending students a letter?

Indiana University officials say borrowing by undergraduates at the school has dropped 18 percent since 2012. That’s when the university began sending students annual letters that estimate their total loan debt and future monthly payments, as part of a push to boost their financial literacy.

Inspired by the results at IU, Indiana last year began requiring all colleges that accept state aid to send letters. Nebraska followed with a similar law this spring.

Republican Rep. Casey Cox, the author of the Indiana legislation, says he gets phone calls from officials in other states interested in the idea. And U.S. Sen. Joe Donnelly, an Indiana Democrat, has proposed requiring the federal Department of Education to keep a list of financial literacy best practices, perhaps including student loan letters.

A growing number of students need to borrow — and borrow heavily — to finance their college educations. And giving them more information about their debt may help change their borrowing habits. Research suggests that students say no to loans when they’re told how much they’re borrowing and how loans could weigh on them in the future.

But the approach carries risks, too. In some cases, borrowing less may make it harder for students to graduate. They might have to spend more time working and less time studying. Or they might opt for less expensive institutions that do less to guide them.

Although IU officials think financial literacy makes a difference, they haven’t actually proven that the letters — or any other initiative — drove borrowing down.

“From a research perspective, we haven’t gotten to the point where we can say it had an impact,” said Victor Borden, professor of educational leadership and policy studies at IU Bloomington. He and a team of researchers are scouring data to find out exactly what worked.

Students Who Borrow Too Much

Cox, the author of the Indiana law, is one of the youngest members of the Legislature. The 30-something is still paying off his law school loans.

He said he was inspired by his alma mater’s efforts and his own memories of how tempting it was for students to borrow as much as possible. “At a young age, you may not really understand the consequences of that debt,” he said.

Some students may not know they’re borrowing at all. Researchers at the Brookings Institution, a centrist Washington, D.C., think tank, dug into federal survey data in 2014 and found that over a quarter of first-year college students with federal student loans didn’t know their loans came from the federal government. About half of those students had no idea they were borrowing money to pay for college.

Students can be confused for a number of reasons. Their parents may be handling the financial aid details, for example. The way student loans are packaged and disbursed doesn’t help, said Andrew Kelly of the American Enterprise Institute, a conservative-leaning Washington think tank.

A few months after a student sends a financial aid application to the federal government, an award letter arrives from the college, which may knock a chunk of money off the tuition bill — or cover it entirely. “It just kind of arrives, like manna from heaven,” Kelly said of financial aid.

Behind the scenes, two things happen: The government calculates how much the student’s family can afford to pay for the education. And the college calculates the total cost of attendance, including living expenses. Both of those calculations determine how much federal and state need-based grants, work-study aid and loans the student can receive. The college may provide scholarships, too.

Students usually accept whatever aid colleges award them without questioning whether they could live more cheaply — and borrow less. And, Cox has said, some students may borrow extra money to fund a better lifestyle.

The temptation to borrow too heavily may be particularly strong for part-time students, who can borrow the same amount for living expenses as full-time students. The students may end up borrowing for many years, racking up more debt or even hitting federal loan limits before they manage to graduate.

More Information May Help

When the news broke that borrowing at IU had fallen, students there told Bloombergthe loan letters had spurred them to avoid debt by working more, looking for scholarships, and avoiding spending on living expenses like new cellphones.

But it’s not clear that IU’s letters are driving the decrease in borrowing. The letters were part of a bigger push to educate students about money that included counseling, a podcast, and a new website that offers quizzes and calculators. The university also has changed its financial aid process to make it easier for students to say no to loans.

Before all the financial literacy work began, said Phil Schuman, the university’s director of financial literacy, “I don’t think students actually knew they had the option to take less.”

IU also has been pushing its 94,000 undergraduates to enroll in 15 credits each semester — the pace necessary for graduation in four years. “It might not necessarily be that students are taking out less money each semester, but that they’re graduating on time,” Schuman said.

Across IU’s seven main campuses, 42 percent of full-time students seeking a bachelor’s degree graduate in four years, up from 38 percent five years ago according to the latest data. This past year, the cost of attendance — including tuition, fees, room and board —ran to $21,412 for in-state IU students.

A team led by IU’s Borden will use statistical analysis to parse all the factors that could be affecting borrowing, from the availability of state grants to student wealth. They will try to determine whether the financial aid letters, the literacy push, or the change in loan processing did the most to lower overall debt. The university made other changes during the period, such as increasing institutional grant aid, which also could have made a difference.

Other research shows that a combination of letters and counseling can change students’ borrowing and academic behavior.

Montana State University students with high debt who received letters alerting them to that debt and encouraging them to seek counseling borrowed an average of one-third, or $1,360, less the next semester, according to a 2015 analysis by Montana State and Federal Reserve researchers.

The students went on to take more credits and earn better grades the following semester, the study found. The same research team found in a forthcoming study that students who received the letters were 2 percentage points more likely to switch to a major associated with higher-paying jobs.

Students with lower grades tended to switch their majors to business, while students with higher grades tended to switch to majors in science, technology, engineering or math.

The federal government mandates that students undergo counseling twice, once before they receive loans and once after they leave the institution. (Most colleges provide this information online.) The Indiana and Nebraska laws don’t require colleges to add additional counseling, although many colleges already offer services similar to IU’s.

Students Who Borrow Too Little

Yet student loan letters can also have a downside. They can deter students from taking out loans they really need to finance their education.

“It’s just a really complex issue,” said Robert Kelchen, an assistant professor at Seton Hall University who studies student debt. “The policy discussion is that students need to borrow less. And the reality is that some students may be able to borrow less, but some may need to borrow more.”

Students may choose to work their way through college to graduate debt-free. But by working rather than studying, they may find it harder to graduate on time — or to graduate at all.

“The one thing we don’t want is students who are so stressed about their finances they can’t focus on their academics,” Schuman said.

Whether a student is borrowing too much or too little depends on a range of factors, from family wealth to the chosen degree and whether the student graduates, said Kelly of the American Enterprise Institute. “Someone who borrows the maximum amount for a solid program at a community college or a four-year college and finishes — it’s hard to say that they overborrowed,” he said.

Schuman said he has had to tell students that debt isn’t necessarily a bad thing, particularly when they’re working toward a degree that will lead to a high-paying job. He recently talked to a chemical engineering major at another institution who had about $10,000 in debt and was scared it was too much. “She was going to be fine!” he said.

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What Happens When You Warn Students About Their Loan Debt?

Fueled by sexual abuse allegations against comedian Bill Cosby and the Catholic Church, and other high-profile cases dating back decades, state legislators across the country are considering lengthening or eliminating statutes of limitations on rape.

Statutes of limitations, which exist for most crimes besides murder, are intended to encourage the timely reporting of crimes. As time passes, evidence deteriorates or gets lost, memories fade and witnesses die.

But it can take years for sexual abuse victims to find the courage to come forward. Advocates for victims say statutes of limitations for rape and sexual assaults are arbitrary and outdated, and note that police departments across the country are still digging through a backlog of rape kits, some of which are three decades old.

Forty-three states have statutes of limitations for sex crimes, according to the Rape, Abuse and Incest National Network. Of the states with statutes, 27 include an exception that allows prosecutors to file charges when there is DNA evidence. State statutes of limitations often range from three years to 12 years, but in some states, accusers have more time to come forward when they say they were abused as children — until they are 21 in some states or as old as 50 in others. Some states don’t start the clock until the victim turns 18.

Legislators in states such as California, Illinois, New York, Oklahoma and Pennsylvania are currently considering bills that would extend statutes of limitations for rape and sexual assault or eliminate them entirely.

In Pennsylvania, where the statute of limitations is 12 years in adult rape and sexual assault cases, prosecutors late last year beat the deadline by just weeks when they charged Cosby for a crime he allegedly committed in 2004. Backers of a bill that would eliminate the statute of limitations for people abused as children have pointed to the Cosby case, and to an attorney general’s report released last month alleging decades of abuse by Catholic priests.

Democratic Attorney General Kathleen Kane accused previous bishops in the Roman Catholic Diocese of Altoona-Johnstown of ignoring or hiding decades of sexual abuse by priests, but Kane said that nearly all of the allegations were too old to be prosecuted.

Nevada last year extended its statute of limitations on rape cases from four years to 20 after a woman who alleges that Cosby raped her in 1989 in Las Vegas pushed for the bill. And Oregon recently approved a law allowing prosecutors to file rape charges beyond the statute of limitations if there is new corroborating evidence or multiple victims come forward.

In Illinois, where former U.S. House Speaker Dennis Hastert admitted molestingstudents when he was a high school teacher and wrestling coach in the 1970s, lawmakers are considering eliminating the statute of limitations for people abused as children. Under current law, prosecutors may file charges up to 20 years after the victim turns 18.

Illinois state Sen. Scott Bennett, a former prosecutor, proposed the measure after Hastert was indicted for related financial crimes rather than for the actual sexual abuse.

“He admitted that he did things with children and you can’t do anything about it, but you can get him on money laundering charges. That seems wrong,” said Bennett, a Democrat.

Changes in public policy often follow cases like Hastert’s, according to Polly Poskin with the Illinois Coalition Against Sexual Assault. “Most law and public policy is really a response to an event,” she said. “Why it’s so critical is because when one person comes forward, if there are other survivors — and inevitably there are — it gives courage to other victims to come forward … you see a pattern.”

In the last several years, Hawaii and Minnesota have approved “window” laws that lift the statute of limitations for two and three years, respectively, to allow people to sue their alleged abusers in civil court.

The Pennsylvania bill also includes a “window” provision, because lawmakers can only eliminate the statute of limitations for future crimes, not ones that have already occurred.

“We’re going to put the liability back on the people who caused this. We need to be able to go back and sue the perpetrators and institutions who covered it up,” said Democratic state Rep. Mark Rozzi, who shepherded the bill through the House and says he was abused by a priest when he was 13.

Tough to Tell

Victims of rape and sexual abuse are often reluctant to report the crime. According to the U.S. Department of Justice, nine out of 10 child sexual abuse victims are abused by someone close to them, and may be hesitant to report them. Many initially feel it is their fault or they will not be believed. For others it may take years, or even decades, to come to terms with what happened and to tell others about it.

“It wasn’t until the last year and a half that I was able to use that word and call it what it really was — rape,” said Victoria Valentino, who says she was raped by Cosby in 1969 in California — a state where the current statute of limitations on rape is 10 years. Calls to Cosby’s attorney were not returned.

Barbara Blaine, president of the Illinois chapter of the Survivors Network of those Abused by Priests, which has advocated for the bill pending in the Illinois Legislature, long blamed herself for the abuse she says she experienced as a child. She didn’t tell anyone about it until she was nearly 30 and a therapist asked her about her first kiss.

“Well, I was in seventh or eighth grade, and it was the priest at my church,” she said.

Blaine said she spent years working with the church to try to keep her alleged abuser away from children. But, she said, by the time it became clear that legal action was necessary, the statute of limitations on her case had run out.

Making a Case

But critics, including some prosecutors and defense attorneys, say efforts to eliminate the statutes are misguided.

Natasha Minsker of the American Civil Liberties Union of California is opposing a bill that would scrap the state’s 10-year statute of limitations for rape. Minsker points out that California already allows extra time to file charges if there is DNA evidence. She said the accused affected by the change would have a hard time mounting a defense.

“When you’re talking decades later trying to reconstruct what you were doing and finding witnesses to testify on your behalf it becomes nearly impossible,” Minsker said.

In Oklahoma, where a pending bill would allow prosecutors to file charges up to 18 years after the crime becomes known to a third party, prosecutors have expressed concerns.

Trent Baggett with the Oklahoma District Attorneys Council said crimes become harder to prosecute the more time passes. Evidence gets destroyed or lost, witnesses’ memories fade, and prosecutors may doubt their ability to persuade jurors “beyond a reasonable doubt.”

It’s understandable that victims want to have their day in court, Baggett said, but the likelihood of a conviction is low. “You hate for that person to get their hopes raised and then feel they’ve gotten victimized again by the state.”

Even some victims are worried about scrapping the statutes.

Sujatha Baliga, who said she was sexually abused as a child, now works in restorative justice, a process in which victims and offenders come together to talk about the incident and reconcile.

She said many victims may be hesitant to use the process if there’s a chance that something said during it might be reported to police. Many victims don’t report what happened to them because they don’t want their abuser, who may be a relative, to get in trouble, Baliga said.

“They need to hear it wasn’t their fault and that the other person is sorry,” she said. “Because the only option is punitive, I suffered in silence for a decade.”

But Susan Howley of the National Center for Victims of Crime said prosecutors should be free to determine whether to pursue each individual case, regardless of how much time has lapsed since the crime occurred.

“If in a given case the prosecutor believes the available evidence is strong enough to prove the charges beyond a reasonable doubt, there should be no arbitrary time limitation prohibiting the case from going forward,” Howley said.

Bennett, the Illinois legislator and former prosecutor, said when victims don’t report crimes right away it can make it harder to win cases, “but that’s true whether it’s been a year after it happened or 20 years after it happened. You’ve got to take more time to explain to jurors why they didn’t come forward.”

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High-Profile Cases Spur States to Reconsider Statutes of Limitations for Rape

Federal health officials recommend that preschoolers with attention deficit hyperactivity disorder receive psychological counseling before they are put on medication. But states striving to promote the use of behavioral therapy have been hamstrung by a shortage of mental health providers.

They also have struggled to convince providers who are used to prescribing drugs first to shift strategies — especially in the face of what some state health officials and ADHD advocates describe as aggressive marketing by the pharmaceutical industry.

The Centers for Disease Control and Prevention released statistics this month suggesting that many states have a long way to go when it comes to promoting greater use of the therapy, which largely relies on teaching parents to reinforce positive behavior while avoiding confrontations.

In 10 states, fewer than half of preschoolers in Medicaid with ADHD were receiving psychological counseling, according to the CDC data. Among children ages 2 through 5 with private insurance, the numbers were even worse: In 26 states, fewer than half of those kids with ADHD were receiving behavioral therapy.

In contrast, more than three-fourths of all preschoolers with ADHD were on medication, generally stimulants such as Adderall and Ritalin.

The Medicaid numbers are from 2011, the most recent year for which the CDC could collect reliable data, and the private insurance numbers are from 2014. The CDC was able to collect Medicaid data from 34 states and private insurance data from 33 states.

Behavioral therapy “may require more time, energy and resources than medicine but its effect can be more long-lasting,” CDC Deputy Director Anne Schuchat said when her agency released the numbers. “We are missing opportunities for young children with ADHD to receive behavioral therapy.”

Some state officials said they are hopeful the CDC’s focus on the issue will promote progress. “To have the CDC shine a spotlight on this … creates the momentum that states need in order to transform practices and prescribing,” said Mary Mayhew, commissioner of the Maine Department of Health and Human Services.

Increasingly Prevalent

Children with ADHD have more trouble paying attention and are more impulsive than other kids. The consequences of the disorder can be life-altering. Children with ADHD are more likely to struggle academically and to drop out of school, and one-third of them continue to be affected as adults. One study cited by the CDC estimates that the health care and educational costs of kids with ADHD totals between $38 billion and $72 billion a year.

The number of children diagnosed with ADHD is rising. As of 2012, the most recent year for which numbers are available, 6.4 million children in the U.S. were diagnosed, up 42 percent from 2003.

In 2011, the American Academy of Pediatricians (AAP) recommended that children with ADHD who are younger than six receive behavioral therapy before they take stimulants, and the CDC backed those recommendations. The American Academy of Child and Adolescent Psychiatry recommended a therapy-first approach for young children at least a decade earlier.

Studies suggest that behavioral therapy is more effective than medicine for younger kids. Furthermore, the CDC notes that the long-term impact of ADHD drugs on young children is unknown, and the medications can cause side effects such as poor appetite, stomach aches, irritability, sleep problems and slowed growth.

For older children, however, AAP recommends both therapy and medication.

State Disparities

According to the CDC survey, which is based on tens of thousands of claims filed, the percentages of children with ADHD who receive behavioral therapy vary greatly from state to state.

Among Medicaid beneficiaries, the percentages ranged from 74 percent in Maryland to lows of 32 percent in Florida and 29 percent in New York. Overall, 54 percent of young children with ADHD in Medicaid received therapy in 2011, according to the CDC.

Among children with private insurance, Wisconsin had the highest percentage of children receiving behavioral therapy in 2014, at more than 61 percent, while Mississippi was lowest, at 23 percent. The overall rate for children in employer-sponsored plans in 2014 was 42 percent, compared to 45 percent in 2011, the year the AAP published its guidelines.

CDC officials said the private insurance numbers are lower because many mental health providers in private practice do not accept insurance, and because many state Medicaid programs provide extensive mental health coverage to children.

More Providers

In the last several years, some states have taken steps to expand the use of behavioral therapy by increasing the number of counselors who can provide it.

In Pennsylvania, the effort grew out of a larger campaign to reduce juvenile delinquency in the state. Since 2010, the Pennsylvania Commission on Crime and Delinquency has handed out nearly $5 million in grants to mental health clinics around the state to provide training in the kinds of behavioral therapy recommended for young children with ADHD.

“If we can address a child’s ADHD symptoms early, they are less likely to have school failure, which we know can have an effect on delinquency,” said Lee Ann Cook of Penn State’s Evidence-based Prevention and Intervention Support Center, which works with the state crime and delinquency commission.

One challenge in Pennsylvania is that its Medicaid program will not pay for therapy sessions that involve the parents of the child with ADHD, Cook said.

All Medicaid beneficiaries in Louisiana are covered under managed care plans (in which providers receive a lump sum for a patient’s total care, rather than being paid for each service). The state is asking those plans to connect pediatricians and primary care doctors to behavioral health specialists who can diagnose and treat ADHD. The state also has enlisted Louisiana State University and Tulane University to train therapists in every part of the state in ADHD therapy.

In Louisiana and many other states, pediatricians often turn to medication because they have no alternatives to offer. “Doctors don’t know who to refer these kids to and stimulants are all they can offer in a 10-minute window,” said James Hussey, interim assistant secretary in the Office of Behavioral Health in the Louisiana Department of Health & Hospitals.

In New York state, two in three counties (capturing 16 percent of the population) have been determined by the federal and state governments as having a shortage of mental health providers. The relatively low percentage of New York children who receive behavioral therapy likely is related to that shortage, said Hal Meyer, founder of the New York chapter of the national ADHD advocacy organization Children and Adults with Attention-Deficit/Hyperactivity Disorder. Rather than waiting months for appointments for therapies, Meyer said, parents are eager for the immediate help that medicines promise.

Because of the way Medicaid services are delivered and financed in New York, however, the CDC data probably did not capture all of the behavioral therapy in the state’s Medicaid program, according to an official from the state Office of Mental Health. The state has also taken steps, including the development and expansion of programs that link pediatricians with mental health professionals, to increase the amount of behavioral therapy for young children with ADHD, the official said.

At the other end of the spectrum, state officials say Maryland’s success in expanding access to behavioral therapy is the result of an aggressive approach by the state’s health and education departments, which began in the early 2000s when the state created a steering committee on better diagnosing and treating young children with mental illnesses. Since 2008, the state has provided training for mental health providers in ADHD behavioral therapy and made efforts to educate pediatricians about diagnosing and treating ADHD.

Overprescribing?

Other states are focusing on discouraging doctors from prescribing ADHD drugs to Medicaid patients.

The Medicaid programs in 16 states (Arizona, Arkansas, Florida, Idaho, Illinois, Maine, Massachusetts, Mississippi, Missouri, Nevada, New Hampshire, New York, Oregon, Utah, Virginia and West Virginia) won’t cover ADHD medication prescriptions unless the prescriber explains the need for medicine in the particular case. Louisiana and Nevada require doctors to confirm that they have rejected other treatable causes for the patient’s symptoms before prescribing ADHD drugs. And seven states (Arizona, Florida, Illinois, Louisiana, Massachusetts, Virginia and West Virginia) require physicians to confirm that they have considered treatment other than medicine, such as behavioral therapy, before Medicaid will cover ADHD drugs.

In recent years, most private insurers have also required doctors to receive permission from health plans before prescribing ADHD drugs for children.

One challenge in reducing the use of medication is that many parents of children with ADHD are desperate for the immediate help the drugs may provide. Behavioral therapy takes longer — and requires hard work on the part of parents.

“By the time a parent comes to meet with me, they are tired and worried about their child. They are concerned their child might jump down a flight of stairs, that the child could get lost in a grocery store, or that the child could be kicked out of preschool,” said Georgina Peacock, director of the CDC’s division of human development and disability.

CDC’s Schuchat acknowledged that behavioral therapy “just might not work for some parents. We think it’s a good investment of time, but we know that it may not be practical for every situation.”

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Some States Lag Behind on ADHD Therapy