Mentally ill children stuck in hospital limbo
Patients find long wait times for beds
By Carey Goldberg, Globe Staff | June 13, 2008

Parents and advocates report that in recent weeks across the state, at least a dozen children and teens in crisis - threatening violence to themselves or others - have waited three, five, even seven days in hospital emergency rooms or medical wards for psychiatric beds.

In some cases, they've been sent home to be monitored in hopes the danger would pass or a bed would open.
By all accounts, the state has made significant progress toward solving the problem of "stuck kids" - children with mental illness deemed well enough to leave hospital psychiatric units but stuck in them for lack of treatment programs outside.

But while it has gotten easier for children to leave the state's mental health facilities, which should make more beds available, it appears to have gotten harder, in some cases, to get in.

Mental illness among young people tends to be magnified every spring as end-of-year school pressures mount. But specialists say they are largely baffled about what lies behind the backlogs and sporadic reports of long waits this year.

"It doesn't make sense, what's going on," said David Matteodo, executive director of the Massachusetts Association of Behavioral Health Systems, which represents private psychiatric hospitals and wards. "The 'stuck kids' are down, and yet we're not seeing an easy flow."

No current statewide data are available on emergency room waits for psychiatric patients, officials say. But more than a dozen reports from parents of extra-long waits and turn-aways have come in this spring to the Parent/Professional Advocacy League, said Lisa Lambert, executive director of the group, which represents families with mentally ill children.

Gail Rowell of Reading said that her 18-year-old daughter, Kelly, waited a full week in Merrimack Valley Hospital's emergency room in March. Kelly has been diagnosed with bipolar disorder and developmental disabilities and has been hospitalized 18 times since she was 9 years old. But this wait "was at least double or triple what we'd seen before," Rowell said.

Children with difficult or multiple diagnoses are often especially hard to place. But "when you've got a kid in the emergency room for a week, that's just wrong," Rowell said. "It's outrageous."

Kelly has always had a hard time calming herself down, Rowell said, and the wait meant that, in her agitated state, she was stuck for days in a locked room with virtually nothing to do, adding to her suffering.

Asked about Kelly's experience, Diane Lovallo, chief nursing officer of Merrimack Valley Hospital, said she could not discuss a specific patient. But "there is definitely a placement issue for children with psychiatric issues because of the shortage of beds throughout the state," she said.

"Merrimack Valley Hospital works diligently to find appropriate placement for our patients," she said, "and we remain dedicated to assuring all medical and mental health needs are met while the patient is in our care."

Young people in psychiatric crisis are often brought to the emergency room to keep them safe, said Dr. Nancy Rappaport, director of school programs for the Cambridge Health Alliance. The irony is, she said, "you have them in an environment that can have its own trauma associated with it."

Younger and older patients are usually mixed in a psychiatric emergency room, Rappaport said, and a young person may be exposed to patients impaired by alcohol, confined in restraints, or in a psychotic state.

"That can be very scary for kids to see," she said.
Recent cases of long waits include a 7-year-old Millbury boy in such crisis that he was brought to the hospital in an ambulance, then had to wait four days for a bed in a psychiatric unit, and a 14-year-old boy from Winchendon who grew violent while riding in his mother's truck, Lambert said. When his mother drove him to the emergency room, she was told to take him home because he had calmed down and there were no psychiatric beds, Lambert added.

The problem is not lack of beds overall, said Matteodo; in fact, many psychiatric hospitals and wards have trouble filling beds and avoiding staff layoffs in the summer. "It's just in these peak times, it's almost as if an acute hospital had a flu epidemic," he said.

Other factors may also be at work, specialists say.
The economic downswing may be adding to the need for psychiatric help, said Kate Ginnis, associate director of emergency psychiatry at Children's Hospital Boston. Staff members at Children's have recently started seeing more depressed and suicidal children "where an enormous amount of their stress is caused by family economic woes," she said.

She also cited problems in the mental health system that lead patients to seek care in emergency departments because they cannot get it elsewhere. Also, she said, there is no coordinated system for allocating inpatient psychiatric beds, leaving emergency room staff to call around trying to find a free bed.

Rappaport believes that another factor at work is the "drastic drop" in the average time that children in crisis stay in the hospital, constrained largely by insurance companies. Children who would benefit from several weeks of hospitalization may be discharged within a few days, she said, and because they are still in deep distress, they may quickly end up back in the emergency room.

Overall, said Dr. Joseph Gold, chief medical officer at McLean Hospital, "a lot of good things are happening" in the state's mental health system for children. The number of children mired at various stages in the mental health system has dropped from 159 a year ago to 89 in March.

"Most of those things . . . probably are all helping to some extent," Gold said. "Otherwise it would be even worse."