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Hospital Emergency Departments Bearing Brunt Of Youth Mental Health Crisis

For Dr. Joeli Hettler, the symptoms kids are showing up with in her emergency room are not only extreme — they’re confusing.

“I have never seen so many kids come in with unusual complaints, like a body part that won't stop shaking, or a body part that they can no longer move,” said Hettler, chief of pediatric emergency at Baystate Medical Center in Springfield, Massachusetts.

Other odd symptoms include children who’ve stopped talking, unexplained bellyaches and headaches, and sleep problems of all sorts.

“And after a careful history and physical exam,” Hettler said, “it's pretty clear that their bodies are OK, but they're suffering because of emotional things happening in their lives.”

The causes are numerous: stress, social deprivation, a loss of relationships to coaches and teachers, a profound rupture in routine.

Some kids have proven remarkably resilient during the COVID-19 pandemic, while many others are suffering. In western Massachusetts, a surge in kids needing acute psychiatric care has meant many of them are ending up in hospital emergency rooms.

'It gets pretty intense'

Health professionals aren’t the only ones witnessing a surge of kids in emergency rooms

“I've never seen it as bad as I did most recently back in November,” Nicole Desnoyers said. “When my son was boarding in the hospital for a week, there were over nine kids that were waiting for a placement in that one facility, and three or four of them had to sleep in a hallway because there was nowhere to put them.”

Desnoyers said she’s been bringing her son Ja-Seir, 11, to the emergency room for crisis care since he was 5. 

While Desnoyers and I spoke outside their home in Springfield, Ja-Seir grabbed a bike and rode around with his younger sister. He is a sweet, loving, exuberant kid with a complex presentation and multiple diagnoses.

Desnoyers said he can become physically and verbally aggressive — a risk to himself and the people around him. His treatments have included acute and partial hospitalization and community-based outpatient care.

“It gets pretty intense,” she said. “He's been in every type of program that you can think of in the mental health system. He's experienced it.”

Ja-Seir returned home from long-term care at a residential program last summer, but Desnoyers said the new pandemic normal — stuck at home, socially distanced from other kids — didn’t sit well with him.

“He did end up getting hospitalized again for about two months,” she said. “So he's been home since November, and we've been on the up-and-up for the most part, I can say.”

Ja-Seir loves reading manga and comic books, and he said he loves going to school — but remote school didn’t work for him.

“I can't hug [my teachers]. It's like talking to a computer instead of talking to really them,” he said. “I feel antsy, and if I’m at school, I could just say, ‘I need a break,’ and walk away. But in virtual [school], they’re like, ‘Where are you going? Where are you going?’”

After returning from his most recent hospital placement, Ja-Seir attended an in-person therapeutic school in Holyoke. His spot at the school was funded by Springfield Public Schools. It was an out-of-district placement his mom said she fought for.

'I'm alarmed'

Last week, Ja-Seir returned to his neighborhood school for the first time in over a year. His experience brings into sharp relief a fact that many families, doctors and educators are discovering: School and youth mental health are profoundly connected.

“There's this unspoken social contract between our schools and society that in addition to teaching, schools will serve all sorts of other roles for our kids,” Baystate’s Hettler said. “In addition to reliably meeting physiologic and safety needs for our kids, our schools also nurture our needs for love, belonging and self-esteem.”

Dr. Joeli Hettler is chief of pediatric emergency at Baystate Medical Center. Her department currently has a record number of children and teens awaiting inpatient placement for mental and behavioral health issues.
Credit Ben James / NEPM
Dr. Joeli Hettler is chief of pediatric emergency at Baystate Medical Center. Her department currently has a record number of children and teens awaiting inpatient placement for mental and behavioral health issues.

While overburdened teachers and administrators have scrambled to provide academic instruction this year, schools operating remotely have struggled to take on a more basic question: Are kids OK? 

“I'm alarmed,” said Ellie Du Toit, Mobile Crisis Intervention Coordinator for Behavioral Health Network. “I'm alarmed by the severity of what we're seeing amongst children.”

It’s Du Toit’s job to find clinical support and hospital placement for kids facing mental health emergencies in parts of Hampden and Hampshire counties. She said foremost among her concerns are the high number of youth overdoses and serious suicide attempts.

A recent national study from FAIR Health (PDF) compared the past year’s private insurance claims for specific pediatric mental health issues to claims made before the onset of the pandemic.

The findings were sobering. The percentage of claims for overdose and substance abuse disorders rose significantly. Incidents of self-harm were up even more dramatically, especially in the Northeast.

“The severity and the extent of the depression is worse than I ever have remembered seeing it for our kids,” Du Toit said.

Waiting weeks for a placement

For many children, this is their first time experiencing severe mental health issues. They and their families are suddenly coming up against one of the most brutal limitations in the mental health care system: the long-term shortage of hospital beds for kids needing acute psychiatric care.

Some beds are scheduled to become available in the coming weeks, but there are currently no psychiatric hospitals serving kids in western Massachusetts.

This is old news to Desnoyers, who’s been forced to send Ja-Seir across the state multiple times, making visitation extremely difficult even before the pandemic.

Standing outside their house, Desnoyers asked her 11-year-old son a question.

“When you have a hard time, and you have to go to the hospital,” she said to him, “what is it like for you when you have to go to, like, Worcester and Westborough, and be very far away?”

“It makes me feel frustrated,” Ja-Seir said. “And I'm gonna be honest — pissed. Because, you know, it's just annoying.”

The shortage of beds is a key factor leading to the pileup of youth cases in emergency rooms.

Baystate’s Hettler said the long boarding times are a real problem.

“The ED is a terrible place for a child who's in crisis to spend any amount of extended time,” she said.

In February, Behavioral Health Network had a total of 30 children and teens waiting for placement, the vast majority boarding at Hettler’s emergency department in Springfield. Thirteen of those kids waited more than a week for placement. Four were waiting more than three weeks.

Du Toit said many of these kids' boarding times at the ER lasted longer than the time they eventually ended up spending in the psychiatric hospital where they were sent.

“Our top longest border or child waiting for a bed waited for 36 days, and that was over a week longer than our next longest border. And that person was identified as transgender,” Du Toit said.

Transgender youth have faced increased mental health challenges during the pandemic. Du Toit said one reason for the long boarding times is that psychiatric facilities often choose to place transgender youth in single rooms, even if the patient has made it clear they are fine having a roommate.

'A welcome-back party'

Meanwhile, the effects of the pandemic accrue. Baystate said it currently has a record number of kids awaiting inpatient placement.

Hettler recounted a story about one kid who really did not want to be there.

“He struggled with us,” Hettler said. “He had been with us for a couple of weeks. He was a big kid. And he finally got a placement somewhere, and we said goodbye.”

All as it should be — except that within hours, staff learned there’d been a mistake: The placement had fallen through. They received a 15-minute warning that the teenager would be coming back. Hettler and other staff were asked whether they wanted security guards to be present.

They said no.

One staff member ran and bought some balloons from the hospital gift shop. Other staff made signs. They grabbed some hospital cookies.

“And we had a big cheering crowd,” Hettler said. “And he showed up, and what could have been a difficult transition and need for security intervention turned into a welcome back party.”

An emergency department in the throes of a pandemic takes on this most pressing challenge: helping a kid feel like he belongs.

The National Suicide Prevention Lifeline can be reached by calling 1-800-273-8255 or visiting suicidepreventionlifeline.org.

This is the first report in a three-part series about the challenges faced by families seeking mental health care for children and adolescents in western Massachusetts. Read part 2 here, and read part 3 here.

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