As psychiatric beds disappear, teenagers fill ERs
Pandemic’s toll on adolescents brings renewed focus to the lack of treatment options for psychiatric patients younger than 18
In March, 13-year-old C. was living semi-permanently in the emergency room at Ellis Hospital in Schenectady.
The Niskayuna teen was not suicidal or homicidal enough to be admitted to the hospital’s pediatric psychiatric ward, but her destructive behavior had become too much for her parents to handle, according to her mother, whose first initial is J.
“She was not making safe decisions for herself and she wasn’t making safe decisions for others around her,” J. said. (The Times Union is using the girl’s middle initial and her mother’s first initial to protect their privacy.)
So C. waited ... and waited ... and waited for a bed to become available at a residential treatment facility anywhere in the state. After 40 days, she was released to her parents.
“She was in an acute setting, with all types of individuals coming in, seeing things that a child should not see,” J. said. “But it was the only option.”
The pandemic’s toll on adolescents’ mental health is bringing renewed focus to the lack of treatment options for psychiatric patients younger than 18.
Mental health facilities across
the state are chronically understaffed and, due to COVID-19, the labor pool has dried up. Local clinicians say they are sending kids in crisis as far as Syracuse and Rochester for treatment.
The shrinking availability of inpatient psychiatric beds for children and teens is putting a strain on the health care system and exposing more youth to the criminal justice system, advocates say.
Ellis Hospital, one of two inpatient adolescent mental health providers in the region, recently paused admissions for teenagers, citing safety concerns due to insufficient staff. Ellis President Paul Milton in an open letter last week wrote that the hospital is “firmly committed to our mental health programs.”
“Frankly, it’s been frustrating. The challenging situation we are in — as a health care provider, and together as a community — is related to the national health care staffing crisis,” Milton wrote. “This crisis wasn’t caused by COVID, but the ripple effects of the pandemic certainly complicate it.”
The other local facility, Four Winds Hospital in Saratoga Springs, is a private 88-bed facility that admits children with acute psychiatric needs.
Four Winds did not respond to requests for comment, but former patients say the waitlist at private hospitals can be months long and commercial insurance plans tend to restrict the length of stay.
Meanwhile, the region’s largest health care systems — Albany Medical Center and St. Peter’s Health Partners — are seeing scores of young patients in their emergency rooms. Since the facilities are not licensed to treat them, the teens may stay in the ER for days or weeks until they are stabilized or referred to a treatment facility, hospital officials said.
At Troy’s Samaritan Hospital, an affiliate of St. Peter’s, there are at least two youths sleeping in the emergency room on any given night, according to Rachel Handler, executive director of behavioral health for St. Peter’s.
“We have ... seen an increased volume in youth presentations for evaluation. This is a very pressing topic with a lot of advocacy, collaboration and support needed,” Handler said.
The crisis is also weighing on pediatric practices. John Southworth, a licensed mental health counselor who works at a primary care facility in Clifton Park, says he sees four to five adolescents a day, many of them struggling with suicidal ideation and self-harm.
“Right now I have no place to send them,” Southworth said.
‘They handled her like a criminal’
The kids who make it to the ER may be the lucky ones.
Police departments are often the first to respond to a home when a child or teenager is in distress. Despite investments in training, police officers are poorly equipped to deal with mental illness.
Too often in communities of color, the emotionally disturbed child ends up in handcuffs or in the back of a squad car, parents and advocates say. Numerous studies show that people of color do not receive the same level of access to care or quality of mental health care as white people.
During the pandemic, videos emerged of police apprehending inconsolable Black children — including in Rochester, Syracuse and Clifton Park. A spate of deadly interactions between police and mentally ill individuals also made national headlines, spurring calls for reform.
After Daniel Prude died in March 2020 following an encounter with Rochester police, Rochester mother Sara Taylor said she stopped involving the cops.
Taylor had watched her then-11-year-old daughter bounce between psychiatric facilities and hospitals for months without a clinical diagnosis or treatment plan. More than once her daughter was discharged from the hospital after one day with instructions to “talk to your caseworker,” according to Taylor.
A social worker herself, Taylor quit her job leading a nonprofit to focus on getting her daughter into long-term psychiatric care.
During a mental health episode in November of that year, it was her daughter who made the 911 call. Over Taylor’s objections, the officers handcuffed the daughter and put her in the police car until an ambulance arrived, according to Taylor.
“Yes, she was all over the place and deregulated, but ... they just handled her like a criminal,” Taylor said. “No one wants to see their child in handcuffs.”
Mobile crisis teams and community-based programs are meant to fill in the gap, providing an alternative to law enforcement and hospitalization, but those programs are grappling with the same staffing and capacity issues as psych wards, experts say.
C.’s violent rages began at age 9, shortly after she learned she was adopted, her mother said. Sometimes she would take her pain out on herself, poking her skin with needles and hiding the marks.
In searching for community-based treatment, the family encountered waitlist after waitlist, according to J.
C. spent the next few years in and out of hospitals and outpatient programs, but she didn’t seem to be getting better.
She was admitted to a stabilization program for teens, but a counselor advised J. that the program couldn’t meet her daughter’s needs.
At times, during a particularly destructive episode, police were called to the home, J. said.
For the most part, “authorities were wonderful with my daughter ... they were really trying to understand, but this is not their job,” she said.
A county children’s services worker finally advised the family that pressing criminal charges against their daughter could expedite the process and help C. get the intensive care she needed.
The court process did get C. into a residential treatment facility — there are designated psychiatric programs for children involved in the criminal justice system — but it also briefly landed her in a juvenile detention center, a brutal environment where she didn’t belong, her mother said.
“Now, she has not only this mental health profile, but now she’s in the juvenile justice system and our parental rights are in jeopardy,” J. said.
C.’s diagnoses include an inability to regulate emotional responses, anxiety and oppositional defiance disorder, but J. believes those serve as a placeholder until doctors can figure out what’s going on with her daughter.
“Our journey continues to this day,” J. said.
A shrinking industry
New York’s mental health crisis started long before COVID-19.
The state has been closing residential facilities since the 1960s reflecting a national deinstitutionalization trend in psychiatric care.
Previously, most people with mental illness or developmental disabilities in the United States were locked away in massive, overcrowded state-run asylums. In 1955, there were nearly 95,000 New Yorkers living in state-run facilities, records show. In 2018, about 2,200 adults resided at state-run psychiatric institutions.
While the facilities began as therapeutic, some quickly grew into hellish prisons. A journalistic report on dehumanizing conditions at Willowbrook State School for children with intellectual disabilities on Staten Island was published in 1972, prompting legislative and judicial action affirming the rights of people with disabilities.
A landmark 1999 U.S. Supreme Court decision, Olmstead v. L.C., mandated that people with mental disabilities receive care in the least-restrictive environments.
But New York, like most states, was criticized for failing to sufficiently invest in communitybased alternatives. Half a century later, the state’s mental health infrastructure is still fractured, leaving police and hospital emergency rooms to plug the gaps, advocates said.
“The downsizing of the children’s mental health system is happening without a plan and that’s contributing to the health crisis,” said Andrea Smyth, director of the New York State Coalition for Children’s Behavioral Health.
Nationally, the number of residential treatment facilities for people under the age of 18 dropped 30 percent, from 848 in 2012 to 592 in 2020, according to the most recent federal government survey.
On the state level, Gov. Andrew M. Cuomo in 2014 rolled out a Medicaid overhaul that included a plan to shutter about a third of New York’s staterun institutions for children and direct resources instead to “wrap-around” community-based services to reduce dependence on hospitals and in-patient
facilities, a joint investigation by ProPublica and The City found.
But there’s little evidence that communitybased programs have reduced hospital visits among Medicaid recipients. In fact, ER visits for mental health have soared, according to state data cited in the March report.
According to state Office of Mental Health records shared with the Times Union, there are more than 1,000 pediatric beds across 38 inpatient psychiatric centers in New York, 748 beds at private psychiatric facilities and hospitals and another 314 at state-run psychiatric centers.
There has only been one unit closure in the last five years, while new facilities have opened, agency spokesman James Plastiras said.
But the figures don’t account for staffing shortages. While most facilities remain open, just a fraction of pediatric beds are in use.
Ellis Hospital can only safely staff two of its 16 beds for adolescents, hospital officials said. Before the pause in admission, the Schenectady hospital was serving six or seven patients at a time.
Similarly, at the staterun Hutchings Psychiatric Center in Syracuse, just five of 23 available beds are usable, according to The City’s expose.
What’s next?
“We have ... seen an increased volume in youth presentations for evaluation. This is a very pressing topic with a lot of advocacy, collaboration and support needed.”
— Rachel Handler, executive director of behavioral health for St. Peter’s
The state in March announced a $21 million investment in a new program that would provide troubled adolescents with high-level psychiatric care at home, modeled after the Assertive Community Treatment program for adults.
Some 15 Youth ACT teams will provide young patients with a personalized array of medical, psychiatric and social services. The program will be up and running by July 1, according to state officials.
The nine-member team includes mental health professionals, a psychiatrist or psychiatric nurse, and a patient advocate. They would meet with the patient in the home on a rotating basis for six to 10 weeks and are available 24 hours a day.
Northern Rivers, a Capital Region-based social services agency, has been contracted to provide services for 36 youths in Albany and
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Schenectady counties.
“The Youth ACT is a high level of care in the community that’s meant to prevent youth from going into placement situations,” said Matt Crave, chief officer of crisis service at Northern Rivers.
The program will build on Northern Rivers’ existing behavioral health services in the six-county Capital Region, which includes a 14-bed stabilization center for 5- to 17-year-olds, longer-term residential schools, and a mobile crisis hotline.
One of the biggest challenges for crisis centers has been trying to educate the community about the various levels of intervention, said Jennifer Eslick, who oversees crisis services
at Northern Rivers.
“Many times, individuals who go to the crisis unit are discharged because they don’t meet the criteria for inpatient care,” she said.
The shortage of psychiatric beds preceded COVID-19, but the pandemic further stressed the system, Eslick said.
“The system needs more treatment,” Eslick said. “We need more inpatient beds, we need more outpatient clinics, we need bigger mobile crisis services ... there’s always been a higher need than is available; it’s just a little more challenging today.”
But it will be hard for organizations to build and sustain Youth ACT programs amid the staff shortage, advocates say.
To ease the hiring crisis. the state should enable licensed mental health counselors, family therapists, and licensed psychoanalysts to diagnose and develop treatment plans without the supervision of a psychiatrist or a licensed social worker, according to Smyth and members of her coalition.
“We are desperate to not have to use a clinical social worker to supervise licensed mental health counselors when the clinical social worker can be doing other things,” Smyth said.