Critics say Children's Healthcare should do more to fill gaps in mental health system
- Source: Atlanta Journal Constitution
- Date: October 13, 2022
- Firm: Penn Law Group
By: Carrie Teegardin, AJC
Children’s Healthcare of Atlanta is building a $1.5 billion, “state of the art” hospital that is rising into the city’s skyline, offering a promise to the youngest Georgians.
“Our vision for the new campus is nothing short of transformative pediatric care —for every patient we see,” the healthcare system says on its website.
Yet some children facing life-threatening conditions won’t be able to get their course of treatment at the new hospital: those who need inpatient care due to a serious mental health diagnosis, an Atlanta Journal-Constitution investigation has found.
Even as its hospitals have seen dramatic increases in the number of children brought to its ERs with mental health crises, Children’s said it determined through careful study that it wasn’t feasible or even wise to try to build an inpatient psychiatric unit.
“We think kids are better served through the specialized psychiatric expertise that is found in many of the facilities across our state, and we work closely with those facilities,” said Dr. Daniel Salinas, the chief community clinical integration officer for Children’s.
Doctors and nurses in the system’s ERs evaluate the children. Some children are sent home from the ER with treatment plans. But those who are seriously ill are held in the ER until beds can be found at psychiatric hospitals for inpatient care. Those deemed most at risk are transferred through involuntary commitment orders, called a 1013, where the child’s parent cannot block the admission or even be assured their child won’t be hospitalized hours away.
That has led some of those working to improve mental health care in Georgia to question why Children’s — an extraordinarily wealthy system with billions of dollars in reserves — isn’t doing more.
With suicide now a leading cause of death for young people and the nation’s leading pediatrics organizations declaring a national “state of emergency” in children’s mental health, pediatric hospitals in many other states are expanding their mental health units or constructing new hospitals devoted entirely to behavioral health.
Rep. Mary Margaret Oliver, D-Decatur, who co-sponsored the wide-ranging mental health parity legislation that became state law this year, said that for 10 years she has urged Children’s Healthcare of Atlanta to do that.
“There’s no question that CHOA is the state’s premier children’s hospital,” Oliver said. “They’re going to save the life of your child who may have cancer or a nightmare of a congenital heart defect. And there’s no question that people all over Georgia will bring their very sick child to CHOA,” Oliver said.
“But that does not mean that they’re serving children with intensive psychiatric needs. . . . I want them to do more, and there are many other people in Georgia that want them to do more for the children who are in crisis, based on mental illness.”
‘High utilizers’ a focus
After Gov. Brian Kemp signed the mental health parity bill into law in April, a commission of experts and lawmakers quickly got back to work, saying much more needed to be done to fix the state’s broken mental health system.
In June, Salinas, of Children’s Healthcare, spoke to the commission to share observations Children’s had about dysfunction in the system.
“Over the last 18 months, the number of kids presenting to Children’s ERs in crisis with a primary mental behavioral health condition has started to really, really go up and those that we have to place under 1013 [involuntary] commitment has gone up dramatically,” he said.
While the AJC found that children in crisis in Georgia often wait hours, even days, for a bed in a psychiatric hospital, Salinas told the experts that Georgia has had enough inpatient mental health beds to meet the demands for most children. However, the rising needs and staffing shortages, he said, are creating challenges.
He also acknowledged that it can be difficult for some children to get inpatient care these days, especially children whose mental illness may be combined with autism or an intellectual disability.
But Salinas was focused on another point: a group of children who visit Children’s ERs extremely frequently.
Children’s studied 68 patients in 2020 who, as a group, accounted for 392 visits to a Children’s ER.
Trauma was common among the patients, with sexual and physical abuse. All had been to inpatient psychiatric facilities at least 10 times. Three in four had suicidal ideation. Many had been in foster care or group homes. They spent an average of 10 hours at a Children’s Healthcare hospital for each ER visit, Salinas said, compared to 2.5 hours in the ER for “regular” patients.
The cases multiply among older children, with dozens of suicide deaths of teenagers across Georgia. Many turned to guns to end lives that had barely started. Others used pills, ropes — even a dog leash attached to a clothing rod.
Suicide is now a leading cause of death for children and teens. Last year 118 children and teens between the ages of 10 and 19 took their own lives, according to preliminary figures from the Georgia Department of Public Health’s violent death reporting system. That doesn’t include the death of the 8-year-old. In 2020, 100 young people died from suicide; in 2019, 88 died.
Deaths by suicide among young Georgians more than doubled between 2010 and 2020.
In rural Polk County in Northwest Georgia last year, four teenagers died by suicide.
A 16-year-old girl hanged herself in the middle of the night. A 17-year-old boy who had been reported missing was found days later hanging from a tree in a wooded area. Two other boys, ages 17 and 15, died after shooting themselves at home.
School officials in the county of 43,000 said it has been hard to find mental health care for children. Those who became suicidal were sent to psychiatric hospitals in Atlanta, more than an hour from home. Often, those experiences weren’t good, and follow-up care wasn’t always available, they said.
“The system is broken,” said Lacey Tuck, who coordinates services for the Polk County School District.
It is not just a rural problem, said Dr. Katherine M. Thomas, the district’s superintendent. “The need is everywhere,” she said.
A Georgia Bureau of Investigation review of suicide deaths among children under age 18 between 2016 and 2020 found that less than half of the children who died — 44% — had received mental health services at some point. Only about one in four who died were currently in treatment.
The state must do more to provide the services children need, Thomas said.
“As a state,” she said, “we have got to say it’s a problem, it’s a problem that we recognize and we’re willing to fund.”
Rural district takes action
Her school district couldn’t wait for that to happen. “The way we look at it, these are our kids,” Thomas said.
Students at the county’s two high schools endured the multiple suicides as well as the deaths of several students in accidents. “The kids were traumatized,” said Norman Smith, coroner.
Those who were in 11th grade also had lost a peer back in 7th grade when a 12-year-old Polk County girl live-streamed her suicide. The video of her hanging death was viewed across the country.
Polk school officials wanted every child who might be suffering to have easy access to help. But school counselors who focus on academic schedules and college plans aren’t trained to handle serious mental health issues.
So the district hired five licensed therapists and is currently seeking a sixth. Anyone can make an appointment – even teachers. It’s free and students just need a parent’s consent.
“We told our board and our community, we can act like it doesn’t exist or we can do something about it, and we chose to do something about it,” the superintendent said.
The district, which has 10 schools, now has an average of 350 students seeing therapists at any given time. Depression and anxiety are common, and there’s grief too, officials said.
Knowing that some children might not opt for therapy, the district launched community-wide messaging campaigns, with signs posted everywhere from school hallways to fast-food restaurant signs, telling students over and over: “You Matter " and “You Belong Here.”
It also brought mental health activities and suicide prevention events inside its schools in ways that touch everyone and normalize talking about mental health.
That’s another challenge throughout the state.
GBI found in its review of suicides among young people that there was a warning sign in only about a third of deaths: The child had talked about suicide.
The others who took their own lives hadn’t let on about any struggles.
Two sons lost
Michelle Cleveland’s 18-year-old son, Thomas, is one who never showed obvious signs of a serious mental health crisis. Yet in 2016, he shot himself in the kitchen of their home in Alpharetta.
Cleveland said his journals, discovered after he died, revealed he was struggling. But he kept his issues hidden to the point that his family didn’t pick up on any signs.
“We didn’t know,” Cleveland said. “We didn’t get him the help he needed.”
Less than a month after Thomas’ death, Cleveland got a call from a hospital in Athens about Thomas’ older brother, Nicholas, saying he had just been brought in.
“It doesn’t look good. You better hurry,” the hospital told her.
Nicholas had attempted suicide, too.
Unlike his brother, Nicholas had a long history of serious mental health issues and prior hospitalizations, dating to his high school years.
He went to a hospital ER with suicidal thoughts and shared that his brother had recently died by suicide, records show.
A doctor ordered an involuntary transfer to a local Crisis Stabilization Unit, which is part of the state’s system of psychiatric care to provide short-term treatment, often when someone is at risk of suicide.
Records show he was seen by nurses but never evaluated by a psychiatrist. Two days later, he was hearing voices, records show, but a nurse assessed him as better and arranged for his discharge.
“As a state, we have got to say it's a problem, it's a problem that we recognize and we're willing to fund."
Nicholas was transported to a homeless shelter, which was full when he got there, and his family wasn’t notified. That night, he jumped from a high parking deck and landed on a fence. He died two days later.
“It’s been six years now, and everything we do is colored by it,” his mother said. “Every choice we make, it’s somehow touched by what happened.”
For those left behind, the loss goes beyond devastation, Cleveland said. The best comparison, she said, is a nuclear bomb that leaves people suffering well beyond the initial explosion. “The fallout continues, and after the fallout it’s in the ground, and it continues to poison your life for decades if not forever,” she said
Cleveland said people frequently reach out to her for guidance as they try to find services for their own children who are in the midst of crisis. “They’re desperate. There’s not enough help. They don’t know what to do,” she said.
She said families need better information, especially when it comes to involuntary commitments, and she said the state needs more qualified mental health professionals, including those providing basic care inside psychiatric facilities. Plus, she said decisions about care should be based on what patients need, not on the bottom lines of the hospitals.
Cleveland said she tries to help, too, by being present with those who have lost their children and demonstrating resiliency. But even years in, Cleveland knows she is still finding her way.
“I have been living with it,” she said. “Now it’s time to figure out how to really live with it and come to terms with it.”
If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org.
