Disorderly conduct

Mental-health services for troubled children are so bad in Massachusetts that ER physicians and pediatricians have started speaking out. Will their attention push the state to commit the needed resources?

by Kristen Lombardi

In many ways, Barbara Fleishman knew it was coming. For days, the Metrowest mother of three had noticed that her teenage son, who suffers from bipolar disorder, an illness characterized by wild mood swings, was growing more and more irritable. He got angry if his medication caused nagging side effects, if his mother cut his requests short with "No," if his siblings glanced at him the wrong way.

"Everything was bothering him,"
recalls Fleishman, who asked that her hometown and real name not be published to protect the privacy of her children.

But when she received a call informing her that her son had been rushed to the emergency department at Metrowest Medical Center in Framingham after a frightening outburst at school -- during which he threw a chair at a counselor, punched a hole in the wall, and then fled -- Fleishman couldn't contain her distress. "I knew," she says, "the ER meant it was going to be a long haul."

Indeed. By the time a psychiatric evaluator arrived at the hospital, Fleishman and her son had spent more than six hours in a tiny, austere room featuring a gurney, splashes of dried blood, and a security guard who shielded the door. Although the evaluator decided the boy needed hospitalization, there were no open beds. And so Fleishman was sent home with her son and some extra medication.

"It's the waiting game," she says with a sigh. "It's a disgrace."

The waiting game, as Fleishman wryly puts it, is nothing new for parents whose children have mental, emotional, or behavioral problems. Overbooked hospital psychiatric units for youths under 18 first made headlines in June 1999, when newspapers got hold of a memorandum by Marylou Sudders, commissioner of the Massachusetts Department of Mental Health (DMH), in which she warned that the demand for acute psychiatric beds had reached "near crisis proportions." Just last month, a Boston Globe article reported that little has changed when it comes to the profound need for beds and a host of other problems plaguing the fractious, multi-level state mental-health system.

What has changed in the past year, however, is that pediatricians and ER physicians are sounding the alarm over what they call the "collapsing" and "broken" network for treating the state's most vulnerable, least visible children. Though these doctors are no strangers to advocacy, they've taken the unusual step of criticizing a system outside their domain, thereby forming new alliances with parents, patient advocates, and mental-health workers who have long fought to improve mental-health care. For the doctors, their action isn't simply a matter of professional duty to sick kids; it's also a matter of necessity. After all, an unparalleled number of the approximately 69,000 Massachusetts youngsters with mental disorders keep appearing by default before them.

According to the US Center for Mental Health Services, about 20 percent of American youth now require mental-health services: five percent of those have a condition serious enough to handicap them. And more and more troubled kids -- kids who beat their siblings, threaten parents with knives, and strangle family pets -- are winding up in hospital emergency and pediatric departments. Once there, they tend to wait for hours, often more than a day, for an available bed in a psychiatric ward. Mark Pearlmutter, who heads emergency services at St. Elizabeth's Hospital in Brighton, says, "When you come into ER the next day and see the same child, you know there's a major problem."

All this inspires a sense of urgency among ER doctors, who have come to realize what those in the mental-health community have long known: tragic things can happen when troubled kids are ignored. Without proper treatment, such children may end up committing crimes, falling into drug abuse, and perhaps even passing on their problems to another generation. In the words of Walter Harrison, a pediatrician at the Salem-based North Shore Medical Center: "The situation is scary. I don't want to see another Columbine in Massachusetts."

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In the mid 1990s, pediatricians and ER physicians began to notice a steady stream of children with mental, emotional, and behavioral problems -- some of them as young as three -- among all those with gashes, broken bones, and infectious diseases that doctors were used to treating. Children have been so disturbed that they've put their pets in microwaves, pushed their mothers down staircases, or cut themselves with glass shards.

Since 1996, for example, Boston Medical Center has seen a 55 percent increase in the number of such children; 60 or so child psychiatric patients per month appear today. Most remain in the pediatric emergency department long after other patients have left. And half of them are then transported to the general pediatric ward, where they will wait as many as 10 days for an open bed in a psychiatric hospital.

The increase in the number of "boarders," as these children in limbo are called, prompted BMC pediatrician Joshua Sharfstein to take a closer look. Sharfstein discovered that from January to May 1999, one-third of the 167 child psychiatric patients arriving at BMC had to be admitted to its pediatric floor. He then tracked 10 children -- including teenagers who had choked their mothers, swallowed too many diet pills, or warned relatives of a desire to kill. Not only did these teens linger in the pediatric ward for up to three days, but they didn't receive the critical services that psychiatric hospitals would provide, such as group therapy, psychological testing, and behavioral planning.

The Sharfstein study, presented in May at a national conference for pediatricians in Boston, marks the first effort to quantify what anecdotal evidence has made clear in virtually every hospital in the state. Pat O'Malley, who heads Mass General's pediatric emergency department, finds many child psychiatric cases far more "heartbreaking" than even the bloodiest gunshot wound. She still remembers the time a three-year-old boy arrived at the ER after setting fire to his mother's couch. It was soon discovered that the child, who suffered minor burns, had developed a fire fixation after sexual abuse at the hands of an older boy. The three-year-old languished in the ER for nearly 24 hours before being hospitalized.

"He was a reasonably distressing case," O'Malley recalls, "and just one of the children caught in the medical loop."

This problem extends beyond Massachusetts as well. Karen Santucci, who directs the pediatric emergency department at Yale-New Haven Children's Hospital in Connecticut, was stunned to learn that the number of troubled youths appearing at the ER there has soared 59 percent since 1995 -- far exceeding the increase in children with such diagnoses as cancer, diabetes, and even the urban scourge, asthma. "I thought that was pretty staggering," she says.

But the situation became even more staggering this past April, when Santucci found herself trying to resuscitate a physically healthy 11-year-old boy who had been depressed enough to hang himself. That Santucci could not save the boy -- a husky kid with a mouth full of braces and a lifetime ahead of him -- has left an indelible impression. "There is a sense of helplessness," she says, "and we are banging our heads over it."

Even when troubled children are saved, the consequences of boarding them can be grave. These youngsters must displace others in the pediatric ward -- children with chronic diseases such as leukemia. That, in turn, disrupts routine hospital operations and stretches staff resources. Child psychiatric patients then find themselves in inappropriate settings with pediatricians who may be adept at treating physical ailments, but not mental illnesses. Most are watched round-the-clock by guards to prevent escape and self-inflicted injury; sometimes, especially violent kids are restrained.

The situation, in short, is a recipe for bad health care. As Karen Norberg, a child psychiatrist at BMC, explains, "We are postponing help for these children." And by delaying treatment, she adds, "you lose a certain momentum, a certain opportunity."

Still, pediatric floors, however unsuitable, are at least safe, comfortable places in which to house child psychiatric patients. Emergency rooms, on the other hand, offer a grim environment. Harried providers rush around tending to people who've fallen out of trees, crashed cars, or suffered seizures. The cacophony of sirens and shouts rarely fades. "These children witness things that would never happen in a psychiatric facility," says Fred Stoddard, a child psychiatrist at Mass General. "This exposure can trigger their own traumas."

Sigmund Kharasch, the medical director of BMC's pediatric emergency department, cannot forget the time an eight-year-old boy showed up at the ER with such severe depression that he'd stopped eating. Waiting for a psychiatric bed, the boy watched while a near-dead baby was brought into the ER. Kharasch and colleagues tried to resuscitate the baby, to no avail. "In full view of the boy," he recalls, "family members started crying." The grief-filled scene led the boy to sob and lash out so uncontrollably that he had to be tied down.

Such situations have left pediatricians deeply frustrated because they cannot do the very thing that doctors are supposed to do: treat patients. "Here," Kharasch says, "our hands are tied with these children. We cannot help them."

In the face of what one pediatrician calls this "overwhelming and scary" trend, doctors have called public attention to the Sharfstein study, among others. They have reached out to state officials through forums and letters. Robert Vinci, the vice-chair of pediatrics at BMC, says that pediatricians across the city are now committing to a fight.

"Someone has to wake up and recognize that we're doing these kids a disservice," Vinci says. "We're trying to make noise and do what we can to advocate for change."

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Kristen Lombardi can be reached at klombardi[a]phx.com.