Disorderly conduct, continued

by Kristen Lombardi

The boarder trend that's prompted some pediatricians and ER physicians to speak out may be especially disruptive to them, but it is just one of many problems in caring for mentally ill children. There are the lengthy wait lists -- some with hundreds of names on them -- for even basic things like case-management services. Strains in services are manifested when kids, like Fleishman's son, are simply sent home with medication. Or when they're placed in facilities outside the state, in psychiatric hospitals as far away as New York or Pennsylvania.

"It all represents the same problem," says Lisa Lambert of the Parents Professional Advocacy League (PAL), an advocacy group concerned with children's mental health. "The logjam is repeated every step of the way."

Perhaps the most tragic sign of the failed system is rooted in woefully insufficient "aftercare" services. David Mattioto, who heads the Massachusetts Association of Behavioral Health Systems (MABHS), which represents 28 psychiatric hospitals across the state, estimates that 50 to 70 youngsters who require acute care are denied help daily because an equal number of youngsters are "stuck" in short-term hospitals. The "stuck kids," many of whom are in the custody of the state Department of Social Services, have stabilized and are ready to move into long-term programs, such as residential treatment centers or foster homes.

"But there is nowhere for the stuck kids to go," Mattioto says. Take the case of one 10-year-old girl with psychosis, who could have been discharged from a short-term facility last August. Instead, she's languished in a locked mental ward all this time because there are no available aftercare placements. An eight-year-old girl with bipolar disorder has remained in the inpatient unit she first entered eight months ago, although psychiatrists tried to release her earlier this year. The bleak scenarios are confirmed by state statistics, which report that 82 kids were "stuck" as of last May -- compared to 16 kids in May 1998.

According to Northeastern University professor David Rochefort, who has researched mental-health care in Massachusetts, such events would not occur if the larger system were providing a "continuum of care," ranging from school-based interventions to outpatient programs to acute hospitals to residential homes. The fact that children fall through the cracks proves, as Rochefort says, that "the continuum is not comprehensive or of good quality."

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To be sure, Massachusetts isn't the only state lacking a comprehensive network to treat mentally ill children. Ever since Santucci of Yale-New Haven Children's Hospital published data on the boarder trend this year, she's received calls from pediatricians in Maine, Vermont, New York, Florida, and Minnesota, all of whom say they've seen sharp increases in the numbers of child psychiatric patients.

"This," Santucci says, "is a national epidemic."

And it's an epidemic with no easy explanation, though societal factors, such as the breakdown of families and the stresses of an ever-changing world, have surely contributed. In the wake of high-profile school shootings, experts say, adults have grown quick to spot possible signs of instability in young people. And even though psychiatrists know how to treat kids, there just aren't enough resources to do so. "It's especially sad," Mass General's Stoddard laments. "We have more treatments available but cannot provide them at the scale we need to."

But although the crisis in Massachusetts reflects a national pattern, it seems to be especially acute here. More children show up in the ERs here than elsewhere; they wait for services longer; they get stuck more often. Lambert has surveyed mental-health services nationwide and is convinced, she says, that "other states don't have the severity of problems."

The plight of stuck kids, in particular, has seemed dire enough to prompt unprecedented action. Last summer, the Massachusetts Psychiatric Society convened a first-ever statewide task force on child mental health, which consists of psychiatrists, social workers, state officials, and pediatricians. The group is now scrutinizing the systemic problems to muster consensus about solutions. At the urging of the state DMH, meanwhile, the Massachusetts Behavioral Health Partnership, a private company contracted by the state to manage $240 million per year in mental-health care for Medicaid beneficiaries, has increased acute psychiatric beds by 43 percent since April 1999, making for a total of 505 today.

Despite this attention, problems persist. "People feel like they're fighting an uphill battle," admits Karen Hacker, director of child and adolescent health for the Boston Public Health Commission. Things may not be at an all-time low, but, she says, "we are close to being at a place where we don't want to be."

The reasons things are so messed up in Massachusetts appear as complicated as the problems themselves. The mental-health system is a highly fragmented network that includes the state DMH as well as other youth-related agencies and community-based providers. Fragmentation makes it tough to address sweeping issues. Lambert, who sits on the psychiatric society's coalition, says, "You can fix one part of the system, but then have the rest of it to deal with."

Also, as Rochefort observes, mental-health care has remained "chronically underfunded." And this perpetual lack of investment has only intensified in an age of managed care and cost pressures. Though the price of medical care has climbed, reimbursement rates have stayed the same for eight years, leading to what's been described as "poor" compensation by private and public insurers. Inadequate reimbursements have forced both inpatient and outpatient programs to shut down statewide. Last April, for instance, Children's Hospital, which has one of the few inpatient psychiatric units left, threatened to close the unit in the face of sustained financial losses. Recently, the hospital announced it would cut all departments by 15 percent to compensate for the deficit.

Other programs for mentally ill children have disappeared altogether. There was the 1993 closing of the state-owned psychiatric hospital for children, the Gaebler Children's Center, followed by closings of dozens of state-operated treatment centers. Residential programs, in addition, have limited their availability by accepting out-of-state youngsters to fill 900 of the state's 3000 long-term beds -- partly because insurance rates elsewhere are higher, and partly because states such as Maine and New Hampshire have come to rely on Massachusetts for such services.

Dwindling resources are made even tighter by demographics. Massachusetts experienced something of a baby boom recently, which has boosted the adolescent population by 24 percent. More kids, naturally, means more kids with mental problems. The supply has yet to catch up with demand. And it's questionable whether the two can be matched, since the money spent on mental-health services nationwide has dropped 54 percent in 10 years. One national study reports that fewer than one-fifth of mentally ill youngsters get any treatment -- which, observers say, is a "travesty" that the general public tolerates.

Says Lambert: "The crisis reflects the stigma around mental illness. If a child needed dialysis or chemotherapy, it would never be all right for the child to wait."

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