Children With Psychiatric Needs Are Overwhelming Hospital Emergency Departments In Connecticut
The night before 11-year-old Ella was admitted to Connecticut Children’s Medical Center in early May, her father Sean thought his daughter’s mood seemed “wonderful.”
Ella had been diagnosed with depression and anxiety, and their nightly strolls, which helped her relax before bed, were a chance to reflect on the day and talk to her parents about how she was feeling.
“She was bubbly. She was talking about her animals — she recently got a fish she loves, and we have cats and a dog,” Sean said. “So it was a really pleasant, positive seeming, really encouraging walk.”
But the following day, Ella was caught trying to stick a sharp object into an electrical socket at school. When confronted by a nurse and counselor, the 11-year-old responded, “I just want to die,” her father said. The CT Mirror is withholding Ella and Sean’s last names at the family’s request to protect the child’s privacy.
“They called 211 because of the suicidal intentions that she declared, and apparently she told them that she had been feeling increasingly suicidal over the past month,” Sean said. “It was very hard to hear.”
Ella was taken by ambulance to Connecticut Children’s Medical Center in Hartford, where she waited with other children in a crowded hallway of the emergency department for about four hours before she could be moved to a room in the unit. She waited there six days, with a psychologist coming in every day to check on her, before a bed opened up at Hartford HealthCare’s Institute of Living.
Ella’s experience is emblematic of what is happening around the state. As the pandemic has dragged into its second year, health care providers are reporting a growing crisis in children’s behavioral health care. Increasing numbers of school-aged children are showing up at Connecticut emergency departments — many of them suicidal, out of control, or with hard-to-treat eating disorders — leading to an overflow of young patients in emergency departments with limited bed space and a long wait for inpatient or community-based care elsewhere, hospital officials said.
“The whole time that Ella was at CCMC, she was confined to a windowless, former exam room,” Sean said, adding that his wife overheard other children talking about also being stuck in the emergency department. “Typically a kid will spend a little bit of time in there while they’re getting checked, and then they just threw a stretcher in there, and she was stuck there for six days. It exacerbated her depression and anxiety.”
Dr. Steven Rogers, emergency department physician and medical director of emergency behavioral health services at Connecticut Children’s, said the circumstances in the hospital’s emergency department have been hard for everyone.
“We’re struggling to try to manage kids in the best way we possibly can and, first and foremost, keep them safe,” Rogers said, adding that sometimes that results in long wait times.
Throughout the month of April, more than 30 children with psychiatric needs waited in Connecticut Children’s 48-bed emergency department on any given day. By the end of the month, that number increased to an average of 40 children showing up in the hospital’s emergency department on any given day, the highest day registering at 47, hospital officials said.
This surge represents a steep increase since the pandemic started, said Dr. Jennifer Downs, a pediatric psychiatrist at Connecticut Children’s.
“Last year, we would have never imagined anything in the 40s, certainly not a sustained number of days in the 40s,” said Downs. “We’re definitely continuing to see the crisis unfold in front of us.”
This surge isn’t unique to one Connecticut hospital.
At Yale New Haven Children’s Hospital’s emergency department, 15% to 20% of its patient volume is related to behavioral health. Hospital officials say that while emergency department visits overall have declined, the number of children who are awaiting inpatient beds for psychiatric care has increased exponentially during the pandemic.
For example, in March, the pediatric emergency department at Yale New Haven Children’s Hospital saw an average of 12 patients daily for behavioral health care. That increased to 26 children on any given day in the facility’s 25-bed emergency department at the beginning of May, according to a Yale New Haven spokesperson.
In comparison, the hospital saw one or two patients daily with behavioral health needs in 2019.
From October 2020 through April 2021, the hospital provided 24,000 hours of care to behavioral health patients in the pediatric emergency department, a sizable difference compared to the 9,500 hours of care provided from January to September of 2020.
“We are lucky to have close to 50 inpatient behavioral beds, but we have exceeded the capacity daily,” said Dr. Lawrence Siew, interim medical director for the emergency department at Yale New Haven Children’s Hospital.
Downs explained that April is usually the time of the year when hospitals see high volumes of kids coming in with behavioral health issues since it’s the end of the school year.
But she doesn’t anticipate any relief until schools let out for the summer.
“I’m really hopeful that we’ll stick to that trend, although everything has been kind of distorted post-pandemic, and I’m not sure we’ll follow the normal seasonal trends exactly,” Downs said. “We’ll probably still be higher than a traditional summer, although I’m hoping lower than we are now in terms of our volume of kids needing support.”
More acute illnesses
Both Connecticut Children’s and Yale New Haven are not only caring for more children with behavioral health problems in their emergency departments, but each facility is also seeing a high volume of patients over the last several months with more acute illnesses.
“Our most frequent diagnoses in the emergency department would be kids with suicide [risk] or kids with aggressive episodes where they’re in danger of harming others,” Downs said, adding that the intensity of their symptoms are “much greater than is typical.”
“Instead of seeing kids who are saying, ‘I’m thinking about suicide,’ we’re seeing kids who have had attempts,” she added. “Instead of seeing kids who are maybe brought in because of parents who feel that they’re verbally out of control, yelling, screaming, saying awful things, we’re seeing kids who are having physical aggression.”
Within the past year, the hospital has also seen an increase in the number of children with eating disorders, Downs said.
“We used to have maybe one or two kids at a time in the hospital with this concern. Now it’s not uncommon to have five or six kids in the hospital with this concern at any given time,” Downs said. “This pandemic has really affected children.”
Yale New Haven saw its highest peak in acuity in March, with more than 42% of the patients screened at high risk for suicide, which is higher than the average of 16% to 20% of patients they screened a year ago.
“The patients who come in wanting to hurt themselves — so not even just having thoughts of hurting themselves but actually you know potentially harming themselves — seems like it’s higher,” said Siew of Yale New Haven Children’s Hospital. “I wouldn’t say completion, but rather really the acuity of their disease, of their mental health disease, is more severe than I’ve ever seen it before.”
At the same time the hospitals are treating more children who need specialized care or with significant medical complexities, Downs said it’s now harder to get them the support they need — which is why so many of these patients are in a holding pattern in hospital emergency departments.
For example, children who are diagnosed with eating disorders need to have their nutrition monitored, which includes knowing how many calories they consume at every meal, making sure the food makes it into their body, weighing them daily and ordering periodic lab work to make sure they’re getting enough electrolytes.
“It often requires us to have a nutritionist on staff, so those kids are very hard to get care for. It’s just another super-specialized type of care with not a lot of options in the state,” Downs said.
The pandemic has not only resulted in more children seeking treatment but has created two distinct camps of anxiety for kids — those who had difficulty with the social isolation of online learning and those who are dreading a return to in-person education.
“They’ve gotten used to this more isolated type of life. They’re getting very anxious about what it will be like to reintegrate to society, to go back to [their] old life,” said Downs. “We’re seeing both ends of the spectrum. There are kids who have really struggled with the shutdown and kids who have actually been struggling with going back.”
Across the board, however, children were affected by the lack of structure the pandemic created when schools and activities shut down and have experienced a range of loss — lost friendships and losses from COVID itself if family members or friends died during the pandemic, experts said. This has resulted in anxiety and depression that can be difficult to get under control.
Sean’s family knows all about that.
Although Sean and his wife believed Ella was doing better when she returned home from the Institute of Living, she was back in the hospital a week later — this time joined by an older sister who also struggles with depression and anxiety.
This past Saturday, Ella and Lily, 13, were rushed to Charlotte Hungerford Hospital in Torrington because they were both trying to harm themselves, Sean said. The girls spent the night in separate rooms, while Sean and his wife split their time between them.
The girls were released the next day after hospital staff determined they didn’t require in-patient care, Sean said, but when they tried to send the girls back to school on Monday, it didn’t go well. Both girls had “episodes,” and Lily ran away from school with a friend. By Monday afternoon, both girls were back in the emergency department at Charlotte Hungerford, but only Lily was being kept for observation until she could be transferred to an inpatient program.
Sean is worried and frustrated.
“If you have mental illness, it’s not your fault. But the way that the health care industry is structured right now, it really feels like it is,” he said. “It feels so horrifically unbalanced that in the span of three hours, Lily was able to slip and break a bone, go to the emergency room, have an X-ray, have multiple people check her out, treat her correctly, mend her and send her on her way. But the experience that we have with kids’ mental health care is they basically stick them in a room for however long and then either they let them out, or they send us to another place. I don’t have the answers. It seems like there needs to be a reexamination of the bottom line: How much resources goes to mental health care?”
“It really does feel to the patients, and the patients’ families, that you find yourself stuck on a turntable, hoping that the song ends and unsure if it’s going to be a weekend, an overnight, weeks, or months or years.”
‘We’re just seeing this whole systemic backup.’
Pediatric patients at both Connecticut Children’s and Yale New Haven are waiting in the emergency department for several days — an average of seven days at Connecticut Children’s in April, hospital officials said.
Hospital officials explained that most of the wait is due to other facilities and programs that normally handle children with these needs in the communities being overwhelmed.
“A lot of times, the care that we’re recommending just doesn’t have openings available. It’ll be several weeks’ wait until they have the capacity to take on a new patient,” Downs said, adding that providers must then decide whether it’s safe to discharge a patient to wait at home for the treatment they need or if they should stay in the emergency department until a program opens up.
“We really try to just figure out any patchwork plan we can put together to bridge these kids to the care that we think they really truly need to make it out of their crisis, and sometimes we can find that more quickly than others,” Downs said. “So sometimes that holds a kid in an emergency department for an additional 24 to 48 hours while we’re trying to put together a plan, because the resources just aren’t readily available, and we don’t want to send them out in an unsafe manner.”
Yale New Haven officials said they are seeing the same scenario at their hospital.
“Pre-pandemic, there were times when we would have some behavioral health patients that would require probably an overnight stay or maybe two nights as a bed was waiting to be opened up,” Siew said. “But rather now … patients who are actually in the psychiatric hospitals are staying longer because they’re sicker.”
But hospitalization is not a good outcome, said Dr. Kirsten Bechtel, associate professor of pediatric medicine at Yale School of Medicine, because “it just means that all the outpatient pieces have kind of failed” and the child is unsafe.
“The community is also stressed, and there are not resources in the community, because a lot of intensive outpatient programs and partial hospitalization programs have gone to virtual,” said Bechtel, who is also co-chair of the state’s child fatality review panel. “Which is something that you would think would have maybe increased capacity because they can see kids on Zoom, but I guess it’s something that hasn’t translated into a very sort of helpful way of taking care of these kids after they leave the hospital.”
Child Health and Development Institute of Connecticut President and CEO Jeff Vanderploeg said the crisis happening in emergency departments is not the fault of the hospitals and agreed with providers that it’s “a system issue.”
CHDI works closely with community-based and state organizations to implement and improve children’s health and mental health in Connecticut.
“So, on the front end of the system, what could we be doing differently or enhancing that would have the impact of reducing the number of kids who are showing up in the emergency department?” Vanderploeg asked.
He said schools could provide social-emotional learning so that kids can recognize and talk about these issues early on. School-based interventions and pediatricians talking about mental health with their patients would also help, Vanderploeg said, and could prevent kids from showing up in emergency departments in large numbers.
Vanderploeg also stressed the importance of people being aware of the statewide mobile crisis program.
“Certainly there are kids who are at imminent risk to themselves or others who need to go to the emergency department for an evaluation to be considered for inpatient admissions, but there are a lot of kids also that can benefit from having contact with mobile crisis and then receiving services in their home or in their community,” Vanderploeg said.
Implemented by the Department of Children and Families, mobile crisis is a statewide emergency psychiatric resource residents can reach by calling 2-1-1. It provides services like psychiatric assessment, behavioral management services, substance abuse screening and referrals to services for any family with a child in crisis.
In 2018, the University of Connecticut School of Social Work released a report that found that, over an 18-month time period, there was a 25% decrease in emergency department visits among children when mobile crisis was utilized.
Last month, 2-1-1 and mobile crisis received 1,363 calls. Of those calls, 1,037 or 76.1% were handled by mobile crisis, according to a monthly report published by CHDI.
“[Mobile crisis] are incredibly resourceful, they’re incredibly helpful, they can help parents triage whether or not they need to go to the emergency department or not,” Bechtel said. “We’re always here, we’ll always be open, we will never turn anybody away, ever. But I think a lot of our parents are realizing what the ED looks like now is much different than what the ED looked like six months ago or a year ago.”
Gov. Ned Lamont’s plan for the most recent round of federal funding calls for the money to go toward expanding programs like mobile crisis by making it a 24-hour service along with plans to expand psychiatric services for kids by providing increased pediatric inpatient bed capacity — the state must use nearly $630 million of the American Rescue Plan funds specifically for child care and mental health services, capital projects and education.
Proposed legislation this session like Senate Bill 2, or An Act Concerning Social Equity And The Health, Safety And Education Of Children, is also aimed at expanding mental health services and interventions for kids by implementing mental health screenings and suicide prevention training in local and district health departments. The legislation has passed the state Senate and is waiting to be taken up by the House of Representatives.
“I think that the governor’s proposal includes a lot of really important ideas, and I think a broader message here is that the governor’s office, the legislature and [the Office of Policy and Management] are showing significant and important interest in investing in the children’s mental health system,” Vanderploeg said. “And it’s very acutely needed.”
But while these proposed resources are on the list of things Downs thinks would be helpful to doctors, families and children, she would also like to see more specialty care for children, like eating disorder treatment facilities, and more mental health resources for kids with autism and intellectual disabilities.
“From the parent’s perspective, the system failed them. From our perspective, we went above and beyond to find new space, to add new staff, to get creative and use spaces that we’ve never used before but try to make sure that they’re safe by having, again, more staff and more resources poured into what would normally be straightforward for us,” Rogers said.
If you or someone you know is experiencing thoughts of suicide, call the state’s 24/7 crisis service at 2-1-1 (press 1 for Mobile Crisis) or text “CT” or “HELLO” to 741741 to text with a trained crisis counselor. You can also call the National Suicide Prevention Lifeline at 1-800-273-8255 for English and 1-888-628-9454 for Spanish. Additional information about youth mental health can be found at Connecticut Children’s mental and behavioral health kit or the CDC’s COVID-19 Parental Resources Kit.