Where is the outrage?

I am an emergency department physician. I am trained to triage, stabilize and transfer or discharge patients who are experiencing acute symptoms. I am not trained as a psychiatrist, a psychologist or a social worker. Yet a substantial number of my patients come to the ER because they are experiencing a mental health crisis.

And of those patients, there is a subset – primarily children and adolescents – who, once stabilized, cannot be discharged because they have no safe place to go. Typically, they do not have acute illnesses that call for inpatient psychiatric care but do have a variety of diagnoses, many of which are linked to childhood trauma. They often use violence as a means of expressing themselves, which is often how they ended up in the ER in the first place. These patients languish, often “living” in our ERs for weeks and months – one child was recently discharged after spending 118 days in one of our ERs. They spent Halloween, Thanksgiving, Christmas and New Year’s in the ER.

This is not a rare occurrence. In 2023, 345 children and adolescents spent more than 48 hours in one of MaineHealth’s nine Maine ERs awaiting discharge to appropriate behavioral health services, and the average length of stay for those children was five days. Imagine experiencing mental health issues and being stuck in a windowless, bare room for five or more days?

There is nothing therapeutic about such an experience. In fact, it is psychologically harmful for children to be isolated and alone, particularly when they are at their most vulnerable. Our failure to provide appropriate care and treatment to these young people only adds to the burden they already carry from histories that often include abuse, trauma, mental health and/or substance use challenges. Our broken mental health system is failing them all over again.

What is the answer? In 2018, the Department of Health and Human Services issued a Children’s Behavioral Health Services Assessment that spoke clearly to our broken system. Among many excellent recommendations, the report recognized the need for residential services to meet the needs of children with aggressive behavior who otherwise were being sent out of state.

Today, five years later, we have seen an increase in the number of children who require these services but no movement by the state towards creating the secure residential options they so desperately need. It is unconscionable that we allow children to spend weeks and months in the most restrictive setting – a hospital emergency room – when we know what needs to be done to help them recover. We are defaulting to our hospital ERs to provide the security that is needed, but failing to recognize that ERs cannot provide the treatment, socialization, access to the outdoors, physical activity or any of the daily activities that young people should experience in the course of their recovery.

The state has a budget surplus. The governor’s supplemental budget identifies the need to build crisis receiving centers. That will help meet the needs of some, but it will not address the urgent crisis faced by families and children who need a higher level of care.

As I write, there is a child who has been stuck at a MaineHealth ER for over a month without a path to a safe disposition. Let’s use this budget opportunity to address the need identified in 2018 and require that Maine build the capacity to meet the residential needs of our most vulnerable children.

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