By Taylor Knopf
Gwen Bartley has spent countless hours in emergency departments and at behavioral health centers around the state desperately trying to get her son help during crisis situations.
He was 4 when she adopted him from foster care and out of an abusive past. On top of the childhood trauma, her boy was diagnosed with Schizoaffective disorder and a developmental disability.
“So we had the trifecta of ‘What could go wrong has gone wrong,’” said Bartley, who lives in Concord and founded Amazing Grace Advocacy to help children like her son.
When she heard the first youth mental health crisis center in the state was opening in Charlotte, she said it “felt like an answer to prayers.”
Monarch’s SECU Youth Crisis Center opened in December, and Bartley has been spreading the word to families and pediatricians. The 16-bed facility provides short-term, inpatient treatment for children working through a mental or behavioral health crisis. Trained staff also work with families to find the best long-term care plan after the child is discharged.
Unfortunately, Bartley’s son is too old for the center which takes children ages 6 through 17, but she said it would have been the “perfect model” for him.
That model is spreading in North Carolina.
A second child crisis center in Asheville just opened its doors in July. The Caiyalynn Burrell Child Crisis Center is described as “an alternative to hospitalization for eligible children experiencing a mental health, substance abuse or intellectual or developmental disability (IDD) crisis.”
For too long, the only way for a child in crisis to get psychiatric care in North Carolina was to go to an emergency department, sit and wait. Sometimes for days or weeks at a time.
Now, there are other options: this relatively new model not just in North Carolina, but in the United States.
Emergency departments not working
Bartley said the worst care her son received was at local emergency departments.
She said there are two common scenarios: The first is where a child and their parents sit and wait at the ED for a bed to open up at a long-term facility, while ED staff who are not trained to deal with these types of situations attempt to help. The second is when a parent brings a child in for help but they’ve calmed down by the time they reach the hospital. So the family is sent away without treatment.
“And then there’s this revolving door where the parents are constantly in and out of EDs, without getting any kind of admission or inpatient stays until something really bad happens,” she said. “It’s either a suicide attempt or they go after somebody and cause harm.”
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Teresa Gaskin, Monarch’s vice president of operations and crisis services, managed emergency departments across the state before taking her current role. She’s seen kids sitting in the chaotic ED environment getting no treatment.
“Our children are the ones who sit in the emergency department the longest, and who need the care the most,” Gaskin said.
She also admits her view of children in crisis has changed since coming to work for Monarch.
“I’ve been in the emergency department and these kids come in and you think they’re just really bad kids, and they need more parental involvement, or they need more guardianship, they need more structure,” she said.
At the ED, Gaskin’s view was limited. She said she didn’t know a child’s background or fully understand what was happening.
“Our goal in the emergency department is get them out of there,” she said. “In here, we do a comprehensive clinical assessment and you see all that. And you are like, ‘These aren’t bad kids. Look what they’ve been through.’ So… you get the whole picture.”
Boarding kids in the ED also puts an unnecessary burden on hospitals.
Asheville’s Mission hospital averaged 153 child crisis visits per month in 2017, according to data collected by Pathways by Molina, which manages the new Asheville child crisis center.
“The child crisis data that has been collected over the past couple years indicates that there’s more children that go into crisis than the system can support,” said Carson Ojamaa, Pathways’ interim state director.
Ojamaa noted that the adult facility-based crisis center, located just up the road from the new child center, has been around for years and helped alleviate some of the burden off local hospitals.
Different than the ED
Though the Charlotte and Asheville centers are managed by different organizations, the concepts behind them and the way they operate are similar.
When a child is admitted, a physical and clinical assessment is done by a registered nurse and licensed psychiatrist. Children can be admitted any time of day, whether they arrive by a family car, mobile crisis unit, law enforcement or EMS.
Monarch takes children from all over the state and works with the behavioral health management companies — known as LME-MCOs — to secure funds for the child’s stay. The Asheville center takes children from within Vaya Health’s 23-county catchment area.
But insurance companies do not recognize the centers because they are such a new model that it doesn’t fit neatly into inpatient or outpatient care categories. However, neither center wants to put a family in financial hardship to secure help for their child, so they take anyone who shows up at their doors and work with the respective LME-MCO to cover the costs.
The average length of stay at the crisis centers is five to seven days, but they will not discharge a child until they are ready and a long-term care plan is in place. Both have had children stay as long as 14 days.
Kids receive both therapy and medication treatment if necessary. Psychiatrists are present to monitor any new medication.
Each child leaves with a provider appointment scheduled within the next week. Both centers make follow-up calls and are there for any continued support.
[sponsor]There are some limitations. The centers do not provide medical trauma care. A wound or physical injury must be treated at the hospital before a child can be admitted. They also draw a line at forced medication and physical restraints to control a child.
Instead, both centers use other techniques, including quiet rooms, therapeutic holds, weighted vests, de-escalating techniques and self-regulation skills. The goal is to try to manage behavior in a way where forced medications and restraints are unnecessary.
Self-regulation and de-escalation
Both centers try to give the children structure and fill their days at the center with therapy classes, counseling sessions, activities and play time. So they stick to a strict daily schedule.
At the Asheville center, even relaxed recreational time has a purpose.
“If they’re doing yoga, for instance, that’s an intervention for sensory regulation and can be used to teach mindfulness,” said Ojamaa.
“Everything can tie back to self-regulation. Because basically, if people can self-regulate, they can solve problems,” she said. “Most of the problems that kids run into are going to be most of the things that lead to a crisis situation, whether kids have social problems or the inability to regulate their sensory input or thoughts or emotions.”
She cited one child who responded so well to yoga sessions and always returned to the same mat for class. So upon leaving the center, the favored yoga mat went home with the child. The Ashville center even intends to start on-site animal therapy soon.
Staff is trained to recognize situations that could escalate into a problem.
“Any time we put our hands on a kid, use restraints or forced medication, it’s a traumatic experience at best,” said Ben Millsap, chief clinical officer at Monarch’s crisis center. It’s his goal to avoid those situations altogether.
And 90 percent of the time, it comes down to a rule that the child takes issue with, Millsap said.
“There are only a couple of things that are truly non-negotiable,” he said.
For example, bedtime is at 9 p.m. every night at the Charlotte center. But if a child is not tired, Millsap said they will not force him to go to sleep.
When center director Pam Coppedge was asked what she thought the name of the Ashville child crisis center should be, only one came to mind: Caiyalynn Burrell.
Coppedge knows the young girl’s father, a local sheriff deputy. The two worked together at the adult crisis center in Asheville.
In August 2014, the deputy’s 12-year-old daughter Caiyalynn died. Coppedge never met the girl but attended her funeral.
“Caiyalynn was a victim of bullying at school and via social media,” Coppedge said at the ribbon- cutting ceremony for the center.
“As beautiful, kind, smart and loving as she was, this bullying eroded her self-esteem and she eventually developed depression,” she said. “As a cry for help, Caiyalynn took a medication not prescribed to her. Unknown to her, this medication is lethal to a child under the age of 12 years old. Her cry for help resulted in her accidental death.”
When Coppedge asked her parents for permission to name the center after Caiyalynn, they asked what she hoped to achieve.
“I told them I wanted it to be a center for hope and healing for all children that come,” Coppedge said tearing up as she retold the story. “Her father said that was ironic because Caiyalynn’s middle name was Hope.”
The father told Coppedge there was no doubt in his mind that if a similar facility had existed when Caiyalynn was alive that she would still be here today.
“I knew then we had the right name,” Coppedge said.
Cautious optimism
Because the crisis centers are so new, they are not filled to capacity just yet. Both are working to get the word out about their services to families, social services departments, pediatricians, law enforcement, schools and courts. But it’s hard to break old habits.
“We spent the past 50 years telling people across the nation, if you have an emergency, go to the ED,” Millsap said. “We’ve been so successful with that mantra, and they do it.”
Many schools and social services departments have existing relationships with their behavioral health ED. But rural counties in particular are starving for more options.
Those who have worked with children in crisis for years look at these centers with hope and some hesitation.
Judge Donald Cureton works in Mecklenburg County’s youth recovery court and said kids in his court often have mental health needs that the parents can’t manage without the help of state intervention.
“In all of these, we see kids that need immediate intervention to stabilize them,” Cureton said.
The cases he sees are often complicated by factors such as poverty, parental unemployment and substance abuse. He agreed that the ED waiting room is not the place for those kids.
“Any time there is something new that is developed, we are always trying to figure out if it’s going to be beneficial. Until we see it in practice, our position on whether this kind of structure will help remains to be seen,” he said referring to Monarch’s crisis center.
He heard the presentation from Monarch outreach staff and said the intention of the center is good.
“We are only as good as the resources that exist,” Cureton said. “That’s why it’s good to have lots of options. Monarch could be one of those options. Our hope is we never have to get to that point where we place someone out of the community, but sometimes it’s necessary.”
Linda McDonough, director of a school in Durham for kids who have developmental, emotional or behavioral issues, echoed the judge’s comments.
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“I think anything that can ease up these long waits has got to be an improvement. It can’t be any worse than the emergency room,” she said.
Not only does McDonough support her students who have gone through these long, unproductive ED waits, she has gone through them with her own daughter.
“We have all been disappointed so many times before,” she said.
Both crisis centers have unique security features to keep the staff and children safe. There are cameras anywhere a child has access.
Every door is anti-barricade, meaning it can be adjusted quickly to swing in both directions if a child is blocking themselves in on the opposite side.
The centers are furnished with anti-ligature hardware, that prevents the possibility of choking.
The facilities are locked at all times. Visitors must be escorted in the front door by staff. All doors leading to the housing units are locked and can be opened by badge or key.
At the Asheville center, Coppedge made the decision to not put any pieces of art on the walls. Instead, she lets every child put a colorful handprint on the wall before they leave. She wants the building to be decorated by the handprints of those they have helped.
Every rooms has a window with special glass and few furnishings. No one can see in and the glass is very difficult to break.
At the Charlotte center, every staff member wears a badge with two orange buttons. The smaller is to let others know their location and signal that they could need help or someone to check on the situation. The larger button is for times when staff need all hands on deck.
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I am so glad to see something like this in Asheville! We sure could have used it a few years ago. I hope it helps others.
My son has aged out of something like this. But it definately sounds like something that would have helped him. I especially appreciate the effort to avoid restraints and forced medication. Awareness of triggers and efforts to negotiate. I hope these programs get the support they need