Link: http://lasvegassun.com/news/2015/dec/01/for-mentally-ill-children-emergency-room-visits-ar/

By Jackie Valley
December 1, 2015

As Dr. Jay Fisher enters Patient Room 12, a 14-year-old boy with curly, brown hair smiles sheepishly from the bed. Dressed in a green hospital gown, he’s quiet — calm even.

Gabe is a ninth-grader, big brother, budding chef, Tom Petty fan, avid science-fiction reader and Dungeon & Dragons player. More than five hours earlier, an ambulance brought him to the Children’s Hospital of Nevada at University Medical Center.

The reason: His mother, Jaleadeanne Robison, caught him browsing inappropriate images on the computer, which triggered his explosive outburst this August afternoon. He stormed up the stairs in the family’s North Las Vegas home, pushed his mother into a door frame and then ran downstairs and out the front door.

Fearing for her son’s safety, Robison called the police. This wasn’t the first time.

“I have neighbors who think mental health is contagious,” Robison tells Fisher, who heads the pediatric emergency department at the county-run hospital.

She’s sitting in a chair in the almost-barren hospital room, designated for children experiencing psychiatric crises. There are no cords or sharp objects they could use to hurt themselves. A closed-circuit camera monitors the room.

It’s all too familiar to Robison, whose son has been battling emotional and behavioral problems for almost a decade. Just 10 days earlier, he was released from long-term treatment in Texas, where he wound up after medical providers suggested it. The family had exhausted its local options.

“There’s no services,” she says. “There’s nothing in Nevada.”

Fisher extends the only comfort he can: “We’re here for you and we’ll do our best.”

On this particular evening, Gabe is fortunate. The manic Gabe that police officers encountered is not the polite, bashful teen now resting on the hospital bed. Staff deem him stable enough to go home, avoiding transfer to a psychiatric hospital. Gabe grabs his bag of clothes, wanders to the bathroom and returns wearing khaki cargo shorts and a gray polo shirt. It’s time to go home.

Patient Room 12 will be empty again, but it may not be for long. Fisher says there are hundreds of children just like Gabe, teetering on the edge of crisis, in the Las Vegas Valley. They often land first in the emergency room.

Staff in UMC’s pediatric emergency department have a nickname for Southern Nevada: the pediatric mental health vortex.

“We call it the polio of our generation,” Fisher said. “This is a health crisis of unbelievable proportions.”

Fisher has worked at the hospital for 23 years. Over the last decade, he said, the number of children entering the emergency room for mental health-related reasons has tripled, while Clark County’s population grew by only 80 percent. Last year, the department treated 932 children, like Gabe, at the third-floor home of the pediatric emergency room. This year, the hospital is on pace to see about 1,200 children for mental health concerns, of which about 400 will be transferred to psychiatric hospitals, Fisher said.

Doctors encounter children and teens who are anxious, self-harming, depressed, manic, hallucinating — you name it. Almost every day, a child experiencing a panic attack winds up in the pediatric emergency room, Fisher said.

And then there are the cases forever stamped in his memory, such as the time a mother brought her teenage daughter to the emergency room because she couldn’t figure out why the girl wasn’t eating. A physical examination revealed the problem in seconds: The girl, plagued by a poor body image, had wrapped duct tape around her abdomen.

Their stories contrast sharply with the cartoon-character murals on the wall and the oversized stuffed giraffe in one corner.

On one particularly busy night in July, Fisher tended to a 17-year-old girl with a history of drug abuse and extreme anxiety who had picked at her skin so much that it bled; a 13-year-old girl who was anxious but couldn’t explain why; a 13-year-old boy with multiple behavioral disorders who has frequently visited the emergency room and this time complained of stomach pain; and a depressed 14-year-old girl who had slashed her arms and ingested 30 cholesterol-lowering drugs. His patients also included 27 other ill or physically injured kids.

Fisher’s concern for these unstable children propelled him to convene a regular meeting of professionals — from the psychiatric hospitals, schools, court system and community agencies — to brainstorm better ways to handle the burgeoning problem.

The first meeting was three years ago. “No one wanted to quit meeting,” said Rosemary Virtuoso, the retired director of the school district’s Department of Student Threat Evaluation and Crisis Response who helped Fisher launch the task force.

The problem certainly wasn’t going away.

Other than a small dip in 2012, the number of children entering Clark County emergency rooms because of mental health-related issues has steadily increased — from 5,071 patients in 2009 to 6,619 in 2013, according to the state. (The state did not have data available for 2014 or 2015.)

“We treat a mental health illness the same as any other illness — diabetes, pneumonia, asthma,” said Ryan Pace, director of the pediatric emergency department at Sunrise Children’s Hospital, which, on average, receives two to three children with mental health issues each day. “Our priority is the medical well-being of the child when they arrive.”

In emergency rooms, doctors’ first order of business is to physically examine the child: Is the child’s behavior the result of medications or drugs ingested? Is he or she speaking normally? Are there physical injuries, such as cuts or bruises, that might indicate self-harm or abuse by someone else? Symptoms that may appear to be mental health-related could be the result of other underlying medical conditions, hence the importance of physicians’ initial examination.

If the doctor suspects the child’s mental health needs are severe enough to possibly warrant transfer to a psychiatric hospital, the staff begins the sometimes hourslong process of securing a psychiatric evaluation and finding a facility that has bed space and will accept the patient’s insurance.

In the meantime, the child lingers in the emergency room, a situation that can sap resources in the department depending on the volume of patients.

“These families sometimes end up waiting eight to 10 hours in this state of crisis, waiting for definitive care to be delivered,” Fisher said. “That’s obviously not optimal for the child.”

A handful of times per year, Fisher says, a child will be stuck in the emergency department longer — sometimes for a few days — if bed space isn’t available at the psychiatric hospitals.

In 2013, Clark County psychiatric hospitals admitted more than 7,200 children, according to state data. That’s a 45 percent increase compared with four years earlier.

The psychiatric hospitals care for children who are considered a risk to themselves or others, usually for short-term stabilization lasting several days or a couple of weeks. If a child needs an “acute stay” in Southern Nevada, the options include Desert Willow, the state-run facility, and four private hospitals: Montevista Hospital, Desert Parkway Behavioral Healthcare Hospital, Seven Hills Hospital and Spring Mountain Treatment Center.

The five psychiatric hospitals combined have about 125 beds for children and teens who need short-term stabilization. Two hospitals also provide beds to youths, ages 12 through 17, who need long-term treatment: Desert Willow has 38 and Montevista Hospital has 36. State officials, however, noted that Desert Willow is only operating 50 of its 58 total licensed beds because of staff shortages. Seven Hills Hospital, which has 10 short-term beds for youths, hopes to add more beds by February.

“Do we have enough youth beds in the community? No, absolutely not,” said Lori Townsend, senior vice president of operations at Sunrise Children’s Hospital. Not every child needs psychiatric hospitalization, but for those who do, Townsend said the shortage of beds in Southern Nevada is worrisome. “If I had a child who needed help, I would want to make sure they got the right help, and it wasn’t just what we were able to give at the time.”

The Robison family poses for photos in August shortly after Gabe returned home from Texas. Gabe, then 14, is on the far left next to his mother, Jaleadeanne Robison.

Several weeks after Gabe’s trip to UMC’s pediatric emergency room, Jaleadeanne Robison’s phone rings as she sits in her kitchen. The caller ID shows it’s from Miley Achievement Center, where her son attends school.

“Hi, what’s wrong?” she asks automatically.

Fear courses through her each time the school district calls. But this call brings mostly good news: After being on the verge of an angry outburst, Gabe regained his composure at school. The school nurse was calling with a question about one of Gabe’s medications — something Robison would need to ask his psychiatrist about. It’s another item on her to-do list.

For the moment, though, she exhales.

“Tell him I’m proud of him for calming down,” she says.

Robison savors the small victories. Gabe, whose diagnoses range from attention deficit hyperactivity disorder to schizoaffective disorder, has been hospitalized dozens of times for mental health-related episodes. He also has suffered seizures and strokes. Abuse by a relative as a young child may have contributed to Gabe's condition, his mother says, but she tries not to dwell on the past. She considers his diagnoses a guide for treatment but not perfect. Her rationale: Each brain is different. Gabe can have three good days followed by three bad days.

“My son is not a diagnosis,” she says, launching into the well-honed speech of a mother who has become her son’s biggest advocate. “He is not a code on a billing form. He is not a stat. He is him. He is loving. He is caring. He is hyper. He is a geek, and he happens to have some mental health issues.”

She knows all too well that Gabe can lash out when he’s angry. He has charged at her during manic fits of rage and has kicked at police officers and teachers. Sometimes he harms himself, which is why Robison sits in the hallway outside the bathroom when he showers and doesn’t let him be in a room alone unless he’s asleep.

Gabe is her firstborn. She has four sons — the two oldest with her ex-husband and the two youngest with her current husband, who considers them all his children. All were born in the month of October. All have medical needs. Her second-oldest son, a year younger than Gabe, has autism. Her 6-year-old has complications related to being born premature. Her baby has cerebral palsy.

“None of my children are broken, damaged, or in any way less than perfect,” Robison wrote earlier this year on her parenting-centric blog that’s become an outlet for her. “My version of perfect is just different than yours.”

The children receive services through fee-for-service Medicaid, which advocates say offers a wider variety of mental health services than private insurance. Even so, Robison says what’s available hasn’t been enough for Gabe, whose recent visit with a child psychiatrist lasted six minutes — a scenario families and health professionals lament as far too common given the region’s high demand and limited workforce.

Robison also thinks the state needs more in-home services that could keep children like Gabe out of residential treatment centers.

Gabe spent 11 months at Texas NeuroRehab Center, a specialized treatment facility in Austin for children suffering from brain injuries, substance abuse and other mental health challenges. When Gabe entered treatment in September 2014, he was one of 233 Nevada children on fee-for-service Medicaid who were enrolled in out-of-state residential treatment centers.

Robison says most people don’t understand the worries that plague families of children with mental disorders. “I worry about mind-altering drugs,” she says. “I worry about sending my kid across the country.”

When she lies in bed awake at night, her biggest worry surfaces: Will Gabe anger someone so much that he will get hurt or killed? Or will he get angry and hurt or kill someone else?

When Fisher started his evening shift in UMC’s pediatric emergency department, a mental health worker briefed him in a hallway, near the wall filled with baskets containing patient notes.

She’s a member of the Mobile Crisis Response Team, an almost 2-year-old program heralded by state leaders and health providers as a success in treating children with mental health problems. The team — the only one in the Las Vegas Valley — responds during a crisis, evaluating the children, providing services and developing a safety plan with the families, said Ann Polakowski, the licensed clinical social worker who manages the team.

Staffed by mental health counselors and psychiatric caseworkers, the team’s aim is twofold: to make emergency room visits and hospitalization unnecessary and to support the family by providing guidance and resources.

The hospital had summoned the team earlier that day to psychiatrically assess Gabe, whom clinicians later deemed stable enough to go home.

Since it launched in January 2014, the Southern Nevada team fielded 1,071 hotline calls and logged 738 responses through the end of September, she said. A similar team has since been created in Northern Nevada.

“We still do a lot of work in the emergency room” in Clark County, Polakowski said. “Our goal over time is, how do we dial that back?”

If the team intervenes in more home, school or other community settings, it stands a greater chance of stabilizing the child before the episode escalates to an emergency room.

Not all children can be stabilized in a home environment, so when necessary, the mobile crisis workers — who respond in pairs — coordinate short-term placements in local psychiatric hospitals.

They have a good track record: Only 12 percent of children assisted by Southern Nevada’s team were referred to a psychiatric hospital at the time of the crisis, according to program data through September.

The team, modeled after a successful program in Milwaukee, visits the child’s home within 48 hours after the incident if a safety plan has been developed in lieu of psychiatric hospitalization, Polakowski said. Some cases remain open as long as 30 days, giving the team’s clinicians and psychiatric caseworkers time to support the families and children — and, they hope, minimize stress while plugging the child into services.

“The earlier we intervene, we can change their trajectory,” she said.

No one wants to see the situation that child welfare officials said happens once or twice a year — parents refusing to pick up their children at psychiatric hospitals. The desperate act hinges on the theory that their children will receive more services in the child welfare system.

In those rare cases, the parents are charged with neglect, said Paula Hammack, assistant director for Clark County’s Department of Family Services. The parents know in advance that it will happen. “Your heart breaks,” Hammack said. “They literally got to the point where they feel like they can’t do it anymore.”

“Hi! Hi! Hi” Gabe sings as he gently bounces his 11-month-old brother on his lap.

The baby grins and, for a moment, they’re locked in a staring contest — big brother looking down, little brother looking up. This is the kind, loving Gabe his mother wishes more people knew. Today, her oldest son exudes happiness: He hugs Robison, excitedly shows her a new library book — a collection of science fiction and fantasy stories — and laughs deep, smiles wide while playing a video game with another brother.

It’s a Thursday after school, and soon a clinical social worker arrives to conduct a therapy session at the family’s home. Gabe receives a variety of services — such group therapy and basic skills training — as part of the Wraparound in Nevada program, funded by Medicaid.

Following the therapist’s instructions, Gabe squirts shaving cream into a bowl. The seemingly fun task is a metaphor: The shaving cream can’t be put back in the can, just like poor decisions can’t be undone.

Lying about mistakes doesn’t solve the problem either, the therapist tells him. Gabe, who’s sitting on the kitchen floor, nods his head.

Almost six weeks have passed since Gabe returned home after residential treatment in Texas.

“What has it proven?” the therapist asks.

“That I can control myself,” Gabe says.

Robison agrees. Gabe arrived home more mature and with a seemingly better grasp of his emotions. Lacking an all-seeing crystal ball, his mother says she takes it minute by minute, capitalizing on the good ones. For instance, she figured the best chance for family photos would be four days after Gabe’s homecoming from Texas.

It worked. Gabe, donning a maroon-colored dress shirt, black tie and flashing a toothy grin that reveals his braces, embraces his younger brothers in a photo now featured prominently on his mother’s Facebook page.

“Society needs to give a damn about these kids," she says, "and realize there’s no stigma to mental health.”

In mid-October, Robison received another call from Gabe’s school.

An incident in the classroom triggered an angry outburst and, this time, unfortunately, her son hadn’t calmed himself down.

Gabe spent his 15th birthday in a psychiatric hospital.