One patient had been charged with rape and aggravated sodomy.

Another was accused of child molestation and rape.

Brant Sanderlin/Staff (ENLARGE)

The Allen Building is shown in the background at Central State Hospital in Milledgeville.

ABOUT THIS PROJECT Federal probe: • Justice Department finds 'critically deficient' conditions | Report PDF • Patients' safety slighted • Remedy will be costly • Feds hit Columbus hospital Call for reforms: • Mental hospitals under review • Consumer advocates seek tighter controls Part 1: A young Sarah Crider is among the victims Part 2: Suicide exposes neglect Part 3: A fatal struggle -- but no punishment Part 4: Lax security, easy escape, tragic ending Part 5: Rapid decline at hospital shatters family Part 6: Patients shunted to inns, shelters, streets • Two who lived — and two who died Part 7: Children housed with alleged offenders Part 8: A lonely end to a life of madness Part 9: Unlicensed homes can pose deadly dilemma Justice delayed?: Worker charged in 2004 sex case still not tried Questionable deaths: • A look at cases around the state Verification: Over 190 abuse cases verified Workers: Volatile environment also threatens staff Solutions: • Experts offer ideas • Feds can step in Interactives: • Map: Locate Georgia's mental hospitals • Video: Reporter discusses findings

Yet another who entered Central State Hospital in April faced charges of aggravated assault, rape and aggravated child molestation.

All three were teenagers — and all three were housed in Central State's adolescent unit, alongside mentally ill children possibly as young as 6.

This volatile mix occurs with regularity at the two adolescent units in Georgia's state psychiatric hospitals, officials say. Along with chronic overcrowding and inadequate staffing, records show, it creates an atmosphere conducive to fighting and sexual assaults.

"There is concern that children who are small in stature and powerless to defend themselves are not safe in state hospitals," wrote regulators with the Department of Human Resources in 2000, after investigating complaints by two adolescent patients who said other teens attacked them at Central State.

Placing teenagers accused of violent crimes amid children with disorders like schizophrenia and autism leaves the younger patients "vulnerable, extremely vulnerable," said Dr. Andrea Bradford, the state hospitals' former medical director.

The state says it is taking steps to separate adolescent patients by age groups. But officials have acknowledged for years that commingling young forensic patients with mentally ill children creates a dangerous situation. For the same reason, the state hospitals almost always segregate adult forensic patients in secure units.

Charges of assaults
Today, a picture of the troubles in the adolescent units emerges from a review of incident reports, internal investigations and other public documents.

In 2001, for example, a 12-year-old boy in the adolescent unit at Georgia Regional Hospital/Atlanta reported that his roommate, an older teenager, had tried to rape him.

At Central State, in Milledgeville, a 15-year-old boy said in 2005 that another adolescent patient had sexually assaulted him. The other patient said the sex was consensual, records show, so state investigators declared the allegation to be unsubstantiated.

Other cases allege beatings and consensual sex between male and female teenagers.

Mentally ill children "may not be able to report [assaults] or defend themselves," Bradford said. Moreover, she said, the hospitals don't have enough workers to monitor the older patients, many of whom are in the institutions to be evaluated for their fitness to stand trial, either as juvenile offenders or as adults.

"Some of it is really inappropriate placements of troubled teenagers who don't have something that can be treated in a hospital setting," Bradford said in an interview. "But there isn't any other place for them, as far as the judge is concerned."

The situation grew especially acute at Central State this spring.

A Superior Court judge ordered the hospital to admit a teenage defendant for pretrial psychiatric evaluation. Like two others already on the adolescent unit, this patient was facing charges for felony sex crimes, including child molestation. Eight other patients had been committed to the unit by juvenile court judges. The unit's other 11 patients were admitted for mental health treatment, not forensic evaluation.

Bruce Callander, Central State's chief of psychiatric treatment and forensic services, asked for relief in an April 11 memo to Bradford, then the medical director supervising all seven state hospitals. In the memo, obtained by The Atlanta Journal-Constitution under Georgia's open records laws, Callander said Central State's adolescent unit was confronting "increasingly difficult challenges."

"Half of our current population is under the jurisdiction of a court," Callander wrote. "Given the physical configuration of our unit, it is difficult if not impossible to separate these populations due to space issues as well as staffing issues. We simply do not have the staff to address the issues of male/female, big/small, passive/aggressive, etc., much less separate them within the unit."

'A tremendous range'
After adolescent units at two other state hospitals closed earlier this decade, the remaining facilities at Central State and Atlanta began accepting young patients from a broader area. The Atlanta hospital admitted only adolescents between 13 and 17 years old, all from metro Atlanta and other North Georgia counties.

Central State, by contrast, drew 11- to 17-year-old patients from the lower two-thirds of Georgia, plus children as young as 6 from across the state.

In his memo, Callander wrote: "That is a tremendous range when you consider the needs of a 6-year-old who may be autistic compared to a 17-year-old who is charged with rape and associated with a gang. ... I do not feel comfortable serving both, given the mix of children and adolescents we are currently seeing here."

Officials are beginning to place older adolescents in the Atlanta hospital and younger ones at Central State, said Gwen Skinner, director of the state's mental health division. But the agency has set no firm age limits on either group, and mentally ill children may still live among adolescents accused of crimes.

"Just because you're involved in the court system does not make you not mentally ill," Skinner said in an interview Friday.

When Callander wanted to send the new forensic patient from Central State to the Atlanta hospital, Bradford declined his request. She wrote back to Callander that Atlanta's adolescent unit already had five new patients, that patients were at "a high level of acuity" and that the unit's regular physician was out sick. "The unit is too fragile at this point to take on this adolescent," Bradford wrote.

In the interview last week, Bradford added: "It was not a good situation to bring a forensic patient with that kind of history into."

Callander last week declined through an assistant to comment.

Bradford declined to give a reason for her resignation as medical director for Georgia's mental health division in May.

Both adolescent units have had trouble keeping enough workers to adequately care for patients.

Inadequate staffing levels came into question in the Atlanta hospital's adolescent unit in February 2006, when 14-year-old Sarah Elizabeth Crider died after a night of medical inattention. Crider was one of at least 115 state hospital patients who died under suspicious circumstances from 2002 through 2006, as reported in the Journal-Constitution series, "A Hidden Shame." The newspaper also documented at least 194 cases of patient abuse during the same period.

The U.S. Justice Department is investigating whether conditions in Georgia's state hospitals have violated the civil rights of patients.

At Central State, Callander wrote, attacks on employees in the adolescent unit exacerbated staffing shortages.

One employee had recently suffered bruised ribs and a dislocated thumb, and was kicked in the bladder, Callander wrote. One worker's hair was pulled out. Another sustained a thumb injury. And a nurse, attacked twice, resigned. The same child caused all those injuries, Callander said: a 5-foot, 8-inch, 230-pound girl, 13.

Other states separate
Many other states take a different approach to treating young mentally ill patients and criminal defendants.

Texas and Michigan, for example, have special adolescent forensic units separate from wards that treat young psychiatric patients. Arkansas operates a separate unit for adolescent sex offenders. Indiana and Oregon closed their adolescent psychiatric units altogether; both now treat young patients in community settings rather than state hospitals.

Bradford said she suggested creating a forensic adolescent unit at another hospital, which would have freed space at Central State and Atlanta for mentally ill youths. Skinner said she hopes to divert mentally ill adolescents to other treatment programs.

"We don't necessarily want to serve children on the grounds of state hospitals," she said.

Dealing with diverse groups of children and adolescents challenges psychiatric hospitals to provide the best possible care, said Dr. Nada Stotland, a Chicago psychiatrist and the president-elect of the American Psychiatric Association.

Young forensic patients may require intensive supervision, or could be housed in their own units apart from other patients, Stotland said. Those approaches, she said, would require money for more hospital workers.

But, she said: "You have an absolute obligation to protect the other kids."