Children in Crisis: How Georgia’s mental health system is failing kids

Children in crisis routinely wait hours, or even days, in emergency rooms for a hospital bed to open. It won’t be at the state’s largest and most well-resourced pediatric hospitals; they don’t provide inpatient mental health care. Nor do most general hospitals. So children are often sent to private psychiatric hospitals that were designed primarily for adults and may not have extensive, fully resourced programs staffed by doctors and therapists who specialize in working with kids.

Parents have little, if any, say in where their child is sent. They go to wherever a bed is open, even if it is far away. “Whoever accepts the child first, that is where they will go rather than being closest to home,” said Dr. Dale Peeples, child and adolescent psychiatrist at the Medical College of Georgia at Augusta University.

Once their children are placed, parents may struggle to even learn about their child’s condition. And, too often, a hospitalization that protects a child from suicide may also add to their trauma, the AJC found.

A panicked mother waited hours with her son at a psychiatric hospital for an evaluation after discovering his plan to hang himself. He had just finished fifth grade and had been a sheltered suburban Atlanta kid with a doting family. When he was admitted, his mother couldn’t go with him. “I was scared out of my mind,” she said. In the hospital, her son was afraid, too. “He said he would hear the screaming of the other kids,” she said. “He had nightmares for years.”

Another mother was shocked when an ER doctor involuntary committed her 14-year-old daughter to a psychiatric hospital she had never even heard of. That stay led to a series of inpatient, crisis admissions for the teen that left her worse, not better. The family resorted to paying out of pocket and sending their daughter out of state to find help.

A 12-year-old boy, admitted to a psychiatric hospital for suicidal thoughts, had a bruise on his face when he left after a stay of a few days. He told his mother and local police that a staff member assaulted him in the bathroom.

A 14-year-old girl, who was suffering from depression, seemed much worse to her parents after a short stay at a psychiatric facility. She eventually confided: She’d been raped by a night-shift employee at the facility.

After a crisis hospitalization or ER visit, some families search high and low, get on waiting lists and pay out of pocket to find the outpatient help their child truly needs to get better. Some families told the AJC that at discharge, hospitals just handed them a list of outpatient providers. “They shove you back in the world and hope you get treatment somewhere else,” said an Atlanta teen who went through three hospitalizations.

Experts say Georgia’s system is broken, a crisis in itself because the need for mental health care for children has never been greater.

More than half of Georgia’s teenage girls and a quarter of boys report intense anxiety, worries or fears that get in the way of daily activities. One in eight teenagers say they have “seriously” considered suicide within the last year.

Last year in Georgia, at least 119 children and teens between the ages of 8 and 19 took their own lives, according to the state Department of Public Health.

Suicides among young Georgians have doubled over the last decade, leaving students across the state touched by the losses.

Parents stream into pediatricians’ offices and local hospitals, seeking care for their children as signs of illness emerge.

At Children’s Healthcare of Atlanta, the number of visits to emergency departments by children and teens in a mental health crisis more than doubled since 2015, and about 40% of the children were so high risk that they had to be transferred to psychiatric hospitals for care.

But Children’s, which doesn’t have inpatient psychiatric beds, noticed that many kids sent away for treatment soon were back in its ERs. Dozens of these children tracked by the system had been admitted at least 10 times to psychiatric hospitals or residential treatment facilities but continued to fall into crisis and return to the ER.

The average child in this group was just 13 years old.

“That is an overall failure of the mental health system,” said Dr. Daniel Salinas, chief community clinical integration officer for Children’s Healthcare of Atlanta. “There’s not one thing that we can say, this entity failed or that entity failed. It’s just an overall failure of the system.”

Gainesville-based Northeast Georgia Health System, one of the few health systems in Georgia to operate a behavioral health unit that takes adolescents, faces the problem every day. The system does hundreds of mental health assessments every month of children and teens who come into its ERs, said Megan Crump, an assessment supervisor. But because the small behavioral health unit for adolescents is always full and it only takes children who are at least 12, Crump’s team spends hours every week trying to find inpatient care for children somewhere else.

Finding a placement for a child under 10 is extremely challenging, she said, and if a child has autism or a developmental disability, placement is even harder. Most hospitals simply won’t take these children.

Even a child psychiatrist whose 17-year-old daughter with autism needed inpatient crisis care for behavioral health couldn’t find placement anywhere in Georgia. “Navigating treatment is like a roadmap through hell,” Dr. Michael Ellis told a state committee last month.

Many private hospitals will also turn down a child with a medical condition — even COVID.

In Southwest Georgia, children in crisis are sent at least an hour and a half away for inpatient care, said Jennifer Jewell, a registered nurse who helps manage the care of behavioral health patients in the emergency departments at the Phoebe Putney Health System in Albany. Some are so young that they have never even been away from their parents. “It’s a very difficult situation,” she said.

Credit: John Glenn-J Glenn Photography

Credit: John Glenn-J Glenn Photography

It’s made more difficult, she said, when a child is being forced to be hospitalized under a doctor’s order, known as a “1013,” because the child is in danger of harming themselves or others. Jewell has to make it clear that the parent can’t block the admission. “We have some really hard discussions about what the process is,” she said.

State Rep. Mary Margaret Oliver, D-Decatur, a co-sponsor of a mental health reform bill approved by the Georgia General Assembly this year, said it’s not disputed that Georgia is at a crisis point when it comes to providing care for children whose lives are threatened by a mental health emergency.

“I don’t think anyone is going to stand up and make an argument that Georgia’s mental health care system serves children well,” she said. “The question is, what is going to be our response?”

Quality of care in question

Two decades ago, hundreds of children and teens every year went to Georgia’s state psychiatric hospitals when they needed emergency mental health care. Hundreds of others went to general and pediatric hospitals that had psychiatric units for children. In those days, private, stand-alone psychiatric facilities cared for only a small share of Georgia’s children in crisis.

But the exposure of dangerous, abusive conditions in the state facilities and a federal lawsuit prompted the state to agree in 2010 to shift most of its care from state hospitals to community-based services.

Some general hospitals closed or sold off psychiatric wards, too, often because of the expense of operating the units. Hospitals in Gwinnett and Clayton counties sold their behavioral health hospitals that served kids to for-profits. The Children’s Hospital of Georgia in Augusta closed its inpatient psychiatric unit.

The exceptions are hospital systems based in Carrollton, Gainesville and Columbus, which bucked the trend by continuing to place a focus on mental health services for minors.

Credit: Bob Andres

Credit: Bob Andres

As a result of the shifts, today the private psychiatric hospitals in Georgia admit most children who need in-patient care. Usually, children sent to the facilities have a clear plan for suicide, have tried suicide, or pose a threat to others. Since 2000, admissions to a psychiatric hospital among Georgia teenagers between 13 and 17 tripled, the AJC found in a review of state records.

The state operates some crisis, safety-net beds for children. But most of the care is handled by hospitals operated by three for-profit chains. Critics say the chains focus on pleasing investors and have a track record of failing to adequately staff their hospitals. All three chains have had issues with poor care or improper billing, some much worse than others.

US HealthVest, a small national chain with two Ridgeview Institute facilities in Georgia, has been faulted by regulators in multiple states for poor care. In Georgia, two adult patients on suicide watch at its Ridgeview Monroe location weren’t checked as ordered and died by suicide in 2018, according to police records. Local police found the facility had falsified records to suggest staff had done the checks.

In 2021, police arrested a therapist working at Ridgeview for forcing a 17-year-old patient into sex. Just this year, the facility was cited for failing to investigate an abuse complaint, where a staff member kicked and hit a patient who was being dragged to an isolation unit.

At Georgia facilities of another national chain — Acadia Healthcare — inspectors have found a myriad of serious shortcomings and multiple patients have filed lawsuits over poor care. Its Gwinnett facility, Lakeview, was raided by police in 2019 following numerous complaints. Police records show that 911 calls come in multiple times a month for the chain’s Riverwoods Behavioral facility in Clayton County.

An Acadia facility in New Mexico lost its state certification and was shut down in 2019 over allegations of abuse of children in its care. Investors have sued the chain accusing it of having falsely claimed a commitment to excellent care, while having inadequate staffing and violence at its facilities.

Acadia and US HealthVest did not respond to the AJC’s requests for interviews.

The third chain, Universal Health Services, tends to have fewer regulatory issues in Georgia than the other chains, the AJC found. Even so, three employees of a UHS facility in Augusta are in prison for sexual abuse of patients, including a 14-year-old girl, in 2017. And this past May, a worker at the same facility was arrested on charges of sexual assault of a 16-year-old patient.

One of the largest players nationally in behavioral health, UHS in 2020 agreed to pay $122 million to resolve federal government allegations related to billing for unnecessary inpatient behavioral health services, failing to provide adequate service and paying kickbacks at its hospitals across the country. The Justice Department said UHS failed to provide adequate staffing and training and improperly used physical and chemical restraints. Part of the settlement covered a UHS facility in South Georgia that gave free transportation to steer patients to its program.

Psychiatric facilities tend to be smaller than general hospitals and most don’t allow visitors to come and go, or parents to stay with their children during treatment. Parents may struggle to even find out about the quality of care their children are receiving.

Some parents told the AJC, they couldn’t get updates from the hospital staff. One mother said her suicidal 16-year-old daughter was transported for miles in the middle of the night this year from a hospital ER to Ridgeview in Smyrna. She couldn’t even see her daughter when dropping off belongings. “It was like prison,” the mom said.

The mother used billing records to piece together what happened during her child’s stay.

A teen girl was transferred nearly two hours away from home in middle Georgia for crisis treatment after her local ER had concerns she was suicidal. But her mother, a nurse, couldn’t get her daughter released when her stay should have ended. The staff would hang up when she called, so she resorted to calling the police.

The girl whose parents were shocked when she was involuntarily committed at 14 became increasingly frustrated during seven hospital placements in less than a year. After the girl was involuntarily committed at Ridgeview Institute-Monroe, her father drove with her outpatient therapist to the facility over concerns about her care.

“They refused to even let them in the building,” the girl’s mother said.

After their daughter was released from her stay, the girl’s mother found a medication that could have triggered a seizure wasn’t discontinued, in spite of an order.

The child, who had been through a series of hospitalizations and seemed to get worse with each stay, escalated to self-harm during her last hospitalization. Her family resorted to paying $9,000 a month for a residential program in another state, where their daughter finally received care that helped her.

The AJC, using patient records, found children in some hospitals were seen by psychiatrists who weren’t board-certified in child and adolescent psychiatry.

Credit: Jason Getz / Jason.Getz@ajc.com

Credit: Jason Getz / Jason.Getz@ajc.com

Even if care is appropriate, most of the facilities in Georgia were not built to comfort children the way most pediatric hospitals are, with colorful furnishings and units designed to incorporate parents into the care. In psychiatric units at private hospitals, children and teens usually gather in common rooms during the day so they can be monitored since many are at risk of suicide. While children and teens can benefit from meeting others with similar challenges, some parents said their children were exposed to things that left them at risk. One joined a group chat called “the suicide squad”; another learned cutting, a common form of self-harm among girls.

The facilities “are not equipped to handle juveniles in any way, shape or form,” said state Rep. Todd Jones, a Republican from Forsyth County, whose oldest child went through a series of hospitalizations starting as a teen. “It is much more of a very sterile, adult institution than it is anywhere someone 18 and under should be.”

Last resort

Trying to find quality care for a child with a mental illness is an issue that strikes home with Jones and his wife, Tracey. While he is a successful businessman and elected official and his wife has an undergraduate degree in psychology, they struggled to find a way to get help for their son, Justin.

Tracey Jones remembers the first time they sat in the waiting room of a private psychiatric hospital with Justin. He was in high school, where he was a popular honor student who had crushed the ACT and scored 4s and 5s on all his AP tests. Yet suddenly, Justin was debilitated by a shocking breakdown.

“You’re in this room, they’re very sterile, you hear people screaming in the background,” Tracey Jones said. “You’re crying, you’re with your child and you’re like “Oh my God.”

In their family’s experience, the hospitals were understaffed and underfunded and couldn’t deliver the kind of care that would help a child get better over the long haul. “It’s woeful, in terms of the inadequacy of our infrastructure,” Todd Jones said. Almost any parent is overwhelmed and isolated, he said, when they try to navigate the “system.”

“You really have no path,” Tracey Jones said. “You’re lost.”

Justin would be in and out of hospitals 31 times over five years, with one short admission after another. The hospital would “stabilize” him and release him with no clear next steps.

“It was a rinse and repeat cycle,” Todd Jones said.

Then, the family was given advice on how to break the cycle.

“When we knew this was really not a broken system, but a ‘gone’ system, is I will say last year when we were finally told, ‘Look, his best help is for him to commit a felony,’” Tracey Jones said

By threatening a police officer and getting charged with a crime, Justin got help through the criminal justice system at a state hospital where he stayed for months. “They would not let him go until they got him out of psychosis. And that was the very, very, very, very, very first time that happened,” she said.

‘Morally unacceptable’

Their experience led the Joneses to speak out on the issue, and their story made Todd Jones a credible advocate when he co-sponsored the mental health parity bill to require insurers to cover mental health equitably with physical health.

Since they have gone public, Todd and Tracey’s phones ring constantly. Parents call, in crisis, desperate for advice on getting help for their kids. They don’t know where else to turn.

“My wife, she could probably start a support group right now in Forsyth County and I bet you 1,000 people would show up at the first meeting,” Todd Jones said.

While Jones is gratified that the parity bill passed, he said much more needs to be done.

Jones emphasized that he’s a staunch conservative asking the government to do more, not less. Not acting, he said, is way too costly for both governments and every member of a family in crisis. States across the country shut down horrific mental health hospitals, but that created a gap and states didn’t shift those resources into a better new system, he said.

“At the end of the day, if you look back on that journey that has been taken, shame on those that were there. Shame on those of us who have allowed it to perpetuate. For us to not act on this, I think is morally unacceptable,” he said. “We have to act on it.”

If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org.