Twelve-year-old Gabi, who lives in South Los Angeles, has been battling anorexia for months. After refusing to eat or drink for four days in late April, Gabi, whose name has been changed, collapsed from dehydration. Her mom, Helen, whose last name has been omitted to protect her daughter’s identity, took the girl to a pediatric emergency room in Los Angeles. The doctors there could care for Gabi’s physical ailments but they were not equipped to treat her psychological problems.
California emergency rooms are chaotic, noisy and generally not staffed to care for children with acute mental health needs. Every year more than 13 percent of hospitalizations in California are due to mental health disorders—more than any other type of illness.
“We were in the emergency room for six hours,” Helen said, through a Spanish interpreter. “They treated her well for dehydration.” But because the hospital didn’t have an anorexia program, the doctors wanted to send Gabi home.
“I felt bad because one doctor told me I didn’t want my daughter at home and I should give her another chance,” Helen recalled. The mother was concerned that if her daughter went home without getting mental health care, she could collapse again—or worse.
Gabi’s parents are immigrants from Central America, and the family, including her two brothers, live in South Los Angeles. Gabi is enrolled in California’s low-income health plan, Medi-Cal. Many specialized psychiatric treatment facilities do not accept Medi-Cal insurance, making it even more difficult for low-income families to access care.
By law, ERs are required to care for anyone who arrives at their doors. However, researchers have found that many ER doctors, including those who specialized in pediatrics, do not feel adequately trained to care for mental illnesses. Some children have violent outbursts, harm themselves or threaten staff and other patients. Caring for children in the throes of mental illness requires expertise and extensive resources, often including secluded rooms and one-on-one sitters.
“We have kids just sitting in the [pediatric] ER waiting for hours, even days, until we can get them dispo-ed” said Patricia Padlipsky, medical director of the Pediatric Emergency Department at Harbor-UCLA Medical Center. Dispo-ed is short for “dispositioned,” which in medical lingo means the most appropriate place for treatment for a patient. Harbor is a county-operated, safety-net hospital in southern Los Angeles County. It is also a Level 1 Trauma Center, which means it can manage the most severely injured victims’ physical wounds, but they often must wait to get psychological treatment.
“Sometimes they don’t get therapy while they wait,” said Padlipsky, “When the kids are in the ER, I’m responsible. They shouldn’t just sit there.” Harbor has psychiatrists on-call; however, most ERs do not have ready access to child psychiatrists or pediatric inpatient facilities. Often, children and adolescents are admitted to medical hospitals to ensure their safety—this is especially true for kids who are suicidal.
In California, nearly 7 percent of kids struggle with a mental disorder severe enough to disrupt daily living. Many do not have access to care. The lack of mental health resources is especially problematic in areas that are poor, rural or have mostly immigrant populations, according to a report from the California Healthcare Foundation. These areas also tend to have higher rates of young people with psychiatric disorders, such as ADHD, depression and suicide, as shown in data from the National Institute of Mental Health.
California has fewer than 1,050 child and adolescent psychiatrists to serve more than 9 million children and teens younger than 18 years. In a community, as the rate of poverty increases so does the rate of mental illness. But, the number of licensed mental health professionals goes down. In LA County, 17 percent of people live in poverty and there are about 20 psychiatrists per 100,000 people. In comparison, the wealthier counties of San Francisco and Marin have the highest rates of psychiatrists in the state at 76 and 70 per 100,000, respectively.
One response to the shortage has come from the LA County Board of Supervisors. They allocated $6.6 million to expand emergency psychiatric services at Harbor, including expanding adult services and opening a new child and adolescent psychiatric ER. The unit is designed to provide prompt assessment and treatment by specially trained staff for youth with acute mental disorders. It is slated to open this fall and is only the second of its kind in the U.S.
“I see the new ER as essentially like a Level 1 Trauma Unit, but for psychiatric illness,” said Patrick Kelly, a child and adolescent psychiatrist and director of Emergency Services for Child and Adolescent Psychiatry. “We want to deal with the crisis and get the kids to the best place, including home if that’s possible.”
Kelly is the director of the new unit. In addition to clinical care, he plans to incorporate research about emergency psychiatry and training for ER doctors, psychiatrists and pediatricians.
The new unit is adjacent but separate from the hectic trauma side of the ER. The walls are painted in muted earth tones. The patient rooms have faux sky lighting and are furnished with cushioned recliners, instead of the typical metallic gurneys. All elements have been chosen to create a calm environment.
“We need to increase resources,” said Padlipsky, “We’re failing [the kids].” Kelly and Padlipsky have been working closely to coordinate the medical and psychiatric care in the ER.
Unfortunately for Gabi, she had a relapse in July and required another ER visit. She was hospitalized at Ronald Reagan UCLA Medical Center in a medical ward for almost four weeks. She was awarded a scholarship for costs not covered by Medi-Cal and will soon have placement in an eating disorders program in Torrance.
Despite the challenges, Helen thinks the ERs have helped save her daughter’s life.