Bellevue One of the Few

East Side psychiatric ER provides care designed for children

In most emergency rooms in the city-and in the state and across the country-children who come in with psychological symptoms are treated much the same as adults. An 8-year-old suffering from undiagnosed attention deficit hyperactivity disorder who has acted up in school, maybe out of frustration over falling behind in his work, and thrown a chair at his teacher might be held in a psych ward with schizophrenic grown men if the ER doesn't have the resources on hand to treat him immediately. A suicidal teen brought in by her concerned parents might not be able to see a child psychiatrist who can understand the nuances and specific troubles of the developing adolescent brain.

It's a nationwide problem, with only about 6,000 practicing child psychiatrists in the country, compared to over 70,000 adult psychiatrists. Emergency rooms struggle to diagnose and treat children who come in needing immediate psychiatric care, and many end up unnecessarily admitted to the hospital, sometimes in the same wards as adults.

With a dedicated staff and a grant from New York State, Bellevue Hospital Center is working to create a different option for children with psychiatric emergencies. At its Children's Comprehensive Psychiatric Emergency Program (CPEP), a specially trained team of doctors, nurses and social workers sees kids as young as 3 and as old as 17 with a broad range of psychological problems.

The program is exclusively intended to help children and often succeeds in catching psychiatric problems long before they might be addressed in the traditional hospital system. The program sees over 2,000 patients every year.

Dr. Jennifer Havens, director and chief of service in the department of child and adolescent psychiatry, said she's been working her entire career to make psychiatric treatment better for kids. One of the reasons she believes so strongly in the CPEP model for children is because without it, kids often fall through the cracks or get unnecessary treatment. "First of all, a medical ER isn't a safe place for psychiatric patients. You go to the ER if you're dangerous to yourself or you want to kill yourself or others," Havens said.

At Bellevue, the children's center is sectioned off as a separate unit. It's brightly lit and clean, with flat-screen televisions and a consciously minimalist aesthetic of bare walls and simple furnishings. There is nothing that might be torn off, thrown or used as a weapon. It's entirely secure and constantly monitored. Police officers who enter the unit must empty their ammunition and fire their weapons into a sand pipe to show that they're not loaded.

"The other problem is, there aren't usually psychiatrists just sitting there waiting for people to come in," Havens said. "For kids and adolescents, what generally ends up happening-not just in New York but all over the country; this is a national problem-is that they're seen in either pediatric or medical ERs," often by people trained to treat adults.

"Children are not just little adults-they have other issues that cannot be treated in the way that adults can be," said Dr. Angel Mendoza Jr., an assistant commissioner for child and family health at the city's Administration for Children's Services who acts as its medical director. He said that having children in their care go to Bellevue instead of a regular ER makes a world of difference.

The agency runs The Children's Center across the street from Bellevue, where they hold children who have been removed from their homes and are awaiting foster care placement.

"We run the gamut of different mental health issues, but what is common among all of them is the history of psychological or emotional trauma," said Mendoza.

Children come to Bellevue through referrals from other hospitals, are brought in by the NYPD or ACS, through the school system or with their parents. Havens said that often the children are simply very angry-and rightfully so-and need to talk to someone who can understand them. They are able to hold children for evaluation from 24 to 72 hours without admitting them to the hospital, which is crucial for the child's potential treatment and recovery.

"A lot of kids get admitted to the hospital [in other ERs] because they need to go somewhere else, they need to get immediate intervention," Havens said.

She said that many children can be treated within the 72-hour window, avoiding a traumatic hospitalization. If young patients are hospitalized, they are admitted to a separate ward with 30 beds. Mendoza pointed out that there are risks beyond just emotional scarring or physical danger if a child is placed in a psychiatric ward with adults.

"There are other kinds of risk that may not be immediately obvious to people," said Mendoza. "For example, a lot of these adults are involved in drug trafficking. You may have a youth [who is] out of the home and would be very susceptible to drug trafficking and even prostitution."

Havens said, "Most of the kids that come to us are very upset. They're either angry or sad; sometimes they're psychotic. It's a real emergency if you have a kid who wants to kill themselves or wants to kill you or is not going to school or is hallucinating."

People with depressive mental illnesses like schizophrenia often present the first symptoms as adolescents, Havens said. The average time between a child presenting symptoms and receiving a diagnosis for that type of mental illness is three to four years, a time during which they aren't getting vital treatment.

"These kids would go to medical ERs, get lousy care in the wrong environment and get admitted, regardless of what they needed," she said.

While the CPEP program is expensive, the goal is to cut down on psych admissions, which actually saves hospital expenses in the long term.

"If [a child] were in a regular ER, not in a CPEP, they would have probably just gotten admitted, whereas it's cheaper to have them observed in a CPEP," because it tends to be for a shorter period of time, said Dr. Judith Joseph, a fellow in child and adolescent psychiatry midway through her rotation in the Children's CPEP.

The program is also designed to put agitated parents at ease and help them cope with their child's condition.

"If you put yourself in the place of a child who is coming in for depression or suicide or psychosis, and the parents imagine going to an adult ER versus what we have downstairs, which is colorful, friendly-just the environment alone is therapeutic," Joseph said. Havens added that the remote controls for the TVs often work as well as sedatives to calm a child down.

Bellevue also sponsors follow-up care through an interim clinic, where patients can return for follow-up visits while they arrange for more permanent care, and through the Home-Based Crisis Intervention service, which brings specially trained social workers to follow up in a child's home and help parents manage their symptoms and care.

"We have a place for you to be, it's comfortable, you can play on the Wii, we know how to work with your family, we can make the right plan for you," she said of Bellevue. "If you don't need an admission you're not going to get one, because we can take care of you. It's fairly basic, but it's shockingly rare."