In the spring of 2016, a 12-year-old named Gabriel Brasfield spent three and a half months in a psychiatric hospital in Chicago. His hair, which he liked to wear cropped, grew long and unkempt. He forgot what it felt like to wear shoes because he was allowed to wear only hospital socks. He missed months of school, and couldn’t go outside. He celebrated his 13th birthday at the hospital, where he said the walls were bare and there was little to do.
And for eight weeks of those three and a half months, he didn’t even need to be there. Doctors had agreed Brasfield was ready to be discharged about six weeks after he arrived, but the Illinois Department of Children and Family Services (DCFS), which is his legal guardian, couldn’t find anywhere for him to go.
As I found during a four-month investigation for ProPublica Illinois, Brasfield is one of hundreds of children in the care of DCFS who are held each year inside psychiatric hospitals for weeks or months, even though they have been cleared to leave. Instead of moving on to a foster home or residential treatment center—a less restrictive facility where children live while receiving treatment—these children have languished in secure mental-health facilities, the consequence of the child-welfare agency’s failure to find them appropriate placements.
These unnecessary hospitalizations are another failure for a state system that has frequently fallen short in its charge to care for Illinois’s most vulnerable children, who suffer from conditions such as severe depression or bipolar disorder. Though statistics to compare how states handle children in psychiatric hospitals are scarce, and other states also experience similar challenges, psychiatrists and mental-health experts say circumstances in Illinois are among the most dire in the nation.
Unnecessarily prolonged hospital stays often have detrimental effects on children. Doctors in some of these cases said the delays caused the children to deteriorate emotionally and behaviorally. Some child-welfare advocates said the children slipped behind their peers in their behavioral and social development, often dramatically. Meanwhile, lawyers who represent many of the children say such stays deny them their right, guaranteed by Illinois state law, to live in the “least restrictive” setting.
While confined to a psychiatric hospital, some children received just an hour or two of educational instruction a day, if that. Two teenagers described the bulk of their schooling in hospitals as completing worksheets; doctors at the hospitals confirmed that some children received only infrequent visits from teachers. One young man told me he had to repeat a year of school after being held in the hospital for months longer than necessary.
“It’s appalling. These are real kids the state is responsible for,” said Charles Golbert, the acting public guardian—the public official whose office advocates for children in state care—for Cook County, which encompasses Chicago. “To spend this much time in a psychiatric hospital after you’ve been stabilized and need to be in a caring placement, not a hospital, is wholly unacceptable.”
Mitchell Glaser, a doctor who has worked with hundreds of children through DCFS in his 20 years as a child and adolescent psychiatrist in Chicago, said the unnecessary hospitalizations leave children impulsive and angry. “It’s a waste of those kids’ lives,” he said.
And a waste of money, too: Unnecessary hospital stays come at taxpayers’ expense. According to DCFS records, the state has spent nearly $7 million from 2015 through 2017 on psychiatric hospitalizations for children as young as 4 that went beyond what was deemed medically necessary. (Time in residential treatment facilities and foster homes is less expensive—and less detrimental to children—than an unnecessary hospital stay.)
Decades of failures and mismanagement at DCFS stand as a backdrop to this latest breakdown. Employees endure crushing workloads and pressure to close cases. DCFS officials have repeatedly promised to reform the agency, yet problems persist.
Last June, Illinois Governor Bruce Rauner appointed Beverly Walker, who goes by B.J., to be the acting director of the agency, which in recent years has had children die on its watch and mishandled investigations into abuse and neglect. Children languishing in psychiatric hospitals are among Walker’s most pressing challenges. “We have a problem,” she said. “We know we’ve got a problem.”
I analyzed thousands of pages of confidential records and obtained data from DCFS under the Freedom of Information Act covering all of the nearly 6,000 psychiatric hospitalizations of children in DCFS’s care between 2015 and 2017. In that period, nearly 30 percent of all children in DCFS care who were hospitalized were held beyond medical necessity, for a collective total of more than 27,000 days—that’s nearly 75 years—waiting and watching the outside world from behind the thick panes of hospital safety windows because DCFS has too few beds in other facilities where they could be more appropriately treated. On average, more than one in five days spent in a psychiatric hospital, the records indicated, were not medically necessary.
In the vast majority of those cases, children were held long past when they were cleared for release, not just a day or two beyond. Eighty percent of the more than 800 children whose stays became medically unnecessary between 2015 and 2017 were held for 10 days or more beyond when they should have been released. More than 40 percent were confined for a month or longer; 15 percent had to wait two months or longer.
In 2014, 88 psychiatric hospital admissions went beyond medical necessity, but that figure jumped to 246 the following year—a surge DCFS has struggled to explain, but that officials at the agency suggested could be due to the cases becoming more complex. Since then, the number of those admissions has continued to rise, though more gradually—from 292 in 2016 to 301 last year, according to DCFS statistics.
The result: Every day since July 2015 through the end of December 2017, at least nine children—and sometimes dozens—were unnecessarily held in psychiatric hospitals. There was a girl who spent so much time in one that hospital staff were asked to bring her a winter coat. She had been admitted in the summer.
Here’s how the system is supposed to work: After children are admitted to a psychiatric hospital, staff psychiatrists assess them and try to stabilize them, develop treatment plans that usually involve managing their medications, and then initiate a course of treatment to be followed with an outside doctor. After that, they’re typically released. Psychiatric hospitals are designed for short-term stays—days or a couple weeks—and staff often start planning for a discharge the day a child arrives.
Any long-term treatment is supposed to occur elsewhere, during appointments with outside doctors or at residential treatment centers, where psychiatrists and therapists have time to develop relationships with the child and address the deeper issues that led to the hospitalization and DCFS’s involvement, according to Christopher Bellonci, the chief medical officer at Judge Baker Children’s Center, a children’s mental-health nonprofit and an affiliate of Harvard Medical School. “Once the treatment is completed and the child is ready for discharge, then they’re just being housed there,” Bellonci said. “The child is not getting educated. They’re really not getting treatment. They’re just waiting, which in the life of a child is deeply problematic.”
DCFS, though, has known for years that when young people are held in psychiatric hospitals beyond medical necessity, problems ensue. In 2015, Illinois lawmakers commissioned an audit to determine just how pervasive the issue was. That, in turn, led DCFS to create a database to track children hospitalized beyond medical necessity.
For the agency, tracking those admissions has been neither easy nor consistent. The database, obtained through a Freedom of Information Act request, is riddled with errors, discrepancies, and missing information.
The officials brought in to fix DCFS have not lasted long in their tenures. Walker, whose predecessor resigned last year amid an ethics scandal, is the 10th director or acting director since 2011. The turnover has led to an approach to priorities and strategies that is informed more by crisis than by evidence, according to a 2015 report by court-appointed mental-health and child-welfare experts.
“It’s impossible for this to be addressed in a meaningful way unless there’s consistent, quality leadership,” Golbert said of the leadership turnover. “It’s a combination of resources and competence, and the state has neither right now.”
Several states have reformed their systems following lawsuits. In Massachusetts, for instance, a federal judge found in 2006 that the state had failed to provide home or community services to children with serious mental- and emotional-health disorders who were covered by Medicaid. Following the judge’s ruling, the state began offering additional screening, in-home therapy, family support and training, and a crisis-stabilization program that sent workers to provide in-home treatment for the child.
Illinois recently settled a similar lawsuit of its own. A federal judge in January ruled the state’s Department of Healthcare and Family Services must offer Medicaid-eligible children who have mental- and behavioral-health disorders screening and treatment in their homes and communities. If they receive timely treatment before they have to be hospitalized—though those services are scarce as well—that could lead to fewer cases of children being held beyond medical necessity.
Until this year, DCFS was still spending weeks just to match children with facilities or foster homes—one of the first steps in the placement process. That time, according to DCFS officials, is now down to two or three days in most cases.
But even when there are beds available in other facilities, some of them refuse to admit children who have spent months at a psychiatric hospital—their extended stays are apparently taken as a sign that the children are particularly difficult to treat. In these cases, the longer they’re held in psychiatric hospitals, the more difficult it becomes to move them to the proper settings.
In fact, children in the DCFS system whose hospitalizations extended beyond medical necessity spent an average of 64 days in psychiatric hospitals between 2015 and 2017, according to my analysis. That’s more than triple the average stay—21 days—for all DCFS children who were in psychiatric hospitals during that time. And it’s about six times the national average of roughly 10 days, according to a 2017 survey by an industry group now known as the National Association for Behavioral Healthcare. While experts said they would expect DCFS children, and especially those held in psychiatric hospitals beyond medical necessity, to stay longer than other children, they said they were struck by how much longer such children spent hospitalized in Illinois.
In DCFS’s defense, it can be extremely hard to find homes for these children. Some are among the toughest to place, and some need extended hospital treatment. Their complex mental-health issues may reflect a devastating history of trauma. They can destroy property, be violent, or act out sexually. Those factors can make the children that much more vulnerable to the effects of unneeded psychiatric hospitalizations, on top of making them more difficult to place.
To DCFS, rushing into the wrong placement can be harmful to a child. “‘Must go faster’ is not necessarily the answer,” said Neil Skene, the special assistant to Walker. “If we hurry kids into a placement that can’t meet their needs and they have another episode, they’ll have a new diagnosis and a new hospitalization.”
But it can be agonizing for children to stay put when their mental health doesn’t require it. Terrence Wardell, now 18, speaks of the time he spent at Hartgrove Hospital in 2015 and 2016 as if it were a prison sentence, saying he “did seven months” at the facility on Chicago’s West Side.
DCFS took custody of Wardell in November 2015, while he was at Hartgrove. DCFS said his family did not get him his medication or take him to the doctor. (DCFS records show that his grandmother said they could not afford to pay for his medicine.) At Hartgrove, the clinical team conferred and recommended that he be discharged and moved to a residential treatment center.
DCFS matched him with three facilities, but two of them had six-month waiting lists. The third option was an out-of-state facility, but child-welfare officials tend to be reluctant to send children far from home. In December 2015, about a month after the clinical team gave its recommendation, Wardell’s lawyer filed a motion in court asking DCFS to explain what it had done to find Wardell a bed at a residential treatment center. A juvenile court judge granted DCFS permission to move him to a facility in Indiana.
But that never happened. His hospitalization dragged on through Thanksgiving, Christmas, and his birthday in March, and he became increasingly angry, arguing with staffers about his stay and even getting into fights with other patients. “I was fighting everybody because they wouldn’t let me go home,” he said.
On March 29, 2016, Wardell finally left for a residential treatment center. He now lives in a foster home. His quick smile matches his fast-talking demeanor. He is back in high school and applying for summer jobs at a couple of fast-food restaurants and a grocery store. In the end, he had been held beyond medical necessity for more than four months.
Illinois’s law is clear: When a child can no longer live at home, the state must find “the least restrictive (most family-like) setting” that is in his or her best interest.
But sometimes the law collides with young people like James Martin, whose severe autism and violent outbursts make him one of the agency’s most difficult children to place. At 18, Martin functions much like a 2-year-old, yet has a 6-foot-2-inch, 223-pound body. Loss marked his childhood. His mother, a teacher’s aide, died when he was not yet 2. His father, DCFS records show, was absent from his life. After his mother’s death, his grandmother became his guardian. When, during his teenage years, she suffered a stroke that left her largely bedridden, his aggression intensified. He broke doors, hit family members, and ran out of the house in the middle of the night. His aunt, Floraline White, then became his caretaker.
“He has no idea why but he harms others,” a social worker wrote in May 2016, after White had taken him to a hospital emergency room because he was increasingly aggressive at home. A DCFS worker offered a possible explanation in a separate report: “As James has limited expressive language skills, he may be expressing his feelings of grief and loss through aggressive physical outbursts and inability to sleep, and isolating himself towards others.”
In the emergency room, Martin vacillated between calmly watching TV and screaming and swinging his fists. Staff frequently restrained him. He was released in late May 2016 but was taken to another hospital days later. He spent most of June “under heavy sedation,” according to court records.
Around that time, as White felt she could no longer safely care for Martin and her nieces, she gave up custody of Martin to DCFS. DCFS transferred him to the Comprehensive Assessment and Treatment Unit at the University of Illinois Medical Center at Chicago, a small, nine-bed unit reserved for the most high-risk DCFS children in need of psychiatric care.
After nearly five months there, doctors determined Martin was ready for discharge. But the days beyond medical necessity started to pile up as the department searched for a residential facility that would accept him. Soon they outnumbered his initial treatment days. His doctor sent an email in April—five months after he was deemed ready to leave—to DCFS in which he wrote he was “disheartened” to learn that DCFS had not finalized a contract with an out-of-state facility. The doctor wanted Martin placed “as soon as possible.”
Two more months passed before Martin was able to leave the hospital for a residential facility in Kansas. By then, he had been held seven months beyond medical necessity, the longest of any child over the past three years. “I wish he could have gotten the help he needed sooner,” his aunt said.
On his first day at the facility in Wichita, he rode a bike. Less than a month after his arrival, workers noted a sharp drop in the number of times he was physically aggressive, destroyed property, or tried to run away. White said she has also witnessed considerable progress in his ability to communicate with her during their scheduled Skype calls and her visits. “Why did it take so long?” she wondered.
Each week, B.J. Walker meets with her staff at DCFS for two and a half hours to go through cases like that of one 8-year-old girl who, in 2015, spent 153 days in a psychiatric hospital—only 20 of them medically necessary. Walker and her colleagues call them “stuck kids.” “We are doing everything under our power to take a look at every single kid and to understand their narrative and their situation well enough so that we can offer them some sort of rescue,” Walker said.
But DCFS faces enormous obstacles. Over the last couple of years, Illinois lost more than 350 beds at residential treatment centers. Some residential facilities had documented histories of abuse and assault by employees and, in some cases, DCFS stopped sending children to them. Others couldn’t continue to operate at the rates the state was paying and had to shutter their programs.
DCFS simply does not have the money to pay facilities enough to hire specialized staff to adequately care for children with such serious needs, said Andrea Durbin, the CEO of the Illinois Collaboration on Youth, a nonprofit that represents child-welfare facilities and groups across the state. Some residential treatment facilities, said Durbin, have had to supplement the money they receive from the state with their own funds. “None of us want to see those kids languishing,” she said. “We know, in fact, leaving them there makes it harder to treat them. The longer they stay, the more angry they get, and justifiably so.”
As the number of available beds in residential facilities dropped, DCFS hoped to replace many of them with therapeutic foster homes run by specially trained caregivers. But the department took away residential beds before the therapeutic foster homes had developed enough appropriate replacements. There are still too few such beds, given how many children needed placements.
The key isn’t just finding additional beds, Walker said. It’s finding the right beds. In fact, DCFS spends tens of thousands of dollars a month on contracted residential beds across the state, but they sit empty because the services the facilities offer don’t match the needs of the children waiting. In addition to severe mental-health issues, some children also have medical issues or juvenile justice records that complicate their care.
Walker acknowledged that identifying the appropriate placements and building them out will take years. Consequently, department officials have started to repurpose existing facilities and are working to modify some specialized foster homes to serve more children, she said. The department also hopes to expand a program that sends teams out to homes of children having mental-health episodes, potentially averting hospitalization. The federal government will be putting money toward that effort.
Still, DCFS should have done more, and done it sooner, said Heidi Dalenberg, the general counsel for the American Civil Liberties Union of Illinois, which monitors DCFS as part of a decades-old court agreement that grew out of a lawsuit over the agency’s failure to provide adequate care. She said that addressing the cases one at a time in the way DCFS staff does during weekly meetings is not a realistic solution to such an enormous and systemic problem.
In 2016, a federal judge signed off on a plan aimed at keeping more children in family-like settings and out of psychiatric hospitals and other institutions. Additional recommendations by court-appointed experts followed in 2017, but there has been “limited or no action by the Department” since October, the experts wrote in April.
As part of that plan, DCFS launched four therapeutic-foster-care pilot programs in 2016. It hoped to have at least 140 beds in those programs by now, but the department halted two of the pilots when it ran into problems with recruitment and training. Instead, there are only 30 or so therapeutic-foster-home beds available, DCFS officials said. DCFS’s inaction in the face of the programs’ failings, Dalenberg said, has been “patently inadequate.”
Gabriel Brasfield, the 12-year-old who spent eight weeks in a psychiatric hospital that he didn’t need to, had been in and out of such facilities since he was 5. By the time he was 10, his grandmother, Lorelei Heric, relinquished custody to DCFS. She said she was no longer physically able to care for him. “It was the worst thing I ever had to do,” Heric said. “Talk about selling your kid down the river.”
The incident that triggered his 2016 hospitalization occurred at Heric’s home. Brasfield had been doing well, and his psychiatrist recommended he stop taking his medication. But when he did that, he began to lose control of his anger. One night, he spray-painted walls and couches, poured chocolate ice cream and a cleaning product on the computer, and stuffed towels in the sink and bathtub before turning on the water. “He is the most kind person until he has a meltdown,” Heric said recently.
After more than two months in the hospital, Brasfield’s lawyer argued that DCFS had “failed to locate a placement for one of its own.” Brasfield told me he spent hours at the psychiatric hospital just staring out the window. “The responsibility to find an appropriate placement for Gabriel falls directly upon DCFS,” the lawyer wrote to a judge in June 2016 as she tried to get him released from the hospital. “Whether the reasons for such failure to find a placement are budgetary, staff related, or a shortage of foster homes is irrelevant.”
Brasfield was released the next month, bringing his total time beyond medical necessity to 58 days. Then, over the next 19 months, he bounced from a foster home to a residential treatment center, and then to a psychiatric hospital. In February of this year, he was admitted to the psychiatric unit at Rush University Medical Center, in Chicago. (Rush declined to comment for this story.) Again, he had to wait two months for DCFS to find him another place to stay. “He feels like he served his time, and he wants to get out of there,” Heric said. “People that go in without a release date have no hope. They have nothing to work for.”
A few weeks ago, after I asked DCFS about Brasfield’s status, he was transferred to a residential facility. The news of the move, he said, made him both excited and apprehensive. As tedious as his time had been at the hospital, he had grown accustomed to the monotony. He and Heric said that the staff had even devised a plan to get him outside twice a week: He’d change into blue medical scrubs, and then employees at Rush would walk him down to a green space or to a parking garage. For 45 minutes or so, he was able to feel the sun on his face.
This post appears courtesy of ProPublica Illinois.