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Shortage of inpatient beds in Maryland psychiatric hospitals is putting children at risk, officials worry

Inside a Maryland juvenile detention facility in Anne Arundel County, officials struggled to manage a girl who tried to injure herself and staffers on numerous occasions.

She threatened to stab workers with colored pencils and attempted to assault them and other youth. After she tried hanging herself, staff at the Thomas J.S. Waxter Children’s Center in Laurel, not trained for the level of mental health care needed, put her in physical restraints inside her cell, one of several times they’ve done so after she attempted to kill herself or harm others.

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What happened to the girl represents the opposite of how state policies and advocates say such cases should be handled, and violates best practices calling for children in need of intensive psychiatric care to be housed in hospitals, not jail cells. She spent at least three weeks at Waxter until the state found an inpatient psychiatric hospital for her, according to the Department of Juvenile Services.

The incident also spotlights Maryland’s serious — some argue dangerous — shortage of staff, beds and treatment options for at-risk youth and, the public defender’s office said, violates state law. The state had been slow to adopt better methods, experts and advocates say, and the sharp uptick in mental health issues facing youth during the COVID-19 pandemic may have only worsened things.

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With juvenile psychiatric beds continually at capacity and a long waitlist, state officials say Maryland is not equipped to handle such incidents in its facilities. In addition, courts increasingly are sending children deemed not competent to stand trial to an alternative residential treatment program for minors. But even that program is currently full, which juvenile justice advocates say is pushing more minors into detention centers.

“We don’t want those places to become the default for people with severe mental health issues,” said Nick Moroney, director of the state’s Juvenile Justice Monitoring Unit, a group in the Maryland Attorney General’s Office charged with overseeing the Department of Juvenile Services’ treatment of children in state custody.

Nick Moroney heads the Maryland Juvenile Justice Monitoring Unit. He's pictured outside the Baltimore City Juvenile Justice Center on Gay Street in December 2015.
Nick Moroney heads the Maryland Juvenile Justice Monitoring Unit. He's pictured outside the Baltimore City Juvenile Justice Center on Gay Street in December 2015. (Amy Davis / Baltimore Sun)

The unit included the account of the girl who attempted to hang herself in the Laurel detention facility its latest quarterly report issued in August.

“During the young woman’s stay at Waxter, behavioral health staff made daily phone calls to local inpatient hospitals to attempt to locate a bed for her,” the Department of Juvenile Services wrote in response to the report.

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While she was at the facility, there were at least 22 incidents where the girl acted out in a number of ways, ranging from swallowing random objects to punching a staffer, the report found.

Several times the girl was placed in mechanical restraints and isolated from other youths on site, sometimes for hours as staffers tried to subdue her. But that’s not how DJS should have responded to a child suffering from severe mental health issues, according to the report.

“The emphasis on compliance in correctional settings and a reliance on maintaining control through use of verbal commands (directives), physical and mechanical restraints and isolation (seclusion) to enforce compliance can be ineffective and re-traumatizing for many youth and can lead to both staff and youth physical and psychological injury,” the report reads.

Moroney, who helped write the report, acknowledged that staffers didn’t have much choice.

“I think they tried to handle the child with as much consideration of her situation and her feelings as they could, given the resources they had,” he said. “They’re not mental health experts. At the same time, they have this overarching mandate to keep the kid safe and to keep everybody else safe.”

In response, DJS says that all detention centers have “onsite clinical expertise to address youth needs” and that, during this period, six licensed clinical staff and two addictions counselors were assigned to Waxter.

“Through their professional yet compassionate care, the Waxter staff protected and supported the young woman during a difficult time,” DJS wrote in response to the report, while adding it tried several times without success to admit her to an inpatient psychiatric program.

The state has been struggling with an ongoing shortage of psychiatric beds, exacerbated by increased demand brought on by the stresses of the COVID-19 pandemic.

Maryland Department of Health spokesman David McCallister said that all state-run inpatient psychiatric facilities were at capacity as of Oct. 25. There are about 1,629 adult and juvenile beds at the five state-run psychiatric institutions, but only 1,026 are staffed, according to state officials.

And data from the Maryland Health Care Commission shows the average bed occupancy rate among acute psychiatric care units in general hospitals rose from about 68% in both the second and third quarters of 2020 to almost 74% by the last quarter, the latest data available.

DJS spokesman Eric Solomon said the department is working with “all-child serving agencies” as well as the Department of Health and Department of Human Resources to advocate for more psychiatric services to be made available for children.

“In addition to providing treatment in our residential facilities, DJS contracts with many providers and are always looking to improve our continuum by increasing the access of behavioral health services to our youth,” Solomon said in a statement.

The state has taken some steps to provide more psychiatric care to younger patients. In June, the University of Maryland Children’s Hospital opened the “Trauma-Informed Children and Adolescent Psychiatric Unit,” a 16-bed treatment facility for children and teens “experiencing acute mental health crises.”

However, it did little to alleviate the state’s occupancy rate for such facilities as evidenced by the waitlist for treatment.

Without private providers adding more beds or the state funding an expansion of youth psychiatric services, the state’s juvenile capacity problem will only be exacerbated by the ongoing demand.

After a juvenile is arrested for a crime, a judge determines whether they need to be evaluated for competency to stand trial. Children also must be evaluated for their maturity and their ability to behave in the courtroom. The standard is based on “developmental normalcy,” according to the Department of Health.

Juveniles who’ve been ruled incompetent to stand trial can be sent to the Spring Grove Hospital Center, a 375-bed facility in Baltimore County “that provides a broad spectrum of inpatient psychiatric services to adults and adolescents, as well as comprehensive residential psychiatric services to adults.”

Children sent to Spring Grove must fit specific criteria, including having a mental disorder, needing inpatient care and posing a danger to themselves or others. But that facility is among those McAllister cited as running at full capacity.

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If cases where they’re found not competent but likely to attain competency within 90 days, some juvenile defendants are sent to outpatient services in their community.

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But increasingly, courts are ordering placement in an alternative residential treatment program at a Maryland Department of Health facility for children in Rockville. The state health department reported that 62% of juveniles found not competent for trial were referred to the Rockville facility’s program in 2020, compared with just 38% in 2017. That’s resulted in “limited space” in a facility where stays typically average a little less than 3½ months, but can be up to 18 months if court-ordered.

Solomon said two minors are waiting to be placed at the Rockville facility as of Oct. 25, with one being housed at a state detention center awaiting an opening.

“Youth are placed in DJS detention facilities through court orders, which DJS is required to follow,” Solomon wrote in an email. “By law, competency attainment services cannot be provided in a juvenile detention facility.”

Jenny Egan, the chief attorney of Public Defender’s Office’s juvenile division, said the courts and DJS are violating Maryland law, which states that if a child is ruled incompetent to stand trial but has a reasonable probability of attaining competency, courts cannot place them in a detention center.

“Our courts and DJS are ignoring the law and holding kids in jail until beds come open,” she said, adding there’s a lack of accountability as “we have long known there are not enough beds and resources for children with psychiatric needs.”

Egan argues the juvenile services department has conflicting priorities, advocating for more rehabilitative services even as it invests millions of dollars into upgrades for a Western Maryland youth detention facility to improve its security for higher-risk juveniles. That Garrett County center has sat dormant for months after the daily population was moved out during the coronavirus pandemic.

“We need comprehensive wraparound services and a continuum of care,” Egan said. “What DJS must do is not just build more facilities ... they need a comprehensive plan to build a continuum of care with a focus on maintaining and treating kids with the highest needs in our communities.”

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