Last September, after watching the girl he had a crush on stroll into a movie theater alongside another boy, 14-year-old Billy quietly went to the men's room, removed his shoelaces and tried hanging himself from the coat hook on a stall door.
A fellow moviegoer, seeing feet dangling from behind the door, alerted the manager, who cut the lace and called police. Billy (a pseudonym), his face spider-webbed with burst blood vessels, was escorted from the theater in handcuffs. Police phoned his mother, Joan (also a pseudonym, to protect her juvenile son's privacy), who rushed Billy to the emergency room. It was his second suicide attempt in a three-week period.
"After his first attempt we got him in to a psychologist, who I called on the way" to the ER, says Joan. "I'm like, 'I don't know what to do.' He said if I was really afraid I should take him to the hospital, because they will have to admit him."
After a series of tests to ensure that no brain damage had occurred, Billy was taken to Meriter's Child and Adolescent Psychiatric Hospital. It was well after midnight when Joan turned onto the hospital's long, dark and winding driveway.
For children like Billy in crisis, the psychiatric hospital is the only inpatient refuge in a multi-county region that stretches across state borders.
Many of the hospital's patients are from impoverished families burdened by chronic environmental stresses. The traumas are as various as the unrest they inspire. Some have witnessed a parent's death or discovered a sibling who'd committed suicide. Others are victims of incest or physical abuse.
Some suffer from severe mental diseases, like thought disorders. Still others, like Billy, are actively suicidal. Many are admitted in times of crisis to stabilize their erratic, often dangerous, behavior.
"A six-year-old who is with us right now is a child who smears feces everywhere," says Nancy Henderson, a clinician specialist. "That's not a typical six-year-old. That child is telling us something is not right in his world.
"Our hospital is a place where we can very intensively assess them. We bring the family in and try to get collateral data from everybody who knows the child. We're a place where we bring all of this data together."
Since opening in 1994, the hospital has never turned a profit. Last year, its operating costs were $5 million, but nearly $1 million was written off as charity care or lost to low Medicaid reimbursement rates. Yet Meriter keeps the hospital open because there is a clear and pressing need for child inpatient psychiatric care.
"As far as I'm concerned, it was quite a significant decision on the part of the Meriter board to establish the hospital, because they knew that, financially, this wasn't even a break-even proposition," says Robert Gore, Meriter's director of behavioral services. "We are supported by more profitable medical programs."
At 20,000 square feet, the Child and Adolescent Psychiatric Hospital sits on 60 acres on Madison's far west side. It has 22 beds, 13 for adolescents and nine for younger children. The two populations are kept separate. A well- trained 60-person crew - including two state-certified teachers, three social workers, five occupational and recreational therapists, 10 mental health specialists, a 15-person nursing staff and a psychiatrist - fills out the hospital's payroll.
Meriter is a safe haven for children in crisis, and a wellspring of information for parents who are new to the mental health care system. Parents cope with their child's illness in a variety of ways and differ in their ability to understand what is occurring.
"We work with families to support their understanding of mental illness, so we do a lot of education," says Henderson. "We have an important obligation to make this a positive experience, because that will impact what they do later. We try to keep that in mind from the moment they walk through the door."
Joan had no idea what to expect upon arriving at the hospital. Her crash course in the mental health care system began three weeks earlier when she discovered a suicide note Billy had written before ingesting a dozen Adderall, an amphetamine prescribed to treat his attention-deficit disorder. The next morning, Billy's pediatrician diagnosed him with depression. He was prescribed Prozac and referred to a psychologist.
"I thought we were on the road to recovery," Joan recalls. "But by that time he was bad. He had the feeling he didn't want to live anymore."
Hospital staff quickly dispelled Joan's apprehensions about placing Billy in a psychiatric hospital. They walked her through the admittance process, showed her the suicide-proof room Billy would sleep in for the next seven nights and informed her that, except for Sundays, there was only one visitation hour each day.
"I didn't want him to think I was abandoning him there," she says. "It wasn't like I could go hang out with him there. It was really emotional. He just looked at me and said, 'It's going to be okay.' So, I left that night knowing he was going to be in a safe place."
From the moment they're admitted, children are under constant observation. Some undergo neurological tests, like MRIs, to look for physiological root causes. Then there's a daily cycle of therapies, counseling sessions and schooling.
"Because they're in an intensive inpatient setting, we can do very in-depth psychological testing, language testing, and intensive family work," says social worker Deirdre Green. "There's a real variety in how parents deal with this situation and how much they're able to engage. Some parents just have difficulty understanding certain things about mental illness."
Parents often find it traumatic to face that their child has a mental illness. They go through a classic cycle of shock, grief, resignation and acceptance.
"It's the grieving," says Marie, whose son has autism with a dual diagnosis of mental illness, "because this person you brought into the world may not be what you had hoped he would be. For a long time I saw myself as someone who has a child with autism, instead of, 'This is my son.'"
Unfortunately, a parent's reluctance to accept that their child is mentally ill can worsen the situation by delaying treatment. And sometimes the parents are themselves mentally ill or have substance-abuse problems, which can greatly compromise their child's aftercare treatment.
"We make every effort to make families better understand," says Henderson. "If a family is unable to do that, and it's a situation that we're very concerned about the child's safety, then maybe it's a neglectful situation and we'll make a report to the county. But, in general, parents are very concerned about their children's health."
Making a diagnosis
According to the National Institute of Mental Health, about one in 10 children and adolescents suffers from a mental illness severe enough to cause some level of impairment. At any given time, says the Surgeon General's Office, five million children have symptoms severe enough that they interfere significantly with their ability to function normally.
And the Centers for Disease Control names suicide as the fourth leading cause of death for children ages 10-14 and the third leading cause of death for teenagers 15-19.
But many psychological disorders in kids go undiagnosed or misdiagnosed. Other times, problems are addressed through medication that could benefit from more intensive treatment.
It's when a situation becomes critical that the Child and Adolescent Psychiatric Hospital gets involved. Getting a full diagnosis based on a thorough assessment and observation is among the most important things the hospital does. But identifying a child as mentally ill is simpler than teasing out a specific disorder from a diagnostic bundle of overlapping symptoms.
Pinning down specific disorders in autistic children, who make up 7% of the hospital's annual 400-patient census, can be especially tricky. It took more than five years and nine hospital visits before Josh, a highly functioning autistic child, was diagnosed with schizoaffective disorder, which, symptomatically, falls between schizophrenia and bipolar disorder on the mood disorder spectrum.
"There's a secondary piece to his autism that has always been difficult to figure out what it is," says his mother, Marie. (Again, both names have been changed.) "Basically, we're talking about a neurological condition whose symptoms can manifest themselves in unsafe and unpredictable behaviors."
Josh, now 15, was hyper-impulsive. He would run into traffic and try jumping out of windows. Once, during a tantrum, he shattered the windshield of the car his mother was driving. The event that first brought him to Meriter occurred in 2001, when Josh was 7. After scaling a 60-foot crane, he socked his grandmother when she lured him down.
"During the first hospitalization, what they needed to do was take him off of all of his medications and assess, 'Okay, where is this child?'" says Marie. "He punched my mother and gave her a black eye! I mean, this is a 7-year-old child."
Marie had suspected that Josh was autistic from the time he was nine months old. The pediatrician disagreed, but as he got older his behavior grew increasingly bizarre.
At age 4, he was diagnosed with attention-deficit disorder, and prescribed Ritalin. Other diagnoses followed: obsessive compulsive, oppositional defiant, sensory defensiveness, Tourette disorder and bipolar disorder. Efforts at treatment were unsuccessful.
His mother still suspected autism. "You can pull symptoms or disorders and pieces of them might fit, but when I looked at the diagnostic criteria for autism, he fit," says Marie, who contacted a physician at Meriter. "He saw our son, did all of these tests, and said it was some kind of pervasive developmental disorder. It was also at that time that Josh's behaviors were becoming more aggressive, and the doctor suggested he be hospitalized."
Like many patients, Josh was taken off his medications so his baseline behaviors could be observed. In time, he was diagnosed with autism and schizoaffective disorder.
"Most of the kids come here because their behavior has been unmanageable," says Green. "And they come because everyone is at a loss of what to do. So, often the behaviors are right out there."
Only the beginning
Days at the hospital are tightly structured. In addition to two hours of schooling each morning and afternoon, patients undergo counseling sessions, group therapies and other checkups throughout the day.
Assessments are done to identify underlying factors, like family issues and developmental disorders, that aren't psychiatric in nature. How the child deals with authority, peers and his or her environment, how well he or she is able to focus and whether behaviors are developmentally appropriate, are closely observed by staff.
The child's interactions with parents during family sessions are given special scrutiny.
"There are some situations, like if a child is being sexually abused, that we really keep our eyes open for," says Green. "Unfortunately, that is something that happens much more often than people are aware of."
Much of the treatment planning and diagnosis occurs through group work. For example, what looks at first like an art class is actually an occupational therapy group where therapist Brian Holmquist gauges how well small children follow directions and sequence multiple-step projects.
"Those groups help us generate some treatment ideas," explains Holmquist "So, if we're identifying kids as having trouble with social situations or peer relations, we might put them in a group to help them learn specific skills."
At 11 a.m. each day, the interdisciplinary staff discuss their observations on each child. The goal is to get a clear picture of where a patient's struggles lie, then suggest a course of treatment. A psychiatrist tweaks each patient's treatment plan based on the sometimes widely disparate opinions of staff.
"To me, that's where the real work takes place - setting up a treatment plan and adjusting that plan on a daily basis," says Gore. "The interesting aspect of this is that we work on it from a team basis. This is really significant, because it's not done that way in a lot of places."
A significant part of what the psychiatric team does is prepare children for a smooth reentry into their world. This often means working to plug families into the county's financially strapped mental health care system.
"Here is just the beginning stage," says Holmquist. "True treatment is going to happen in the real world."
While Dane County is rich in resources, waiting lists for services are long.
"We often need the county to be involved, but they have such limited resources, and things get tighter each year," says Green. "That's really frustrating, because I don't have a lot of ability to change that, but I can advocate strongly for a patient."
Gore says almost every child in crisis is admitted: "The only thing that would prevent us from taking a patient is that the diagnosis was not appropriate to what we deal with as treatment."
Paying the price
Two weeks after his discharge from the hospital last fall, on the eve of Halloween, Billy again tried hanging himself. This time, he bolstered his effort by lacerating his arms. At some point, his will to live supplanted his desire to die and he woke his mother. He was taken to the emergency room, where he received 27 stitches, and was then readmitted to the psychiatric hospital.
"I didn't know what to do. We had a great night carving pumpkins," says Joan. "I was just thankful I had another chance to fix this. Then it hit me again that this is so serious. I had a couple nights where I cried because I didn't know what to do to stop him from doing this again."
But now a new dilemma was emerging: Billy's first visit had nearly exhausted his annual mental health benefit.
Billy's first hospital stay cost $20,000 for seven days. His second visit was billed at $14,000. Joan's insurance policy covered $30,000 of this, leaving her with a $4,000 bill. A $30,000 inpatient benefit is, relatively speaking, generous. But even this was not enough.
"Each [insurer] provides a slightly different type of coverage, but the bottom line is that you're not provided the same level of coverage for mental health services as you are for medical services," says Gore.
State law requires insurers to provide a minimum of $7,000 in mental health coverage annually. In 1985, the year this threshold was set, $7,000 covered about 30 days of inpatient care. In 2007, it covers about three. Forty-one states have in recent years increased the minimum mental health coverage they require. Until this summer, North Carolina didn't even require insurers to provide any mental health care benefits.
Gov. Jim Doyle has included language in his 2007-09 budget that would increase this minimum benefit. Similar legislation has repeatedly been introduced and defeated over the last two decades. At the federal level, both the House and Senate have introduced parity legislation, but President Bush has vowed to veto any mandated increases in mental health coverage. The federal parity hasn't changed since 1998.
And the Medicaid reimbursement is 24 cents of each dollar billed. "That's just the rates," says Gore, adding that last year the hospital lost $730,000 in unreimbursed Medicaid charges. An additional $273,000 was written off in charity care. Parents can have their bills reviewed by a non-compensation committee, which can write off or make adjustments to a patient's bill.
"You have to make a profit to build the kind of facility we built," says Gore. "If you want the best clinical staff, you have to pay the best wages. If you want equipment, you need to spend money on equipment. Yet you don't want to discharge somebody and send them home with a $30,000 bill."
The summer months are the hospital's slowest. But the start of the school year often brings a spike in admissions.
"That's when things really fire up," says Gore. "It's an interesting phenomenon that when school starts, we shoot right up to 16 to 18 patients."
Billy hasn't made another attempt on his life since last October, and though she worries about the pressures that come with a new school year, Joan is optimistic. "We're so far ahead of where we were a year ago this time," she says. "It's not one day at a time anymore, when my job was to keep him alive; he's doing great."
Two years have passed since Josh, now 15, was last hospitalized. Following his last stay at Meriter, he was admitted to a special school for autistic children in Oconomowoc, where he spent 10 months before returning home last winter.
"We had tried to do this about five years prior, but the county denied us, saying that we hadn't tried all of the resources," says Marie. "But my husband and I are tireless advocates for our son. So, we kept at it."
A seamless transition from inpatient to outpatient is considered a successful discharge. But many staff express that the worst part of their job is discharging a kid back into a situation where there is a low chance of success. It can, at times, seem hopeless.
"But then you get a little nugget of success," says Holmquist. "You really need to rely on colleagues for decompression, because this is tough work. Most days you're not going to go home with a success story."