By Ben Rappaport
This is the first in a two-part project about the children’s mental health crisis in Bladen, Columbus, Robeson and Scotland counties. Read the second story, which focuses on the foster care system, story here.
A 9-year-old girl who spent four months last year inside the Columbus County hospital’s emergency department lashed out at nurses and clawed at the drywall. She wasn’t allowed to use a fork over fears she would use it as a weapon.
Each day, staff at the Columbus Regional Healthcare System tried desperately to secure a bed for the child at a pediatric mental health facility. But such placements can be hard to find in North Carolina.
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The girl had been in numerous foster homes where she experienced physical and mental abuse, said Dr. Jugta Kahai, the pediatric medical director at Columbus Regional in Whiteville. “Here is a 9-year-old who’s been severely traumatized,” Kahai recalled during a recent interview. “Yet, she’s sitting in a concrete bunker with no window, no therapist and heavily medicated.”
Nationwide, children are dealing with a mental health crisis that experts say is fueled by bullying, the COVID-19 pandemic, discrimination and other stressors. Health care professionals in rural southeastern North Carolina say more and more children are suffering – and struggling to find help in a poor region that needs more mental health specialists.
As a result, children end up staying days, weeks or even months in emergency departments or at local departments of social services, both of which are considered by the state “inappropriate crisis settings.”
Eastpointe, a health management organization that serves Robeson, Scotland and several other counties, saw an average of six Medicaid-enrolled children at any given time in such settings during the first three months of 2023, data shows – an average of five in emergency departments and one in a DSS office. The figure marks a 20% increase from the previous three-month period but doesn’t include children with private insurance who were awaiting treatment.
Trillium Health Resources, which serves much of eastern North Carolina including Bladen and Columbus counties, saw a 55% decrease during the same period, with an average of four Medicaid-enrolled children at any time in emergency departments and one in a DSS office.
The decrease doesn’t paint the whole picture, however. Kahai estimates that more than a quarter of her patients have behavioral and mental health concerns. In her 24 years as a pediatrician, including the past seven in Columbus County, she said she has never seen such intense need.
The 9-year-old she treated was one of countless children in the area who have been involuntarily committed to emergency departments for extended periods with nowhere to receive proper psychological care, Kahai said. The girl was eventually placed in an out-of-state psychiatric care facility.
Greg Wood, the outgoing chief executive at the Scotland Health Care System, said a young teenager had to stay so long at the Laurinburg hospital while waiting for a behavioral health placement last year that staff arranged for local first responders to show up in a fire truck to ease the kid’s boredom.
“He always wanted to see a fire engine,” Wood said. “He got to climb on the fire engine.”
Officials say rural southeastern North Carolina needs more of every kind of health care provider, from nurses to specialists. The shortage has been felt acutely in behavioral health.
In Columbus County, home to 50,000 residents, there are about 600 patients per mental health provider, according to the 2023 County Health Rankings from the University of Wisconsin Population Health Institute. The number is even higher in neighboring Bladen County – 1,020 patients per provider.
Columbus, Bladen and Scotland are among 68 North Carolina counties that don’t have a children’s psychiatrist, according to the American Academy of Child & Adolescent Psychiatry. Robeson County, home to 117,000 people, has one.
Meanwhile, suicides per 100,000 children increased from 1.1 in 2018 to 1.7 in 2022 in North Carolina, according to the latest “report card” from NC Child. More than one in five high school students said they have seriously considered attempting suicide, reported the nonprofit organization, which gave the state an “F” grade in April after examining 15 indicators of child health.
Adverse childhood experiences
In one afternoon at Advanced Pediatrics & Family Care in Whiteville, Kahai saw a newborn who tested positive for opiates, a toddler who was cared for by great-grandparents because the child’s mother was using drugs, two children with attention-deficit/hyperactivity disorder and one with clinical anxiety.
The same day, she was scheduled to see two patients under the supervision of the local Department of Social Services, but neither showed up.
Children everywhere and from all backgrounds are experiencing mental health concerns, experts say. Adolescents in rural southeastern North Carolina have challenges that include poverty, drugs, racism and climate uncertainty. Some families are still displaced from their homes following hurricanes in 2016 and 2018.
The percentage of children living in poverty in Columbus County declined by 8.4% between 2014 and 2022. But last year’s poverty rate of 26.6% remained much higher than the statewide rate of 17.9%, according to Data USA.
Poverty is considered among adverse childhood experiences – often called ACEs – that can have lasting negative impacts on children. Others include experiencing or witnessing abuse, growing up in a household with substance use or mental health struggles and being separated from parents who are incarcerated, according to the Centers for Disease Control and Prevention.
Nineteen people died of drug overdoses in Columbus County in 2022, the highest number since the N.C. Department of Health and Human Services began tracking on its data dashboard. In Robeson County, 103 people died.
The opioid epidemic is contributing to an overburdened foster care system. The number of children in foster care more than doubled between 2018 and 2022, according to the local Department of Social Services.
Columbus County has seen an increase of more than 84% in the number of children under DSS supervision since 2018, according to the local Department of Social Services. As of August, there were 112 children in foster care – and not enough foster families to care for them.
“When you come from a strapped rural county where funding is cut every year,” Kahai said, “you have to manage by compromising. It’s a sad reality. Often those kids need the facilities the most, yet they end up deprived.”
Dr. Jugta Kahai
Meanwhile, North Carolina’s hesitancy to expand Medicaid has compounded the mental health crisis, officials say. More than 23,000 additional people in Bladen, Columbus, Robeson and Scotland counties could qualify for the health care program once Medicaid expansion begins in December, according to the Cone Foundation.
Between 43% and 56% of residents in the four counties currently receive Medicaid, according to the N.C. Department of Health and Human Services.
Some say Medicaid expansion will help lure mental health professionals to rural, low-income areas. But North Carolina has not increased Medicaid rates for psychiatric care since 2012, giving psychiatrists and other mental health professionals little incentive to accept payments from the federal program run by states.
Wood said Scotland Health has tried twice over the years to bring psychiatrists to town. Both times, he said, the hospital system lost money. Unlike counselors or therapists who might see patients once a week, psychiatrists make money by prescribing medication less frequently – and when there aren’t enough patients, there isn’t enough money.
“They’ve got to see an awful lot of patients,” Wood said.
Kahai said trying to manage any clinic on Medicaid patients alone is “a non-viable situation.”
“When you come from a strapped rural county where funding is cut every year,” Kahai said, “you have to manage by compromising. It’s a sad reality. Often those kids need the facilities the most, yet they end up deprived.”
Over the last decade, funding for health care in Columbus County has plummeted. Between 2010 and 2019, the county’s health department saw a 68% decrease in revenues, the BBI previously reported.
Funding issues
David Pope, who will succeed Wood as chief executive of the Scotland Health Care System in December, said changes are needed in pediatric involuntary commitments, or IVCs, which are put in place when patients are deemed dangerous to themselves or others.
Patients who are held under IVCs “lose the right to make their own decisions while being treated under a court order for psychiatric problems or substance abuse,” NC Health News explained in an article in September. They can’t walk out of emergency departments, where the average wait time is 16 days for a placement at a state psychiatric hospital, according to NCDHHS.
“Keeping patients in [emergency department] settings for three, four, five months is a really bad way to care for people,” Pope said. “If I kept you in a small room for an extended period of time, that’s the sort of thing that tends to lead folks to aggravating mental health issues.”
While there are private mental health facilities available — including Holly Hill in Raleigh, Old Vineyard in Winston-Salem and Keep Hope Alive in Greenville — beds are still hard to come by, according to Kahai. It’s also difficult for children on Medicaid, who account for the majority of pediatric IVC cases in the region, to receive treatment at these facilities.
Long stays at emergency departments are largely a result of underfunded and understaffed state psychiatric hospitals. Nearly 3,700 positions were vacant at the state’s three psychiatric hospitals earlier this year, more than triple the vacancies reported in 2020, according to NC Health News. In turn, only 600 of the state’s 894 psychiatric hospital beds are being used, according to DHHS.
North Carolina lawmakers overhauled the mental health care system more than two decades ago, when the state had nearly 1,600 psychiatric beds. The state’s psychiatric facilities saw a 57% decrease in people served, from 5,754 in 2011 to 2,450 in 2020, according to a state report.
State lawmakers and health care providers are trying to combat the crisis. UNC Health announced last year it would build a 54-bed inpatient psychiatric hospital for children and adolescents in Butner in partnership with NCDHHS and a substance abuse treatment provider. The facility is scheduled to open later this year.
The recently passed state budget also invests hundreds of millions of dollars for mental and behavioral health services. That includes $50 million for UNC Health’s construction of a new children’s mental health hospital in the Raleigh-Durham region. The budget also includes $20 million in bonuses for workers in the state’s psychiatric hospitals and increased rates for mental health and substance use service providers. Over the next two years, the state also allocated $80 million for families with children suffering with mental health challenges.
Funding is also provided to establish the Psychiatry Access Line, which allows primary care physicians and pediatricians increased access to behavioral health specialists when they see patients with mental health needs.
To fill the need for child psychiatrists in rural communities, the state established funding to pay mental health specialists up to $100,000 to work in economically distressed Tier One and Tier Two counties, including Bladen, Columbus, Robeson and Scotland. New psychiatrists can also have part of their medical school debt relieved if they agree to work in rural communities for five years, under the $50 million expansion to the N.C. Loan Repayment program.
“Community-based mental health care options should be upstream,” Pope said. “But because those options don’t currently exist, we end up far down the river, very close to the waterfall.”
David Pope
Medicaid expansion could also help people in mental health crises seek help from primary care providers instead of emergency rooms. Pope said IVCs and placement in emergency settings should be a last resort, but due to a lack of community-based mental health services, it’s become the go-to option for many pediatric patients.
Pope said community care should attempt to intervene early so an individual’s mental health doesn’t end up in crisis.
“Community-based mental health care options should be upstream,” Pope said. “But because those options don’t currently exist, we end up far down the river, very close to the waterfall.”
Seeking solutions
Kahai takes time to build relationships with her young patients and their families. She says the effort brings a clear picture of the state of her community.
“It’s a new crisis every day,” she said. “And somewhere in between I have to find the time to see the other sick kids, too.”
While she may have a strong exterior, Kahai said the burden of patients’ mental health issues, lackluster communication from the Department of Social Services and the need to work longer hours at the hospital is beginning to take its toll.
“I really have not been sleeping well,” she said. “And with all I see every day, it’s hard to turn the work off and de-stress when I do get home. It’s just always something.”
According to a 2022 Addiction Professionals of North Carolina survey, 85% of behavioral health workers reported at least one symptom of burnout in the last few months. The most commonly reported symptoms were emotional or physical exhaustion, feeling overburdened or overwhelmed with the workload, increased strain on the ability to provide consistent resources and energy to work, and procrastination and trouble focusing on tasks.
“The folks that I know that work in hospitals are doing it because they truly care for people, and they want to make things in their communities better,” said Pope, whose academic dissertation focuses on access to mental health care in rural North Carolina. “But when the very person that you’re trying to care for is physically violent toward you, is verbally assaulting you, it’s hard to sustain that level of compassion.”
Pope’s dissertation was published earlier this year for the UNC-Chapel Hill Gillings School of Global Public Health, where he graduated last spring. In his research, which included interviews with more than 20 experts in mental health, he found “compassion fatigue” was a persistent problem leading people to leave the field.
Kahai said she is not planning to leave pediatrics any time soon, but she said there is a need for systemic changes when it comes to treating children’s mental health.
To avoid staff burnout and create more community-based care, Pope says the state needs to invest money toward mental health organizations. The state budget gives Trillium $2.5 million annually for the next two years and Eastpointe $1.6 million, which is similar to the organizations’ allocations for the past three years.
Making the investment Pope would like to see would “ensure that every county has access to robust mobile crisis response, a regional facility-based crisis center, and outpatient involuntary commitment for Medicaid and uninsured patients,” his dissertation reads.
Trillium already provides some of the community-based approaches Pope recommends, including mobile crisis units, which give patients access to doctors and therapists via telehealth and on-site certified medical assistants and peer-support specialists. The three mobile clinics in Bladen and Columbus counties each serve about 50 residents per week, the BBI previously reported. Robeson County also received funding in this year’s state budget to establish its own mobile crisis unit.
In June, Trillium announced an investment of more than $1 million for a family solutions program that will support the recruitment and training of additional foster care families. More than $89,000 of that funding is going toward the Boys & Girls Homes of North Carolina in the Columbus County town of Lake Waccamaw.
Other efforts are underway. UNC Health announced in August that it will partner with Bladen County Schools to bring four in-person therapists to the district. Students struggling with depression, anxiety and other issues will have access to telehealth appointments with specialists and psychiatrists through “virtual care centers” within the schools.
“Youth across our state are experiencing a behavioral health crisis, and a lack of resources in rural areas is compounding the challenges,” Dr. Mike Steiner, pediatrician in chief at UNC Children’s Hospital, said in a news release. “We are optimistic that this project presents a terrific opportunity to turn the tide and improve treatment for behavioral health conditions.”
Another important solution is improving health literacy, said Cindy Ehlers, chief operating officer at Trillium. Making sure adults are aware of the signs of depression, anxiety and other illnesses is an important step in providing children with proper treatment.
According to the UNC-Chapel Hill Health Literacy Map, a majority of neighborhoods in Bladen, Columbus, Robeson and Scotland counties rank in the state’s lowest quartile when it comes to health literacy.
“Health literacy is the first step in educating people so we can collectively work toward a solution,” Ehlers said. “When we don’t do enough to teach our young people about anxiety, depression and trauma, we perpetuate this stigma around mental health.”
The mental health care system in North Carolina is “profoundly broken,” Pope said. But he and Kahai both say they are hopeful that change is possible through a strong community spirit and a desire to help one another.
Hanging in Kahai’s office in Whiteville is a poster of a rainbow jaguar with pink and purple lettering that reads, “Pediatrician: an expert in all things related to booboos, owies and calming down parental nerves.”
Kahai knows that some of the worst booboos and owies are the ones that can’t be seen.
