Series: Crisis Point
How New York Wrecked Mental Health Care for Kids
Sara Taylor felt the knot in her stomach pull tighter even before she answered the phone. The call was from the hospital taking care of her 11-year-old, Amari. And she knew what they were going to say: Amari was being discharged. Come pick her up right away.
Taylor was sure that Amari — that’s her middle name — wasn’t ready to come home. Less than two weeks earlier, in March 2020, she threatened to stab her babysitter with a knife and then she ran into the street. Panicked, the babysitter called 911. Police arrived, restraining Amari and packing her into an ambulance, which rushed her to the mental health emergency room at Strong Memorial Hospital, not far from her home in Rochester, New York.
This had all become a sickeningly familiar routine. Amari had struggled since she was little, racked by a terrible fear that Taylor — who is her great-aunt and has raised her for most of her life — would leave her and not come back. She often woke up screaming from nightmares about someone hurting her family. During the day, she had ferocious tantrums, breaking things, attacking Taylor and threatening to hurt herself.
Taylor searched desperately for help, signing Amari up for therapy and putting her on waitlists for intensive, in-home mental health services that are supposed to be available to New York kids with serious psychiatric conditions. But the programs were full, and it took months to get in.
During Amari’s worst episodes, Taylor had little choice but to call 911 — which Taylor, who is Black, said made her nauseous with fear. She and Amari live just a few miles from the block where Daniel Prude, a Black man with a history of paranoia and erratic behavior, was hooded and pinned to the ground by police until he stopped breathing, in a 2020 incident that began after his brother called 911 for help. Prude died days later at the hospital. In 2021, a video went viral that showed Rochester police officers handcuffing a 9-year-old Black girl and pepper-spraying her in the face while she sat, sobbing, in the back of a squad car. Every time police entered her home, Taylor was terrified that Amari would end up hurt or dead.
“We know that Black children with mental illness are criminalized,” Taylor said. “When you have men with guns coming into your house to handle your sick child, that’s frightening.”
Several months earlier, in 2019, Taylor had filled out paperwork to apply for a place where she thought Amari would be safe: a residential treatment facility for kids with very serious mental health conditions. But the application was still pending in March 2020, and Taylor had no idea how long it might be before Amari got a spot.
Since the early 1980s, New York’s residential treatment facilities have served as an option of last resort for very sick children and adolescents, after outpatient and community-based services have failed. Like psychiatric hospitals, they provide round-the-clock medical and mental health care, but they are designed for much longer stays. Kids typically end up in them after cycling through emergency rooms and hospital beds without getting better. Often, they’ve had multiple encounters with police and their families see residential treatment as a last-ditch chance to get help before they end up in a juvenile lockup — or worse.
In the past 10 years, however, more than half of New York’s residential treatment facility beds for kids have shut down, with the total bed count plummeting from 554 in 2012 to just 274 this year. Sick kids often wait months to get into the remaining beds, despite a 2005 federal court settlement in which the state agreed to cut waitlists and make admissions faster.
State officials, who license and regulate residential treatment facilities, have done little to fix the problems, an investigation by ProPublica and THE CITY found. Instead, the officials made bed shortages worse, greenlighting facility closures even as the number of kids in psychiatric crisis soared. In recent years, the state also made the admissions system even more complex, keeping sick kids in limbo while they wait for care.
“Years ago, when you needed to move a kid up” to a residential treatment facility, “it just got done,” said James Rapczyk, who directed mental health programs for kids on Long Island for more than a decade. In the last several years, “the system just froze up.”
The residential treatment facility closures are part of a larger trend. New York has repeatedly promised to fix a mental health care system that officials have acknowledged to be broken, but in fact the state has made it even harder for the sickest kids to find treatment. As we reported in March, New York has shut down nearly a third of its state-run psychiatric hospital beds for children and adolescents since 2014, under a “Transformation Plan” rolled out by former Gov. Andrew Cuomo. At the same time, the state promised to massively expand home-based mental health services designed to prevent kids from getting so sick that they needed a hospital or residential program at all. In reality, those services reach a tiny fraction of the kids who are legally entitled to them.
That’s why, when the hospital called to say that Amari was ready for discharge, Taylor made one of the most difficult decisions of her life: She refused to pick Amari up. Taylor knew that she would be reported to child protective services and investigated for abandoning Amari — and that there was a chance she could lose custody of her altogether. But she was banking on the hope that, if Amari had nowhere else to go, state officials would fast-track her into residential care.
“The last thing I wanted to do was send my little girl away from home,” Taylor said. “But I couldn’t keep her safe.”
Up through the 1930s, children who were violent or psychotic — or even suicidal — were likely to either spend their lives in state-run asylums or be labeled as delinquents and sent to reform schools on the theory that they could be punished into good behavior.
Residential treatment programs appeared in the 1940s, founded on the premise that kids with mental health and behavioral problems were sick, rather than criminal, and needed specialized treatment. Over the next several decades, the model evolved to include a sprawling assortment of group homes, boot camps and therapeutic boarding schools — some with horrific histories of abusing and neglecting children. As of 2020, just under 19,000 kids were living in close to 600 residential treatment centers in the United States, according to federal data.
A few of those programs are run directly by states, but the vast majority are operated by independent providers that survive on a mix of public funds, private insurance reimbursements and patients with deep pockets. Often, insurance covers a stay of a month or two, and then families may be on the hook for anywhere from $50,000 to $200,000 for a year of treatment.
New York created its residential treatment facility program in the early 1980s as an option for young people who tend to get kicked out of other settings. In a typical year, more than 80% of kids in the facilities are physically aggressive; about 60% have histories of running away. When young people are admitted, the state nearly always enrolls them in Medicaid, the public insurance program, which reimburses providers $500 to $725 for each day of stay. Kids live in dorms, attend full-day schools and do art and recreational therapy, in addition to traditional counseling.
After a surge in the use of residential treatment in the 1980s and 1990s, however, advocates and the federal government have pushed to reduce the number of kids in institutions. This is partly because of new research: Studies show that young people who receive intensive mental health services at home have better outcomes — at far lower costs — than those who are removed from their families and communities. It’s also because kids in institutions are especially vulnerable to abuse. New York’s residential treatment facility providers have been sued at least five times in the past 10 years by kids who say they were sexually or physically abused by staff or other patients. (Four of the cases are still open; one was closed with no finding on the facts.)
A decade ago, the Cuomo administration announced a plan to cut psychiatric hospital beds. Residential treatment facilities warned state officials that they might have to close beds down, too. Reimbursement rates hadn’t gone up in years, and providers couldn’t pay enough to attract employees, according to a 2013 report commissioned by a coalition of mental health care agencies.
Rich Azzopardi, a spokesperson for Cuomo, told THE CITY and ProPublica that facility closures were part of “a national movement away from one-size-fits-all institutionalization and redirecting resources toward out-patient treatment.”
This year, thanks to a budget surplus and an infusion of federal money, the state legislature approved increases to funding for residential treatment facilities — up to about $25 million, in addition to nearly $9 million for COVID-19 relief and employee recruitment. The state also earmarked funds to open 76 new beds where kids can stay short-term during emergencies, according to the Office of Mental Health. But much of that new money has yet to reach providers, some of whom have lost hundreds of thousands of dollars on the programs in recent years.
Keeping staff in place is a persistent challenge. Residential treatment facilities rely on workers who earn as little as $15 per hour — not enough to convince most people to work with kids who are confrontational and sometimes violent, said Cindy Lee, the CEO of OLV Human Services, which runs a residential treatment facility in Lackawanna, New York. “Our wages are not competitive with Walmart, Tim Hortons, Burger King. You can go work an eight-hour shift at Target for more money, no mandated overtime and not be challenged by children with trauma.”
The 2013 report’s alarm bell went unheeded. By 2020, three facilities had shut down, while others cut back on beds. Then, in 2021, the system went into freefall when The Jewish Board of Family and Children’s Services — one of the state’s largest providers of mental health care for kids, and one of just a few agencies to run residential programs in or near New York City — got out of the residential treatment facility business altogether, closing three sites in the Bronx and Westchester County.
In addition to budget deficits, the facilities had faced several “programmatic concerns,” including excessive use of restraints, kids going AWOL and allegations of serious abuse, according to The Jewish Board’s closure application. But the model had also become obsolete, Dr. Jeffrey Brenner, the agency’s CEO, told ProPublica and THE CITY. The Jewish Board is expanding other programs that keep kids close to their families and get them home faster, Brenner said.
By law, proposed residential treatment facility closures must be reviewed by a state oversight board called the Behavioral Health Services Advisory Council, which hears petitions and makes recommendations to New York’s mental health commissioner. In September 2021, when The Jewish Board presented the council with its closure plan, however, all of the residents had already been discharged. At the Bronx site, staff had vacated the premises and the parking lot was stacked with moving boxes.
During the council meeting, members discussed their concerns about the disappearance of residential treatment facility beds. Michael Orth, the commissioner of the Westchester County Department of Community Mental Health, said that referrals had increased in the region, and that facility closures left “significant gaps” in care.
In the end, however, the council unanimously voted yes on The Jewish Board’s closure proposal. “Telling folks to stay open when it’s fiscally unfeasible makes no sense,” another council member said.
In response to questions about the timing of the closure application, a Jewish Board spokesperson wrote that the agency had worked with the Office of Mental Health, “diligently obtaining the required approvals at every stage of the process of closing down our three RTF programs.”
The Office of Mental Health did not address the timing of the closure application submission, but said that all of the children from the Jewish Board facilities were appropriately discharged.
Amari was 11 months old when she came to live with Taylor. Her biological mother — Taylor’s niece — was 18 and “so smart and capable,” Taylor said, but she was also alone and struggling with a depression that seemed to suffocate her after Amari was born. She had dropped out of high school and was bouncing from house to house when her sisters — Amari’s aunts — asked Taylor to take the baby in.
Taylor’s own son was grown. The idea of raising another child seemed unimaginable, but she didn’t want to see Amari end up in foster care. On Memorial Day weekend in 2009, she met her nieces, with Amari, in Erie, New York. “They gave me a $100 bill, a child carrier and a gym bag and said, ‘Here she is.’ I cried like a baby,” Taylor said.
At first, Amari saw her mom by video every night, but the calls faded away. She started calling Taylor “mommy.”
From the beginning, she had a terrible fear of separation. She sobbed inconsolably when Taylor left her at day care in the mornings, and she threw toys and hit other kids. As she got older, she seemed to have trouble focusing and following simple instructions. Her pediatrician prescribed her medication for ADHD when she was 4.
Later, social workers would make lists of Amari’s strengths. She loves her family and has a great sense of humor. Even at her most recalcitrant, she likes showing off her gymnastics moves. And she has very big ambitions: When she grows up, she plans to be a rapper, a nurse and an actor, she said in one clinical interview. But she was also lonely. At school, she sat by herself most of the time. At home, her tantrums spun wildly out of control. She’d exhaust herself, sobbing, “I want my mom. Why doesn’t she want me?”
When Amari was 9, Taylor took her to a therapist, who helped to get her approved for in-home mental health services, including a crisis-response team that would come during emergencies and a specialist who would work with her on coping and social skills. But the waitlist was more than six months long, and by the time Amari finally got into the program, everything had fallen apart.
It was the spring of 2019, and Amari was 10 years old. Her mother came for a visit, but when she left, she didn’t answer or return Amari’s phone calls. The family’s pastor, whom Amari had known since she was a baby, died suddenly. And then Taylor went on a business trip, leaving Amari with a cousin. When Taylor came back, Amari told her that the cousin’s boyfriend had molested her.
Over the next 11 months, “our lives were chaos,” Taylor said. Amari had always been a bad sleeper; now she refused to get up in the mornings. When Taylor dragged her out of bed, she’d throw things, punch the walls, grab onto Taylor’s neck and refuse to let go. Sometimes, she told clinicians later, a “bad emoji” would tell her to do things like run out of the house, into the street. More than once, she jumped out of Taylor’s car and into traffic.
After Daniel Prude’s death, the City of Rochester — along with many other jurisdictions, including New York City — promised to transform how emergency services responded to people experiencing mental health crises. Carlet Cleare, a spokesperson for the City of Rochester, told THE CITY and ProPublica that police officers participate in numerous mental health courses and training activities, and that all uses of force are reviewed by supervisors. In the coming year, the city will add staff to its crisis intervention programs, Cleare wrote in a statement.
Those efforts, however, remain small and limited. The reality for most families is that, if they can’t physically contain a child who is threatening to hurt themselves or someone else, there is no option except to call 911 and wait for police.
What happens next depends on who shows up at the door, Taylor said. Once, she and Amari got lucky. An officer who happened to have an autistic child saw Amari rushing at Taylor. Instead of putting his hands on her, he got between the two of them and talked Amari down.
Other police officers got physical far too fast, Taylor said. “They would handcuff her, manhandle her. I would be crying.”
By 2020, Taylor had left her job in order to take care of Amari. She started organizing support groups and advocating for families of color with kids in the mental health system, who are often reluctant to seek help because they are afraid that they’ll be reported to child protective services or that their kids will be treated like criminals, she said.
After Prude’s death, “Black and brown parents were terrified,” Taylor said. “Nobody with a Black child with a mental health condition was calling the police.”
Taylor, too, decided that no matter what happened with Amari, she would handle it on her own. But then, just two months after the video of Prude came out, Amari called 911 herself, intending to report Taylor for refusing to let her out of the house. When police arrived, Taylor could feel her heart pounding, she said. She tried to force the image of Prude, face down on the sidewalk and suffocating, out of her mind.
“I went to the door as articulate as I can be, because I can’t have them coming in my house harming my child,” Taylor said. “I said, ‘My child is highly dysregulated. This is not a criminal justice issue; this is mental health. I need you to take it easy when you come in my house.’”
At first, the officers tried to talk to Amari, but when she ran toward Taylor, they grabbed her and forced her into handcuffs, Taylor said. “I’m frantic, begging them to take it easy, telling her to calm down, saying, ‘Don’t touch her like that.’ They take her outside — rough, like a criminal. I’m crying, ‘Stop, stop!’”
Amari struggled, refusing to get in the police car, Taylor said. “I’m watching them physically wrestle each other. It was like flashbacks. What’s going to happen when they get her in the car?”
Eventually, an ambulance arrived, and Amari climbed into it, unhurt. But Taylor thinks a lot about what it must have been like for Amari — how much it must have scared her, and what it taught her about herself — to be physically overpowered, again and again, by adults with guns, nearly all of them men, most of them white.
It’s damage that can’t be undone, Taylor said. “If I’m traumatized as a parent when they handcuff her and take her out like a criminal, can you imagine how she feels? This child who from the age of 10 has had multiple restraints and arrests? I can’t even imagine what that’s like for her.”
New York’s application system for residential treatment facilities has been a subject of contention for a long time. In 1999, the Legal Aid Society filed a lawsuit against New York state’s Department of Health and its Office of Mental Health on behalf of kids who were sitting on waitlists for residential care. Many kids waited more than five months for a bed, the lawsuit alleged; some waited over a year. During that time, they were either locked in restrictive hospital units or left unsafe at home. Some ended up in juvenile or adult jails.
The state settled with plaintiffs in 2005, with a requirement that the state must place kids in residential treatment facilities within 90 days of certifying them as eligible. A judge encouraged officials to solve the problem by opening more beds. Instead, providers and advocates say, the state created a complex, multilayered application system that slows down applications and keeps kids off the waitlist.
“If you deem a kid eligible, you have some responsibility for providing services,” said Jim McGuirk, who recently stepped down as the executive director of Astor Services, which operates a residential treatment facility in Rhinebeck, New York. The state evades that responsibility by doing “whatever you can to reduce the waiting list by not approving people. By making it harder,” he said.
Two years ago on Long Island — in the far corner of New York state from Rochester — a 16-year-old named M (his first initial) spent more than a year in the limbo of the application process. As a little boy, M had watched his dad abuse his mom for years, according to treatment records. After his parents split up, M got violent with his mom, hitting her and threatening to kill her when she didn’t give him what he wanted. It got so bad that his mom would lock herself in the bathroom to hide.
When M was 12, the Office of Mental Health placed him in a community residence — a group home that’s less restrictive and has fewer services than a residential treatment facility. As M got older, however, his behaviors only got worse. He attacked workers and bullied kids who were smaller than him. M “will conduct himself in a charming manner to get what he wants,” according to notes from mental health professionals who treated him, but he “displays no remorse” and “has no empathy.”
In June 2020, M’s treatment team submitted an application for a residential treatment facility. He urgently needed intensive treatment — in a more controlled environment — before he became an adult, his providers said. The first step was to bring his case to a regional outpost of the Office of Mental Health, where a local committee would decide whether to forward it to a second committee, which can authorize kids to be placed in residential treatment facilities.
The rationale for the multiple layers of screening is that these facilities are such restrictive environments that, under federal law, it’s the state’s responsibility to try everything else first. In practice, providers say, the result is constant deferral and delay. If a committee doesn’t make it through all of its pending applications, “Well, wait until next month,” said Christina Gullo, the president of Villa of Hope, a nonprofit mental health care agency in Rochester that closed its residential treatment facility this year because it was running at an annual deficit of over $500,000.
Rather than referring M’s application to the authorization committee, the local committee said that he should try to find a spot at a residential school, paid for by the state Education Department. The schools, however, rejected M because he was too aggressive and his mental health needs were too great. M’s team came back to the Office of Mental Health in October 2020. This time, the local committee declined to advance the application because it had questions about M’s physical health: Was it possible that his neurological issues or sleep apnea caused the behavior problems? Had the family tried getting services through the Office for People With Developmental Disabilities? (The answer was yes — it had turned M down too.)
“My jaw just dropped at that one,” said a family advocate who worked with M’s mom through the process. “It’s a sin that they’re not helping this boy. He’s just falling through the cracks, and he has been for years.”
Finally, on the third submission, the local committee agreed to pass M’s application to the authorization committee, which approved M for placement and sent his information to individual providers. By that time, however, three residential treatment facilities in the region — run by The Jewish Board — were getting ready to close. The shutdowns hadn’t yet been made public, but the facilities were discharging the kids they had, not taking new ones. One by one, the facilities turned M down.
State data shows that delays and denials are common. While the number of applications for spots in residential treatment facilities has gone up since 2018, the share of applications that the committees approved has dropped, from close to 70% in 2018 to just over 50% in the first half of 2021. The percentage that were denied nearly doubled, from 16% to 29%. Close to 20% of committee reviews resulted in a deferral.
And even when kids are authorized for admission, many don’t end up entering residential treatment facilities. In 2020, for example, 444 young people were approved by the authorization committees, but only 364 were actually admitted.
Some of those kids may have gotten the treatment they needed in the community, according to James Plastiras, a spokesperson for the Office of Mental Health. In that case, “the family may decline to proceed with an RTF admission, or the child may no longer meet RTF eligibility criteria,” Plastiras wrote in a statement.
No one would disagree that it’s best for kids to live at home whenever possible, said Rapczyk, who directed the Long Island community residence where M lived. But it doesn’t make sense to close beds when young people still can’t find outpatient care, Rapczyk said. “It was so crazy to me that they were closing all of these places without any contingency plan, in a pandemic, without any hospital beds available and kids’ mental health skyrocketing,” he said. “It was just crazy to me that this was going on.”
For M, time ran out. He aged out of the group home and moved into an adult housing program, which — unlike in the kids’ system — can kick him out if his behavior is too disruptive.
The next stop would be a homeless shelter or jail, M’s mom said. “He never got the help he needed, so what do you expect? The system says, ‘Oh, we’re here to help you,’ but it’s such bullshit. They just give you the runaround.
“My fear is that it’s gonna be a complete train wreck and my son will have a truly horrible life,” she continued. “I think his evils will take him over.”
What Taylor did in the spring of 2020 — refusing to pick Amari up from the hospital — is not so unusual, said Dr. Michael Scharf, chief of the Division of Child and Adolescent Psychiatry at the University of Rochester Medical Center, which encompasses Strong Memorial Hospital.
Amari first went to Strong Memorial in April 2019. She’d woken up in the middle of the night, shaking uncontrollably. Taylor took her to the emergency room, where a security guard scanned her with a wand for potential weapons and escorted her to the hospital’s Comprehensive Psychiatric Emergency Program. A heavy steel door locked shut behind them. Staff sat behind thick glass.
Once kids are inside, they wait — sometimes for hours, sometimes for days. The setup delivers the message that kids with mental health problems are bad rather than sick, Taylor said. “Children with medical conditions — they treat them completely different than children with psychiatric disorders. Our families are blamed; our children are blamed.”
Scharf agrees that the emergency room is not a good place for kids in crisis. But like the rest of New York, Rochester faces a crisis-level shortage of outpatient mental health care. The hospital’s outpatient clinic — the largest in the region — gets calls from about 100 families a week looking for services, and it typically has at least 125 kids on a waiting list, according to a hospital spokesperson.
Without access to outpatient care, the sickest kids often cycle in and out of hospital beds, where providers focus on treating their most acute symptoms, not on addressing long-term behavioral problems.
The cycle is exhausting and scary for kids and their families, Scharf said. Often, hospital staff get involved in the search for residential treatment, but there are never enough beds available. “It’s almost silly to be in some of these meetings” with the Office of Mental Health, Scharf said. “They will say, ‘This child is on our highest-needs, crisis list.’ The parent thinks, ‘OK, that means something is going to happen.’ But there’s 70 people on that list. That list doesn’t necessarily mean a bed is coming.”
In a way, Amari was fortunate. In April 2020, less than a month after Taylor refused to pick her up from the hospital, the Office of Mental Health worked with a social service agency called Hillside Family of Agencies to get her into a residential treatment facility in Rochester.
For Taylor, it was an excruciating victory. She believed that if the mental health system had done its job, Amari would never have had to leave home. But she also blamed herself. Amari’s worst fear was being abandoned, and now Taylor was dropping her off and driving away.
She remembers sobbing all the way home. At one point, she pulled the car over to throw up. “The guilt and shame runs so deep,” she said. “I was sick in bed for two days.”
At the facility, Amari cried for Taylor and begged to go home. Many of her behaviors got worse. Counselors wrote that she frequently tried to run away, was aggressive with her peers and made homicidal threats. She would yell and swear, pounding on the walls and flipping tables. She told an evaluator that she often wanted to hurt herself. After a few weeks, she was placed on a “prevent from leave” status, meaning that staff should physically restrain her if she tried to leave a building without permission. Even so, there was a night when she ran out of the facility and was left outside, unsupervised, with a 17-year-old boy, until morning.
To Taylor, it seemed like she was constantly getting calls from staff saying that Amari had been restrained. She thought about bringing Amari home, but then what? Ending up in a juvenile justice facility would surely have been worse, she thought.
Maria Cristalli, Hillside’s CEO, told THE CITY and ProPublica that staff rely on nonphysical interventions whenever possible, using restraints only as a last resort. “Hillside is committed to maintaining therapeutic environments that are free of violence and coercion,” Cristalli wrote. “We do not tolerate unnecessary, inappropriate, or excessive physical intervention.”
In November 2020, Amari was in such constant crisis that the residential treatment facility staff applied to get her into a state-run psychiatric hospital for acute care. The hospital was full, so Amari waited more than a month to get in. When she came back to Hillside, the facility told Taylor that Amari needed an even higher level of supervision. They wanted to transfer her to their Intensive Treatment Unit — a residential treatment facility that was more restrictive, with a lower staff-to-resident ratio.
At first Taylor said no. She spent weeks trying to secure in-home mental health services, but no one could promise her anything other than what Amari had been getting before. Eventually, she gave up and agreed to the higher-level facility. Beds were full there, too. It took six months before a spot opened up for Amari.
Last month marked two years since Amari left home. Taylor hopes she’ll come back in the fall, in time to start a new school year. She’s given up the idea that Amari will get the services she needs at home — or that anyone, really, will be there to help her.
“At this point, I’m just trying to keep her alive,” Taylor said, her voice breaking. “I have a very sick child. She wants to come home. How do I keep her alive?”