By Allison Schatz
Prior to the pandemic, community-based behavioral health screenings were as challenging as they were needed in communities throughout Illinois. For residents of the state, anyone in need of an assessment is eligible for screening and support as part of the Illinois Children’s Mental Health Public Act of 2003.
In Illinois, one in 10 children is diagnosed with some form of mental illness that causes significant impairment, yet only 20 % of these children receive treatment annually. In response, the state developed the Screening Assessments and Support Services (SASS) to support the cooperation and distribution of Medicaid-funded behavioral health services in Illinois, and to address the significant shortfall in treatment for these at-risk youth.
When COVID-19 struck Illinois, it threw crisis workers like Melissa Coleman into a tailspin, as she struggled to adapt to new modalities of treatment and to managing the myriad anxieties of being a frontline essential worker. COVID-19 has complicated the practice of community-based behavioral health service providers in significant ways that are too often not acknowledged by the community-at-large.
Coleman, who has been a SASS counselor for nearly 30 years, is part of a small team that serves roughly 1,300 children and adolescents in a typical year. Access to SASS services is provided through the Crisis and Referral Entry Services (CARES) hotline, under the Illinois Department of Health and Human Services.
Tell me about the work that you do as part of SASS
In Illinois, everyone has access to care. If a family doesn’t have insurance, they still get assessments and treatment through Medicaid. All crisis calls now come through the CARES crisis referral entry line for Medicaid funded families. Each area of Illinois is divided into local area networks. If you live in downtown Chicago, you have one area with one crisis response team on call. If you live in the Blue Island area, or other south suburb, Metropolitan Family Services is the center on call, and that’s where I work. We are provided demographics, background info, etc. Once we get the call, we have 90 minutes until we have to be in front of the family. Generally, the range we see is between 3 and 20.
With a child as young as 3, we usually are dealing with children who have fetal alcohol syndrome or who have been drug-exposed, who have reactive attachment disorder (RAD,) who have been seriously physically or sexually abused, children who are developmentally delayed, or who are impulsive, fighting classmates in school, and so on. These are usually kids who are so aggressive they cannot be safely managed at home, and so we help get them placed in pediatric psychiatric units to be observed.
How has the pandemic affected the crisis intervention work that you do?
The issue is that it all hit so fast, and we were not ready. When everything shut down, we had to start doing assessments via Zoom. I had never done that before. I had not even done an assessment by phone before. When I started here in 1996, we were told that you cannot assess someone over the phone. We were told to never do that, that you have to be face-to-face, you have to be able to look at them. So, things we had always been told not to do were now suddenly the norm.
It is very difficult to get a child in front of the camera who is oppositional, who is aggressive, who is yelling, who is screaming, who does not want to respond to directions for safety. A child with disruptive mood disorder, or a child who is bipolar, a child who is acting out−it is extremely challenging.
Once we maneuvered how to do assessments through Zoom, we also had to maneuver how to call an ambulance, not from the house of the patient, but remotely. This meant learning how to screenshot documents and send them virtually and manage the paperwork without being on-site in order to get payment back from the state. And all of this while we were quarantining and getting our PPE, which we did not initially have.
Because infection rates are rising in Illinois as we move into winter, the risk factors for us as frontline workers is increased. I am actually going into the homes of people I do not know, and am around people who may or may not know if they have been exposed. Even with all of the PPE on, and with all of the safety precautions we are taking, to work in people’s homes, to have to be concerned about a family’s child’s safety, as well as my own safety, it’s a lot. THe amount of energy it takes to do the job, these days, seems to be so much more, and it is exhausting, and I don’t see it getting any better.
What sorts of calls do you receive and how do you handle them?
The biggest call volumes we get now are for anxiety and ADHD. The children are struggling with Zoom classes, to have to look at the camera and stay regulated and get their work done. It is very hard for them. Schools like Easter Seals, who have children that are on the autism spectrum, or who are developmentally delayed in any kind of way, those kids are used to a certain level of structure. When they lost that structure, that regularity, in the beginning that was very tough for those families. So, a lot of the calls we have been receiving have had to do with families who have been unable to maintain their children in these settings.
One of the things we deal with during a regular school year is the bullying that happens through social media. When you take kids out of the school, the social media volume goes up really high, and so they have more of an opportunity to bully each other, to say hateful things to each other, because they have nothing better to do. And when that volume goes up, in turn, the volume of overdoses and impulsivity goes up, because they are not thinking, and they do not have an outlet.
Most of what we are seeing, going back even just the last few weeks, if it is not attempts to cut the wrists or cut the body because of anxiety−and these are children who self-harm because of anxiety−then it is overdosing. We are seeing a major increase in both overdose attempts and acts of self-harm. I have also seen a number of children who have had plans to hang themselves. The level of acuity is way up, and I think it is just going to get worse as COVID-19 gets worse and the weather gets colder, in turn forcing kids to be inside.
Another issue we are having is that pediatric and adolescent psychiatric units will not now allow us to do an assessment and transfer a child to the unit of observation. Because of COVID, we have to go in through the ER, and the family has to sit there waiting for COVID test results to come back. Sometimes that means waiting more than a day in the ER. There have also been outbreaks in units, and then those units shut down for a week or two, which means there are fewer beds available for us to admit to. It is a very tense time.
Finally, I would add that COVID-19 has impacted family’s privacy for these types of calls. Pre-COVID I could just pull up and walk into a home. Now, I pull up, have to get out, dress in full PPE, and by the time I walk up to the door, half the neighborhood is watching. And if I have to call an ambulance, then those EMT’s are also geared up, and they draw more attention. So then that family ends up having half the neighborhood wondering what is going on, calling, knocking on their door asking questions. It’s awful for them.
Another tragic aspect to the pandemic and the social distancing has been the removal of mandated reporters and responsible adults in an at-risk child’s life. Are you seeing this problem at work?
Prior to the pandemic, the signs and symptoms that presented themselves could be seen by people who they interacted with every day: the basketball coach, the teacher, somebody at the park district. But when they’re inside, there’s nobody there to say, “Hey, what’s going on with you? You don’t look the same.” So, another reason we are seeing suicide attempts go up is that kids are stuck in the house, and sometimes alone because the parent or parents is an essential worker and not at home. Or, other times, that child is stuck at home with their abuser, who is suddenly not working.
Calls are down because kids don’t have the same daily interactions with reporters. But the calls we are getting, the crisis intervention work we are doing, it is because the child is in severe crisis. Instead of getting the call that a child has made a suicidal statement, now it’s usually after a suicidal gesture, because the child is now not surrounded by a network of people.
Usually March and October are our busiest months, for whatever reason. In October, it is normally not unusual for me to do two or three assessments a day. October is 24-hour, nonstop, you just brace yourself and go. This October, the level of acuity was much higher.
This interview has been edited for brevity and clarity.
Allison Schatz is a Social Justice & Investigative Reporter who covers mental health at Medill. You can follow her on Twitter at @AllisonSchatz8