Adolescents in the southwest region of the state in dire need of intensive mental health or substance abuse treatment struggle for options and face a long journey away from home to seek critical care.
When a patient's needs are greater than those that could be treated with weekly visits to a facility, they may need to receive inpatient and residential services. These facilities treat patients with significant mental health issues or significant drug use.
Inpatient services are services in which the patient stays in a facility 24/7 to receive care in a hospital setting - a psychiatric residential treatment facility. It is typically short term.
The next step down from that is the therapeutic residential treatment facility. The care is less intensive, but is longer-term and takes place in a more relaxed environment.
Badlands Human Service Center in Dickinson has a residential treatment facility, but it only allows for the treatment of adults, as does its only crisis bed, which is used for people in a mental health or substance use emergency.
Youth in crisis
There are no crisis beds in the area for youth.
The North Dakota Behavioral Health System Study stated that: "Stakeholders noted that crisis services for children and youth are particularly lacking, and over a quarter of those who visited an emergency room for a behavioral health issue during the study period were under age 18."
The counselors at Dickinson High School said they often work with CHI St. Alexius because they don't have a school psychologist.
They said the district has psychologists, but they are tasked with other things.
"They're looking at evaluating to see if kids have learning disabilities, those types of things, and they're helping with educational plans for those kinds of students, so their time is really just taken doing that kind of evaluation," said school counselor Trista Fisher.
So instead, they send the students to CHI's emergency room.
"That's a severe situation where they're maybe talking seriously about suicide," said DHS counselor Amy Schye.
There they would be assessed and if determined that they are in fact in a crisis, arrangements are typically made for them to go to a residential treatment facility.
Youth not in school can also go to Badlands for assessment.
There are some private residential treatment facilities available to youth in the area, such as Home on the Range, but Brad Brown, regional director for Badlands, said there have been problems with waiting lists and screening.
"There's been problems with screening, which means related to certain behaviors, they may not be able to get into that facility," he said.
Kori Stockie, clinical director at Badlands, said, "If they don't feel they can handle the behavior of a youth or child coming in, they're going to decline them, and then that comes back on the counties and the state to try to figure out 'where do we place these children?'"
She said the more complicated a child's or adolescent's behavioral health issues, the harder it is to get them services.
The North Dakota Behavioral Health System Study released by the Human Services Research Institute last April stated that: "Multiple stakeholders expressed concern that some residential treatment facilities 'cherry pick' individuals with lower levels of need and are reluctant to take children and youth who have challenging behavior."
Juvenile Court Officer with the Southwest District Juvenile Court Carrie Hjellming said cost can also be a barrier in getting kids' treatment at those facilities.
"If we don't have the proper services in place through our human service center, some of those people won't get the service they need 'cause they simply can't afford it, and that's a hard reality," she said.
Hjellming said the costs can be "astronomical and not feasible for most people."
"Insurance will only cover the treatment part of it," she said. "There's still a responsibility for room and board. ... That's where the cost becomes prohibitive. That could be $300-$400 a day depending on where you go, so if you do that times 30 - most people can't pay $9,000 for room and board while their kid gets this treatment."
Since there are only a couple of private options for adolescents needing inpatient treatment, many adolescents are sent to the eastern part of the state to Fargo or Grand Forks - or even farther, out of state.
The counselors at Dickinson High School are all too familiar with the challenges their students face in getting mental health care. When asked if they knew of cases in which students have had to be sent elsewhere because they couldn't get treatment in Dickinson, the school's counselors said "all the time," and "every week."
Problems with out-of-town care
Sending youth out of town for treatment presents its own challenges.
"Some parents don't have the ability to drive their child to Fargo, so transportation can be an issue," said Lauren Roemmick, DHS school social worker.
Hjellming said that having these services close to home instead of hours or even states away is better for their treatment, especially those leaving for drug rehabilitation.
"So you get all better, you're not using drugs because you're not hanging out with the same people that you hang out with, and you're not near the dealers that you know," she said. "You're in a place where you focus on treatment. What do you think is going to happen when you just say OK you're done; you're successful; you've finished; you can go home now? And you haven't done any of that stuff to mitigate the triggers in their own communities. They're just going to start using, immediately."
Roemmick said she also thinks it is helpful for an adolescent's treatment to be closer to home.
"Family visits, family therapy, I think that's definitely better if the parent can be involved in that," she said. "That's often a component of their treatment."
The distance from their families can sometimes be hard on youth seeking treatment. Megan Patrick's 12-year-old son Asher was sent to a behavioral health facility in Arkansas for treatment, as she was told he could not be treated in state.
She said her son has reactive attachment disorder, but he was not tested here for it, as he missed the appointment.
"(Arkansas is) too far away, and he has a problem attaching to his primary caregivers. It's psychologically detrimental to send a child with RAD away from their caregivers," Patrick said. "In fact, when they do inpatient treatment with children with RAD, it's intensive family treatment."
Trouble with access
It can also sometimes be a struggle to get adolescents admitted to those far away facilities.
Jeffrey Herman, Chief Executive Officer of Prairie St. John's in Fargo, where many of the adolescents from the area are sent for treatment, said they also had trouble with waiting lists, though they have been able to successfully combat the problem in the last two years.
"Two years ago, we deflected over 400 patients regionwide that we were unable to treat," he said. "We changed that to (where) last year, we weren't able to treat around 45 patients that we couldn't admit because of capacity."
He said it is still an ongoing issue whenever the population increases.
When those places are full, it puts the youth and local mental health workers in inappropriate situations, Brown said.
"Some of these counties, smaller counties, if there isn't a place for ... youth to go right away, a lot of times they end up having to spend time with them, watch them, either right at the county facility or hotel or whatever," he said. "Again, time consuming, cost consuming. It's just not therapeutically appropriate."
Organizations are taking steps to alleviate the problem and provide much needed services.
Dickinson High School developed a Mental Health Task Force Committee to find ways they could better help meet the mental health needs of their students.
They're looking to CHI and Badlands for help.
"I know (Mr. Hepperle) was going to reach out to Badlands to see if they had a school psychologist that would be willing to come here if we had emergencies, so we don't always have to send them to the ER or where they could come here and deal with medications and things like that just because we have such a high need and it's not always met," Fisher said.
Prairie St. John's is looking at moving into the old St. Joseph's hospital, where it would provide both adult and youth behavioral services, encompassing both mental health and substance use treatment.
"It takes a lot of community resources to bring patients from the region to Fargo," Herman said. "It's helpful in the treatment, but it's not the best place. We'd much rather serve people in their communities."
He said the biggest obstacle to opening the facility is reimbursement by Medicaid. For an institute of mental disease (IMD) to receive funding from Medicaid, it must have 16 or fewer beds. Herman said he thinks the community needs more than that.
"We could open up a program now up to 16 and get our Medicaid reimbursement, but my belief is that between the child and adolescent and adult beds, 16 isn't enough, and then we'd be looking at just a population where it's just kids or just adults, to stay under that 16," he said. "That's only meeting part of the need in the community."
The federal government does offer an IMD exclusion that would allow them to get that funding, but the state must apply for it.
"We're trying to work with this year's legislature around filing a waiver to exclude us from that IMD so we can get reimbursement, 'cause to start a new program and not get paid for it is very difficult," he said.
Hjellming said she thinks the state spends so much time focusing on getting adults treatment that juveniles are often on the back burner.
"You should be putting your money into the kids," she said. "Those are the people that you're most likely able to mold because of development and those are opportunities so that they don't get so far into usage that we're just treating them from adolescence until their elder years because of addiction. I would like to see a kind of rearrange of how we fund those services with front loading kids and secondary adults."