Sixty-four percent of Connecticut’s youth who use Emergency Mobile Psychiatric Services (EMPS), the state’s mobile crisis intervention team, have experienced one or more traumatic incidents, such as domestic violence, cyber-bullying, physical assaults, or gang warfare, experts report.

Research shows childhood exposure to violence, physical or sexual abuse, and other traumatic events can cause chronic health and behavioral health problems, and such exposure is associated with increased involvement with the child welfare and criminal justice systems.

“The number of children who have been exposed to trauma is a significant concern. It’s a common occurrence among young people,” said Jeffrey Vanderploeg, vice president for mental health initiatives for the Child Health and Development Institute of Connecticut (CHDI). He is director of the EMPS Performance Improvement Center, which is housed at CHDI.

Expanded Role For Crisis Intervention

EMPS is a crisis intervention program with a statewide network of about 150 mobile mental health professionals who assist children up to age 18 with behavioral or mental health emergencies. When a call is placed to 2-1-1 from any Connecticut town, clinicians respond within 45 minutes, either by telephone or at a face-to-face crisis assessment and intervention at home, at school or in the community. They can remain involved for up to 45 days, creating care plans, coordinating services and following up.

Last fiscal year, EMPS provided 12,376 instances of care – up 11.4 percent from the previous fiscal year – and some worry that demand will soon exceed the program’s capacity.

State lawmakers are currently considering future funding for EMPS and other mental health initiatives.  In October, Gov. Dannel Malloy issued an “action plan” for children’s behavioral health that called for using $160,000 to post a full-time EMPS crisis-intervention worker in the emergency department of Connecticut Children’s Medical Center and a part-time worker in another hospital. The plan also said the governor was “considering” enhancing the EMPS network by increasing the hours of service from 11 hours a day to 18 hours a day, at an expected cost of $3 million. Current EMPS costs are about $10.5 million this year.

EMPS was created to assist children in their homes and communities, reduce emergency department visits, and divert youth from more restrictive and costly interventions, such as hospitalizations, residential care settings or arrest. Funded by the state Department of Children and Families in partnership with United Way of Connecticut, the program serves all youth regardless of health insurance status.

Heightened awareness about behavioral health issues and the EMPS program accounts for some of the increased demand for services, experts said. But clinicians also report an increase in the severity of cases, compounded by the shortage of outpatient and residential treatment placements and the inability of many families to afford the behavioral health care their children need.

“We’re seeing kids who require an intense level of services that might not be available right away. We’re being called in to provide treatment in the interim so their situation does not escalate. Some children need a high level of care. But others can step down from the crisis,” said Jessica Welt, director of crisis services at the Child Guidance Center of Southern Connecticut. The center is one of six agencies that provide crisis intervention services from 15 satellite sites statewide.

“EMPS clinicians are doing a tremendous job of responding to crisis, but their ability to follow up with clients is being stretched,” Vanderploeg said.

More Youth At Risk

Twenty percent of Connecticut youth – that’s 156,000 children under age 18 – could benefit from behavioral health treatment, but many can’t access services, according to the Connecticut Children’s Behavioral Health Plan. The plan was developed after the Sandy Hook Elementary School shooting that killed 20 students and six adults in 2012.

But more Connecticut children and young people with mental health problems are being hospitalized. Mental disorders surpassed respiratory problems and all other ailments as the leading cause of hospitalization in Connecticut in 2012 for children ages 5 to 14, teenagers and younger adults, according to a new state Department of Public Health report. Common conditions among children include mood disorders, depression, attention deficit disorder and disruptive behaviors.

Youths 13 to 15 years old (37.6 percent) and 9 to 12 years old (24.5 percent) accounted for most EMPS clients. Harm or risk of harm to self or others (36 percent) is the most common reason parents, school staff and police call EMPS, followed by disruptive behavior (22 percent), depression (15 percent), family conflict (6 percent) and anxiety (6 percent).

Elizabeth Peralta, a social worker and manager of crisis intervention at Danbury Hospital, assists children and adolescents who come to the emergency department. Volume has remained steady, she said, “but the cases are very much more involved and intense.” She steers youth who do not require hospitalization to EMPS to connect with community behavioral health services.

“There is a huge need for mental health services for children and adolescents,” said Peralta. “They and their families are struggling. It’s heartbreaking.”

Stressors On Multiple Fronts

“We’re seeing more kids who are traumatized by problems at home and at school. Their actions and behaviors are more understandable when you view them in the context of what is happening in their environment,” said Amy Evison, senior program director for Community Health Resources in Middletown, which handled more than 1,200 crisis calls last year.

Social media is a major source of angst. “We see lots of kids who are struggling with how to manage social media,” said Evison. “They have contact with people in the community and the world that they don’t even know, yet they’re immediately impacted by what they say. Kids are saying very violent and threatening things over social media.”

Christine Mullin, one of five social workers serving 2,600 students at New Britain High School, contacts EMPS clinicians at the Wheeler Clinic in Plainville about four times a month and sometimes twice in a week.

“The number of kids who need help keeps increasing each year,” said Mullin. “It’s hard to keep up with demand.”

Mullin sees students who are experiencing trauma, anxiety, panic attacks and depression, with some teens threatening to harm themselves and others. Students face multiple stressors, ranging from academic pressure to succeed to concerns about unemployment and hunger at home.

“What is wonderful about EMPS is that they come out to the school for all forms of crisis, not just when a student is suicidal,” said Mullin. “They can help students who are in a state of serious duress that could worsen without early intervention. It’s a preventative measure.”

With assistance from EMPS, Mullin has been able to keep students from inappropriately using the emergency department. EMPS clinicians also “bridge the gap” by following clients for up to 45 days until children and families are connected to home- and community-based services.

“I know our families and kids are in good hands when EMPS is involved,” she said.

Latin America children traumatized by their journey to the United States and their experiences back home represent a growing portion of youth accessing crisis services, said Welt, of the Child Guidance Center. The agency – which saw a 33 percent increase in crisis calls last fiscal year – serves Stamford, New Canaan, Greenwich and Darien.

“Fairfield County has a large immigrant population. We’re seeing an increasing number of children and young adolescents who have been exposed to horrific traumas en route to the United States or in their country of origin,” she said. These include youths who have experienced or witnessed physical or sexual abuse, assault, homicides, separation from loved ones, gang violence and more.

For some youths, the trauma of witnessing the arrest of a parent or caregiver can have long-lasting implications, said Lt. Sean Grant of the Manchester Police Department. Grant is the liaison for REACT (Responding to Children of Arrested Caregivers Together), which brings police and EMPS clinicians together to support traumatized children.

“We understand kids are seeing a lot of traumatic events in the world and in our community,” said Grant. “As much as we are called up at times to be social workers, we don’t have expertise in this area. It’s nice to be able to call EMPS professionals when we don’t have all the answers.”

Limited Access And Affordability

Experts don’t expect demand for crisis services to lessen anytime soon, given the shift from congregate to community-based treatment settings, a shortage of child psychiatrists, and the lack of sufficient inpatient and outpatient treatment placements.

Families with health insurance plans that have high co-payments and deductibles are struggling to find affordable behavioral health services. Some child psychiatrists don’t accept commercial insurance at all.

“We see many families who may have insurance, but they still can’t afford the services their children need, such as medication, partial hospital programs or an intensive in-home program,” said Evison. “Health care is out of reach for many working poor families.”

Disparities in access to care among children with private insurance and those enrolled in HUSKY, the state’s health insurance program for the poor, exacerbate the situation.

“People in the child welfare and court systems have access to a more robust range of evidenced-based mental health services at home and in the community than what is available to people with commercial insurance,” said Vanderploeg. “Access to services even differs for children (covered by the state) depending on whether they entered through the child welfare or court system. These are all issues that were struggling with and need to change.”

For now, advocates are calling for increased funding from private and public insurers to support mental health services for children, including the EMPS program. “There are many kids out there facing mental health problems that need to be addressed,” said Welt.

For a partial list of mental health services offered in Connecticut click here.

On May 7, C-HIT will host a community forum on teen mental health at The Lyceum, 227 Lawrence St., in Hartford. The event, which features an expert panel, is being held in collaboration with ConnectiCare and Hartford Hospital’s Institute of Living. For information and to purchase a ticket, go here.

It’s a dramatic turnaround for Joey who met Kunkel when she was summoned to Thomaston Center School because he had threatened to harm himself. Now Joey, who has autism, is back at school with a modified curriculum to suit his individual needs and his parents have access to an educational advocate and community resources.

Tony Bacewicz Photo

EMPS crisis clinician Heather Kunkel visits with Joey Smith, 10, at his home.

The Smiths are among the thousands of Connecticut families turning to the Emergency Mobile Psychiatric Services (EMPS) — a crisis intervention program that includes a network of 150 mental health professionals who assist children experiencing a behavioral or mental health crisis at home, school or in the community. Like a SWAT team called into action, EMPS clinicians can respond immediately by telephone or mobilize to provide face-to-face intervention within 45 minutes of a call to 2-1-1 placed from any Connecticut town.

Last year, EMPS served 10,560 children and families – that’s a 61 percent increase from 2010 – and experts expect the demand for services will continue increasing. Funded by the state Department of Children and Families in partnership with United Way of Connecticut, EMPS was designed to serve children up to age 18 in their homes and communities, reduce the number of emergency department visits, and keep youth from more restrictive and costly interventions – such as hospitalizations, congregate care settings or arrest – whenever possible.

Meantime, Connecticut has saved about $3.5 million in Medicaid funds by diverting children from inpatient settings, while the percentage of youth in DCF’s care who are served in congregate settings has decreased to 23 percent from 29 percent.

“Clearly the ability to quickly respond to children in crisis at their homes is a vital part of a healthy system of care,” said Joette Katz, commissioner of the state Department of Children and Families, whose administration has worked to “re-align” the mental health system so more “children get the services they need while living with their families and in their communities.”

“Kids do much better when they get help in their natural environment,” said Tim Marshall, EMPS contract manager for the state. “The more restricted the level of care, the more artificial the environment, which makes it difficult for kids to develop the habits and coping mechanisms they need to live in a normal environment.”

Most calls to 2-1-1 for crisis intervention come from parents and family members (43 percent), followed by educators (33 percent) and Emergency Department personnel (11 percent). The EMPS program is open to all children, whether or not they are associated with DCF or have health insurance. EMPS staff can provide follow-up services at home or school for up to 45 days following an intervention.

“We see the entire gamut from little ones with temper tantrums to children with attention deficit hyperactivity disorder who can’t be controlled to older kids who may be suicidal, homicidal, or injuring themselves. Whatever the crisis, we work with families and schools to support the child,” said Michelle Andrews, EMPS team leader at Wellmore Behavioral Health in Waterbury. Wellmore is one of six agencies that provide crisis intervention services from 15 EMPS satellite sites statewide.

“By bringing services to children and families, we’re able to reduce major barriers to accessing mental health care, including a lack of transportation and a reluctance by some to visit a mental health office,” said Jeffrey Vanderploeg, director of the EMPS Performance Improvement Center at the Child Health and Development Institute. He cited data showing children served by EMPS experience “positive outcomes,” including improved overall functioning and a lessening in the severity of their problems.

The growth of the EMPS program comes at a time of heightened awareness of the need for mental health services following the massacre that left 26 people, including 20 children, dead at the Sandy Hook Elementary School in Newtown last December. EMPS clinicians were among the first responders to arrive at the firehouse to assist and comfort families waiting for news about their children.

“We thought we were responding to a school shooting involving one death. It wasn’t until we got to the firehouse that we realized the magnitude of what was happening,” said Andrews. “We did whatever we could to help in the moment, whether it was holding hands, looking at pictures of the children, or contacting family members. The inner strength of those families facing such unimaginable loss left me in awe.”

An estimated 39,000 children live with a serious mental health condition in Connecticut, according to the National Alliance on Mental Illness. Sixty-three percent of the children served by EMPS last year reported one or more trauma exposures.

“We’re seeing a growing number of kids with more severe mental health problems,” said Brenda Concepcion, a social worker at Central High School in Bridgeport, which has 2,300 students. She contacted EMPS about 17 times last year, primarily for help with students who were suicidal, harming themselves, or severely depressed.

“The fact that (EMPS staff) are mobile is the biggest and greatest thing,” said Concepcion. “They are my second set of eyes and ears.”

At the Marine Science Magnet High School in Groton, principal Nicholas Spera contacts EMPS clinicians “any time a student is thinking about or already harming themselves.” He has seen an increasing number of students who are “cutting” themselves, behavior that can lead to more self-harm without early intervention. That’s where EMPS comes in. “Their knowledge and ability to connect with students is amazing,” said Spera. “They help students acquire the skills they need to be safe and healthy and learn.”

Dr. Peter Jacoby is chairman of the Department of Emergency Services at St. Mary’s Hospital in Waterbury, which handles nearly 70,000 emergency department visits a year. St. Mary’s has a contract with EMPS to assist children and teens with mental health problems when they arrive at the emergency department.

“Emergency departments across the state are overcrowded and they’re often not the best place for a child with a behavioral health issue,” said Jacoby. “We work with EMPS to get kids out of the emergency department who don’t need to be there and make sure they receive follow-up care in the community.” EMPS assists hospital staff to find the appropriate setting for children who require a higher level of care, he said.

Tony Bacewicz Photo

Lisa Smith, Joey’s mom, listens as Kunkel completes her home visit.

Marshall believes EMPS also helps to keep youth out of the juvenile justice system. “We’ve seen an increase in the number of kids entering the juvenile justice system for behavioral health reasons that could have been avoided,” he said. “One of the unintended consequences of having officers at schools is that police become involved in behavior and discipline issues in school districts that aren’t clear about their role. Incidents that may have led to a suspension in the past, can now lead to arrest.”

The need for mobile intervention services surfaced a decade ago because the state was “spending a disproportionate amount of funds to treat children with mental health needs in institutional settings,” said Robert Plant, chief clinical officer at Wellmore, who helped design EMPS when he worked at DCF. But the program “wasn’t producing the results we needed,” prompting DCF to contract with the Child Health and Development Institute to improve quality and performance, he said.

A revamped program was launched in 2009 with changes that included the statewide use of 2-1-1 to access EMPS (rather than every community having its own system) and incentives to local providers to conduct in-person interventions. Now 93 percent of all calls to EMPS result in a face-to-face response. The median response time for a clinician to arrive at the scene is 29 minutes.

While the number of children served by EMPS has increased, experts suspect many more could benefit if they knew about program or didn’t hold back due to the societal stigma associated with mental health. “You wish there’d be less need for services, but that’s not the case,” said Plant. “A lot of children and families are under stress.”

Despite the inherent challenges of the job, Kunkel echoes sentiments shared by many of her colleagues.  “I can’t imagine doing anything else,” she said, especially when there are success stories such as Joey Smith’s. “That makes everything worthwhile.”

Back in Thomaston, Lisa Smith remains hopeful that changes underway at home and school will make a big difference in her son’s life. “He’s more positive and a lot happier,” she said. “This program has helped our family tremendously.”

EMPS counselors are available immediately to talk by phone or evaluate the situation, 24 hours a day, 365 days per year. EMPS hours of mobility are: 9 a.m. to 10 p.m., Monday through Friday; and 1 p.m. to 10 p.m. on weekends and holidays.