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What's going on at Virginia's public psych hospital for kids?

Randi B. Hagi

The state's watchdog agency released a report on psychiatric hospitals in December. It recommended that the Commonwealth Center for Children and Adolescents in Staunton be shut down. WMRA's Randi B. Hagi discussed the findings with a psych nursing professor, and filed this report.

The Joint Legislative Audit and Review Commission is the entity in Virginia that looks into how state-managed and -funded programs are performing. In December, it released a report on public psychiatric hospitals, and found pervasive issues with understaffing that led to unsafe environments for both employees and patients. The worst facility, by nearly every metric, was the Commonwealth Center for Children and Adolescents, or CCCA, the one state-run psychiatric hospital for minors.

One of the most alarming statistics concerned patient restraints – which means that a person's movement was restricted by hand, a device such as straps, or sedation. The commission found that the CCCA's restraint rate was 40 times the national average for similar institutions for minors. Of the state's nine public psych hospitals, the CCCA had the highest rates of physical incidents between patients, among patients and staff, and self-injurious behavior.

Tony Wilt is one of the state legislators who directs the JLARC to study specific agencies and issues.
Tony Wilt
Tony Wilt is one of the state legislators who directs the JLARC to study specific agencies and issues.

TONY WILT: We certainly don't like to hear those types of reports.

Delegate Tony Wilt, who represents Harrisonburg and part of Rockingham County in the General Assembly, serves on the commission.

WILT: There needs to be a move, I will say that. So, what that move is, exactly, I think it can be up for debate.

He said he's not convinced the CCCA should be shut down, but the staffing issues there must be addressed. The hospital turned over almost two-thirds of its staff between fiscal years 2020 and 2023, and without contract workers, it would have had a vacancy rate of 43%.

WILT: Across the board, it's finding more people, or paying the people that you have that's providing this care, and it's strenuous, you know, my heart goes out to those workers. … We need to step up as a state and help them.

The Department of Behavioral Health and Developmental Services, which oversees the state's psychiatric hospitals, pushed back on the report. Commissioner Nelson Smith, who was appointed to run the agency in 2022, wrote in a response letter that they were already working to improve conditions at CCCA, and in 2023 had reduced its restraint usage by 116% compared to years prior.

Communications Director Lauren Cunningham declined WMRA's request for a facility tour or interview, but said in an email that [quote] "a new facility director started in January 2024. We are now seeing some staffing increases and huge reductions in restraint usage." She did not respond to a follow-up email asking for specifics.

To get more insight into these issues, I spoke with Melissa Gomes – the associate dean for diversity, equity & inclusion at the University of Virginia School of Nursing. She teaches mental health nursing and runs her own outpatient clinic in Hampton.

I asked about some of the challenges specific to working with youth.

MELISSA GOMES: Children and adolescents present with irritability, present with agitation, less tolerance for stressors, especially when they're not feeling well, and I think it can come across to an assuming adult or a misinformed adult … as noncompliant, disrespectful, or they have an attitude.

Melissa Gomes is a a nurse scientist and psychiatric nurse practitioner.
Randi B. Hagi
Melissa Gomes is a a nurse scientist and psychiatric nurse practitioner.

Gomes noted that the vast majority of CCCA patients come in as civil admissions, rather than from the juvenile justice system.

GOMES: In order to get admitted, they have to be considered a danger to themself or others. So, what does that look like? That looks like fighting, could be self harm. It could be risky behaviors like persistent running away.

She saw a direct connection between the high levels of staff turnover and the variety of safety concerns.

GOMES: If I don't have enough staff to even care for the amount of patients that we have, so potentially there's going to be a pocket of patients that might not be within my line of sight because I'm doing something else, or maybe I might be outnumbered in a situation. Or, if you think about – do the children or adolescents even have a chance to de-escalate in a way that is not threatening to other people before they're restrained?

One of the report's suggestions was for the state to close the CCCA and develop contracts with private hospitals to admit those young people.

GOMES: Are we just moving the problem? … That's not the answer. The answer is prevention, number one. Number two, it's training. Number three, it's supporting your staff to feel comfortable speaking up, actually, because that was something that came up in the report.

She does see potential in the state's plan to build community-based crisis stabilization programs, where kids can get help sooner and closer to home. The General Assembly approved $58 million for crisis stabilization units in September, and the governor's new biennium budget proposes an additional $46 million for CSUs and other crisis services.

Gomes previously ran a crisis stabilization program for students in the Hampton City Schools.

GOMES: So these were the kids that were risky in school, getting in fights and, you know, throwing stuff across the room, and a danger. We would bring them to our facility and they would get their schoolwork and they would get support groups. It was like one teacher to 12 students plus clinical staff. We didn't have any issues, and you could see the students … they just wanted to have someone listen to them, and get an alternative perspective, and respect them.

Earlier intervention, she said, could prevent kids from ending up in the hospital in the first place.

Randi B. Hagi first joined the WMRA team in 2019 as a freelance reporter. Her writing and photography have been featured in The Harrisonburg Citizen, where she previously served as the assistant editor; as well as The Mennonite; Mennonite World Review; and Eastern Mennonite University's Crossroads magazine.