It was a painful decision, but Doris felt like she had no choice. 

Staff at Northern Light AR Gould Hospital in Presque Isle called Doris on Feb. 8, 2023, and asked her to come get her 15-year-old daughter from the emergency department, where the girl had been staying after she had started anxiously picking at her skin and writing on the walls with her blood at a nearby behavioral health crisis center.

But Doris did not want her daughter to come home. Her daughter was still in desperate need of mental health care that Doris had been searching for and couldn’t find. 

“They told me if I did not come get her, they were going to take her to a homeless shelter and report me as ‘abandoning her,’” Doris said, recounting in a recent interview her conversation with the hospital staff.

“I told them, ‘Go ahead,’” she said.

This experience illustrates an extreme dilemma playing out for parents, children and medical professionals in emergency departments across Maine, where guardians don’t want to take their children home because they don’t have services to support them safely.

A new state dataset offers a window into how often parents and guardians have resisted bringing their children home, as Doris did, giving a sense of scale to a trend alarming families and medical professionals alike.

Hospitals across Maine reported at least 50 instances over the 12-month period spanning August 2023 to July 2024 when guardians said they did not want their children returning home or abandoned them in an emergency room. That’s according to a Bangor Daily News analysis of data that hospitals submitted to the Maine Department of Health and Human Services and that the BDN received through a public records request.

The scenario usually unfolds like this, according to interviews with hospital officials, parents and disability rights advocates: A parent or police officer takes a child in the throes of a mental health crisis to the emergency room, where hospital staff confront a statewide shortage of more appropriate behavioral health treatment options.

Emergency rooms are designed to triage patients who are experiencing a medical emergency, not keep them for long-term, mental-health stays. But in recent years, hundreds of children and adolescents have remained inside emergency departments for days, weeks and even months, waiting for an inpatient hospital bed, a crisis stabilization unit or a plan to go home with community-based services.

In some cases, the primary reason children stay in a hospital for a long time is because their guardians don’t believe it is safe for them to come home or disagree with medical providers about the discharge plan. Medical providers, meanwhile, feel unprepared and ethically conflicted about keeping a young psychiatric patient in a chaotic, windowless emergency department for extended periods. This limbo can be traumatic for kids who have less power to decide what ultimately happens to them.

In interviews, parents and hospital staff framed this conflict as one of the most alarming, challenging situations to emerge from Maine’s continued struggle to offer enough behavioral health services for children, especially in rural areas. The wider crisis prompted the U.S. Department of Justice to sue Maine in September.

While most children in hospitals will eventually go home from the emergency department or find another treatment option, some have nowhere else to go but a homeless shelter. Despite concerns from a social worker on her case, that’s where Doris’ teenager ended up.

Doris estimated that she and her husband have fostered nearly 100 children over four decades. They adopted six, including kids with developmental disabilities. In the years since they fostered and later adopted their daughter, who had been severely neglected as a child, the girl acted out in troubling ways. Their relationship deteriorated.

Doris asked to be identified by her middle name to protect the girl’s privacy; the BDN confirmed the details of the family’s experience using treatment and child welfare records. The BDN was unable to reach the girl.

The daughter got into fights at school, screamed when she didn’t get her way, mistreated her siblings and snuck out of the house at night, once to drink alcohol to the point of passing out, Doris said. She never seriously hurt anyone, but Doris worried she might hurt herself, and later told child welfare officials that she had found knives, razor blades and a hammer hidden in her daughter’s room. Shortly before her hospitalization in early 2023, she threatened to kill her parents and herself, and burn down their house in Aroostook County.

Before arriving at the emergency department in Presque Isle, Doris’ daughter had spent nearly three months at two separate crisis units to address her depression, anxiety and excessive drinking, only to be transferred when they couldn’t meet her needs or she upset other patients.

Meanwhile, Doris had been working with state health officials, a case manager, psychiatrists and a disability rights advocate in an attempt to get the girl a more intensive, long-term mental health service. But, even working together, everyone struggled to find a place that would accept her. At one point, the team considered finding her a foster home because the bond between the girl and her parents had suffered so much.

At the emergency room in Presque Isle, Doris’ daughter denied any desire to hurt herself or others, according to a psychiatric evaluation. Still, Doris worried, especially about her other kids, she said.

“I knew I could not contain her at home. I wanted to. I loved her. I wanted to help her,” Doris said. “But there was no help to be found.”

‘Done doing it alone’

In 2021, lawmakers passed a bill that requires hospitals to submit data about children who spend more than 48 hours in the emergency department waiting for mental health care. The legislation aimed to provide state officials with a more detailed picture of how many kids were getting stuck and why.

Hospitals submitted information about children’s length of stay, diagnosis, the primary and secondary reasons that patients had an extended stay, and the discharge location. Proponents of the data collection hoped that capturing a more detailed picture of the problem would build urgency to find a solution, said Lisa Harvey-McPherson, a trained nurse and vice president of government affairs and advocacy for Northern Light Health, which operates Maine’s second largest hospital system.

The BDN reviewed a year’s worth of data that 28 hospitals submitted between August 2023 and July 2024, showing at least 410 prolonged admissions for children needing behavioral health treatment. The figure could include the same child more than once.

The primary reason that 18 individual young patients — 10 boys and eight girls — had an extended stay in the emergency department was because they were “abandoned by guardian.” In another 21 cases, hospitals noted that the patient’s guardian did not wish for them to return home.

The numbers are likely an undercount because not all 33 hospitals in Maine submit data every month, said Jeff Austin, vice president of government affairs and communications for the Maine Hospital Association. Some hospitals also may not have any patients to report.

Hospitals listed abandonment or a guardian’s resistance to bringing children home as a secondary reason prolonging their stay in 12 other instances. All but three of those patients were waiting for a bed in a residential treatment facility or an inpatient hospital.

One 11-year-old boy with autism, whose grandparent felt unable to control his violence, was waiting to be admitted to a secure residential program in New Hampshire. Another 15-year-old boy involved in both the juvenile justice and child welfare systems had been transferred to an emergency department in Lewiston after spending nine days at a smaller hospital in western Maine “despite having no medical reason to be there,” hospital staff wrote.

In more than half of the 51 cases, the hospital had treated the child before. At least eight patients had been seen by the same emergency room on 10 or more previous occasions, the data show.

For cases that included a discharge date, kids spent an average of two-and-a-half weeks in the emergency room. Their time ranged from two to 132 days. (Eight of the 51 cases did not include a discharge date.)

Hospitals recorded children were “abandoned” when emergency department staff believed a child should go home but a guardian disagreed, Harvey-McPherson said. She and others cautioned that the term can be misleading. “Abandonment” often describes parents who have not stopped caring about their child’s welfare despite pushing back against the hospital, they said. In many cases, they likely searched exhaustively for help.

“The term abandonment is tough because it feels like we are blaming someone,” said Dr. Ross Isacke, chief medical officer at MaineHealth Franklin Hospital in Farmington. In reality, the situation more often reflects the desperation of families who are grasping for help when it doesn’t exist, he said.

As for the children caught in limbo, “almost every child I’ve talked to just wants to go home,” said Atlee Reilly, managing attorney for Disability Rights Maine, a legal advocacy group that represents children with disabilities. “What we see generally [are guardians] who do want their child home but are done doing it alone.”

‘So morally injurious to our staff’

The data cast light on the difficulty, anguish and conflict that can unpin these cases.

In the summer of 2023, state police found a 13-year-old boy living in “squalor” after his mother “gave” him away to another family because he had sexually assaulted other young children, according to a submission by Sebasticook Valley Hospital in Pittsfield, where officers brought the boy to be treated.

His mother refused to pick him up from the emergency department, but the state was unwilling to take custody of him, the hospital wrote. The boy remained at the small hospital, while medical staff searched, unsuccessfully, for an in-state residential facility to discharge him to. He ultimately ended up on a waitlist with nearly 70 other children for an out-of-state residential program, according to the hospital. It is unclear when he left.

When guardians don’t want to take their kids home from hospitals due to a lack of services, the hospitals usually call child welfare officials at the Office of Child and Family Services. Jim Bailinson, a lawyer for MaineHealth, the state’s largest hospital system, said hospitals err on the side of making reports, but that doesn’t mean the state always opens an investigation.

Similarly, Northern Light hospitals call child protective services frequently, but it is unusual for the agency to take custody of children when they believe parents are still involved in the decision making around their child’s care, Harvey-McPherson said.

“Calling CPS to report abandonment because parents fear their child. I mean, how bad is our system? How bad has it gotten?” she said.

Meanwhile, the lack of action can be “so morally injurious to our staff because they are watching this child every day deteriorate in the ED,” Harvey-McPherson said.

She and other hospital staff have long decried the conditions children endure when they spend long periods in an emergency room because they have little access to sunlight, recreation and mental health treatment. Some have even likened it to imprisonment.

More clear-cut cases of abandonment do still occur. In legislative testimony last spring, Harvey-McPherson described an instance where a parent refused to answer phone calls from the hospital about their child because they were going on vacation. In that case, the state did not take custody of the child, she said. But it has happened to other children.

After she was admitted to Northern Light Eastern Maine Medical Center in Bangor three weeks before Thanksgiving last year, a 15-year-old girl with diagnoses of post-traumatic stress and borderline personality disorder remained there for nearly 78 days because her father “refused” to take her home or engage in her care, according to the state data. She only left when state child welfare officials took custody of her and found her a foster home.

“The decision about whether to seek removal of a child is highly fact specific, not taken lightly,” said Lindsay Hammes, a spokesperson for the Maine Department of Health and Human Services, which oversees both child protective services and children’s behavioral health programming.

State custody is rarely seen as a solution to these cases, and a recent bill that would have required the state to take custody of children abandoned in hospitals was roundly opposed last spring. State workers confront the same paucity of services that parents do, according to those who testified against the bill, some of whom questioned its legality and impact on families.

‘They are desperate’

In February, staff at Franklin Hospital in Farmington confronted a similar situation to what Doris did more than 200 miles away in Aroostook County. They were struggling to find a residential mental health treatment program for a 17-year-old boy with post-traumatic stress disorder, according to the data. After 18 days, he was ultimately discharged to a homeless shelter.

The case was one of four instances in the data where hospitals listed “shelter” as a discharge location. They would likely discharge more kids to shelters if they could. Staff at three homeless shelters across the state — in Portland, Bangor and Mars Hill — said they field routine inquiries from hospitals asking whether they can admit a child with nowhere else to go.

“Sometimes it is the same kid getting referred over and over because they are desperate,” said Kiersten Mulcahy, who manages the Preble Street Teen Center in downtown Portland.

Anecdotally, those calls seem to be growing, she said. In early October, Mulcahy said the shelter had been going back and forth with a hospital for several weeks over whether to admit someone whose parent would only allow their child to come home if intensive, at-home behavioral health support was in place, Mulcahy said. The waitlist for one of those programs is nearly 125 days long, according to a state dashboard.

“The lack of intervention when someone is left at a hospital should not equal homelessness,” she said. In an interview, she urged the Maine Department of Health and Human Services to “step in and prioritize putting a system in place.”

Hammes, the department spokesperson, said that staffing and hiring challenges in the behavioral health field have hindered the department’s efforts to boost programs.

“Despite hundreds of millions of dollars of new investments, including reimbursement rate increases and policy changes for increased support, providers continue to face the same workforce challenges as other sectors,” Hammes wrote in an email.

She also drew attention to a team that is dedicated to coordinating services for especially complex cases, which families can request help from through a case manager or directly through an online request form.

The department is currently leading a work group studying ways to solve the crisis of children getting stuck in emergency departments. Reilly, the lawyer with Disability Rights Maine, sits on the group. He doesn’t suspect it will come up with a solution any different from what he and other advocates have been saying for years.

“We’re looking at it from the hospital perspective, and it’s awful, but there’s not a special solution for that group [of kids],” Reilly said. “Everything gets plugged up if you don’t have a robust community system.”

After Doris refused to take her daughter home from the emergency room in Presque Isle, the hospital discharged her two days later to the Northern Lighthouse, a youth homeless shelter in Mars Hill, documents show. Since it opened in the fall of 2022, the shelter has recorded 18 admissions from an emergency department, said Blake Hatt, the program’s chief operations officer. This year alone, the shelter has denied more than 15 additional requests from emergency departments over concerns that the shelter would not be able to properly care for the children, he said.

Doris believes it was her daughter’s homelessness that finally applied enough pressure to get her into a residential program 11 days later, she said.

By then, their relationship had reached a point of no return. State child welfare officials investigated Doris for abandoning her daughter but did not find that her decision, in light of everything that had gone on, amounted to neglect, records show.

But Doris and her husband ultimately relinquished their parental rights anyway, she said. The girl went on to allege that Doris’ husband touched her inappropriately, in what the woman believed was an act of retaliation. Child welfare officials did not substantiate the allegation, Doris said, but, in the midst of that process, the couple made it clear they would not allow the girl back home, so the state terminated their custody.

Doris believed that decision was also in the girl’s best interest, she said. She couldn’t see how to move forward as a family any longer.

Callie Ferguson is a reporter at the Bangor Daily News. She may be reached at cferguson@bangordailynews.com.