By Medha Nair
Every 15 minutes, certified nurse assistant Lily Menyelshewa would check in on her young patients. She wasn’t working in the intensive care unit, but rather in UNC Medical Center’s child and adolescent psychiatry ward.
There had to be a plethora of staff members like her to patients to keep track of everyone, because there may be a patient who is an elopement risk.
“Which is terrifying because you don’t want someone who is suicidal running away,” she said.
The units are constructed differently; there are sliding doors, no machine wires or anything that can be used negatively, since most of the people are coming in with self-harm or suicidal ideation.
Sometimes, the patients she would see in the ward one week would be gone the next, and a new group would come in. But some of them stayed for a long time, even two to three months, she said.
The children would still go to school if they could. They would attend the UNC Hospital School, which is a unique school within the hospital and part of the Chapel Hill-Carrboro City Schools district, to allow students receiving medical care access to education.
One day a week, the children would go to the pediatric game room.
There would be therapy groups centered on mindfulness.
The whole experience is to make the space as therapeutic as possible.
According to its goals and mission statement, the inpatient psychiatry ward strives to make its care interdisciplinary, which means children have access to the attending child psychiatrists, psychiatry residents, nurses, occupational therapists, recreation therapists, social workers, teachers and psychologists when consulted.
The care in the psychiatry ward is truly intensive, with the frequency of monitoring and the standard of care. So how does a child with access to this level of care transition to life outside the hospital? How do all the forms of care translate?
“While mental health doesn’t discriminate, access to care definitely does,” Menyelshewa said.
The Next Step
Outpatient clinics tend to be a step down from inpatient care, which means the child will visit their mental health support team in a facility for their appointment while staying with their family at home.
As a nurse practitioner serving patients in both inpatient and outpatient clinics in Charlotte and the Triad, Rahel Ayalew helps adolescents struggling with eating disorders, anxiety and depression with medication management.
While some people may come in already having gone to therapy, Ayalew said that a lot of the time, people wait until the last moment before they receive care, so sometimes they need to go to the hospital if they require more intensive care. However, for patients afterward, the outpatient clinic fits their needs well.
Ayalew said that ideally, for depression treatment, medication starts at a six-month term. With anxiety, sometimes adolescents need therapy help to learn anxiety management before taking medication.
Treatment is not a one-size-fits-all formula, and it can sometimes be a trial-and-error process.
That is why having an encompassing support system becomes important.
Holistic Care
Insurance is a recurring issue, said Lindsay Ray, the executive director of clinical operations at Hope Services, a community-based health agency that helps provide therapy for people with all private insurance and those who qualify for Medicaid.
Providers are not always getting reimbursed properly, so it becomes easier for clinics to not accept insurance, and in places where there are already shortages of care, this can prove really difficult, she said. Hope Services originally only accepted Medicaid, but it expanded its coverage to be more inclusive of patients with insurance that may change over time.
“We wanted them to be able to stay put,” Ray said.
These financial barriers do more than delay care — they shape what kind of care is possible. Limited options can mean fewer specialists, longer wait times or settling for providers who may not fully meet a child’s needs.
A big part of sustained care after hospitalization is affordability. While the therapists at Hope Services might not be receiving as much income as a clinic not accepting insurance, children from all socioeconomic backgrounds have a better chance of accessing important services, Ray said.
For children coming back from hospitalization who may still need more attentive care during the transition process, Hope Services offers a Medicaid-only service in which therapists go into the child’s home for two-hour sessions up to five days a week.
Some children who are missing school because of their mental health issues or other behavioral health issues have the option of day treatment for six hours a day, either with a modified school day or instead of school.
Chronic absenteeism is already an issue in North Carolina, with 26.7% of students considered chronically absent from school. One of the things that can contribute to that is behavioral health or mental health crisis emergencies, since students are out of school so much.
The therapy sessions most sought after are after school, which is why offering virtual sessions or having more providers helps, Ray said. Still, there are a limited number of appointments available at those times, given how in-demand they are. The therapists at Hope Services have to work at least three late nights until 7 or 8 p.m. to accommodate all their patients.
While Hope services offers specialized care for youth discharged from the hospital, therapy is not the only way students can receive help or at times just a listening adult. Luca McElreath, a N.C. State University student and a teacher at Apex Elementary School, has had conversations with students who come to him with conflicts that impact their mental health.
He said that the most important thing on his end is considering where the students are developmentally, and that because of where they are developmentally, daily conflicts really matter to them.
With high school-age and middle school-age students, it can be hard to explain prolonged absence due to hospitalization, but having safe adults to communicate struggles with is extremely important.
While working with another organization, McElreath had worked with a sixth grade student who revealed to him that she was hospitalized previously and was struggling with anxiety and depression.
Caring for her outside of the hospital was a task that he had learned to do by being a safe place and “not making it feel like they’re not like every other kid,” he said.
An important part of that is acknowledging the background of students.
Ray said that because students are coming from different cultural backgrounds, their therapists may not have the same background as well, and that can affect care. Children want to be seen and understood.
“Instead of cultural competence, I don’t have to be competent in every culture, that’s impossible,” Ray said. “But I can be humble to a patient to say, ‘Our backgrounds are different, what is that like for you to talk to me?’”
The big picture
Organizations like NC Child aim to serve and support children on a larger scale.
The organization held its State of the Child Summit in April to “engage parents, lawmakers and leaders across communities, sectors and organizations.” The data they gather assists them in advocating and addressing policy change and support in the framework of the state.
NC Child’s data analyst, Ashtin Crawford, compiled and mapped mental health markers among youth to create a composite score per county.
After spending so much time with the data, Crawford saw a trend.
“Mental health struggles are on the rise — depression, anxiety, suicidal ideation are on the rise for kids in North Carolina,” Crawford said.
The Overarching Issue
Resources at UNC Medical Center are still not up to par with what is needed for children, said Menyelshewa. However, what is available to them is much more than some other hospitals in North Carolina that are more accessible, depending on which county they live in. Menyelshewa said that some children traveled up to two hours to receive help at the medical center.
Some rooms also get blocked off because even if there are two beds in them, having someone who has a delusion-type disorder with someone who has depression is not a good mix, Menyelshewa said. Older kids also can’t be placed with someone of the gender they are attracted to.
While some services like UNC Hospital School or Durham Public Schools’ Hospital School at Duke University Hospital help bridge the gaps in schooling during times of recovery, many counties don’t provide a complete service like that.
Resource shortage continues to be an issue, especially when it comes to child and adolescent psychiatry. However, Ayalew said that the stigma is changing and with it so are the resources. As more people seek out help for their needs, the more supply will eventually be available.
Psychiatric mental health nurse practitioners are a relatively new field that began licensure in 2000, with a new updated test allowing more states to open the field to more people, only coming in 2014. In North Carolina, licensed nurse practitioners don’t have full practice authority and are required to be under the supervision of a physician.
Universities like East Carolina University have tried to bridge the gap of mental health providers in the state by having a specialized nurse practitioner program. According to them, the only thing prohibiting them from admitting more people to the program is the lack of qualified faculty.
“Since this psychiatric nurse practitioner provider position has been added, it’s been kind of really adding a lot of providers to the society, so I think that was helpful,” Ayalew said.
Menyelshewa worked as a CNA while she was completing her undergraduate degree. Now, she is looking into becoming a psychiatrist. She said that there is a stigma surrounding the field that there’s not meaningful and impactful change because there is no clear “cure.”
According to the American Academy of Child and Adolescent Psychiatry, having 46 or fewer child and adolescent psychiatrists for 100,000 children in a county is a shortage, while some counties like Orange County boast a high rate of more than 100 psychiatrists for 100,000 children. A county like Wake County had about 17 psychiatrists for 100,000 children in 2022. This matches the average rate in all of North Carolina.
For social workers in North Carolina, the numbers tell a similar gap. Sheps Health Workforce NC provides data and analysis about licensed health care workers. The average rate across counties was about 12 social workers per 10,000 people. Two counties had zero per the same population.
The lack of graduating and practicing social workers and mental health professionals is what drives the shortage of child-focused mental health care. Despite the fact that people are attempting to lessen the scarcity, without more graduates, there just aren’t enough people per child, especially since each child needs multiple people directly interacting with them.
The Web
Long-term care for children is a whole network that starts with parents. But because of some barriers like insurance and transportation that parents face, especially parents who work odd hours or long hours, preventing a crisis and watching for the signs can be much more difficult.
Leaving the hospital does not mark the end of treatment. Instead, it signals the beginning of a longer, less structured phase of care, where progress depends on consistency in environments that are far less controlled.
Care comes in all shapes for children and adolescents; however, being in an inpatient psychiatry ward, care is very tailored and intensive to the child.
When exiting that environment, having to curate a support system of therapists, counselors, psychiatrists and parental help in order to sustain the progress proves to be a harder transition. What was once built in is now coming from different venues.
But it is being done.
“Any improvement in the quality of life is an improvement,” Menyelshewa said.
Reporting contributed by Karen Zhu
