For 40 days last fall, James’s entire life fit within the four walls of an emergency department room in Leominster.
The 15-year-old lived in a windowless room, ate hospital meals, wore thin papery scrubs, and was allowed to leave only to use the bathroom or shower down the hall.
But unlike other patients who came and went, the 15-year-old wasn’t sick, much less in need of hospital care. Instead, he was in the custody of the state’s long-overwhelmed Department of Children and Families — and, like dozens of children around the state, was kept in the hospital because the department had nowhere else to house him.
For years, Massachusetts’ child welfare crisis has meant kids shuttled around the state in the back seats of workers’ cars or sleeping on couches and bean bags in agency offices. But amid a persistent shortage of group home beds, foster homes, and other placements, the state is also holding children in hospitals for up to weeks or months on end, even when they’ve been medically cleared to leave.
The child welfare agency calls it a last resort for kids who are waiting until another appropriate placement opens up. But many of the state’s hospitals and emergency departments are already swamped by workforce shortages, new patients, and limited resources, and it’s put their own beds — which can cost a thousand dollars a night or more — in increasingly short supply.
“It’s a travesty, an absolute failure,” said David Schildmeier, a spokesman for the Massachusetts Nurses Association, which represents 23,000 health care professionals around the state. “Right now, it’s a war zone in many emergency departments. . . . And to put kids in these chaotic situations when they’re already traumatized? It makes no sense.”
DCF spokesperson Andrea Grossman did not answer questions about how many children in its custody are boarding in emergency departments because they are waiting for a non-hospital placement. But overall, the number of children involved with the agency who are waiting in hospitals has risen significantly, according to agency data.
For each of the last six months of 2022, more than two dozen children on average were in inpatient beds for “administratively necessary” stays, meaning they were otherwise ready to be discharged — a 40 percent increase since the start of the pandemic. During the same time period, the average number of such children “boarding” in emergency departments — waiting for placements or for inpatient beds — grew by 60 percent.
A spokesperson for the Leominster hospital declined to comment, citing patient privacy laws. Grossman, of DCF, also declined to discuss details of James’s case, citing state and federal privacy requirements.
In a statement, she said the state has started making several changes to help reduce the number of children boarding in emergency departments, including more funding for new beds and trying to provide other mental health options outside of hospital settings.
“For children in custody of the Department of Children and Families (DCF) who require a higher level of mental or behavioral health treatment than DCF foster care can provide, DCF works with multiple state agencies to find appropriate placements,” Grossman said.
When James entered the UMass Memorial Health hospital in October, neither he — nor his family — had any idea he wouldn’t see sunlight again for nearly a month and a half.
At first, he was told he was being held there for a psychiatric evaluation, said James’s mother, Marie, who had voluntarily sought the state’s help in late 2021 to help supervise her son, whose anger management, truancy, and other issues worried her. (The Globe is referring to both by their middle names to protect their privacy. James declined to discuss his hospital stay, but his mother shared details, e-mails, and records with the Globe.)
Within days of James’s arrival, hospital staff determined he wasn’t in crisis, records show. But without another placement available, his social worker could not transfer him, leaving him stuck for several more weeks.
“I felt helpless,” said Marie. “He was just being held there.”
The shortage of places to house kids caught up in the state’s child welfare system is not new. But it has become more challenging during the pandemic, especially in swaths of Western and Central Massachusetts.
According to agency data, DCF places on average 5,300 children in foster care each year, many of them initially relocated without court orders. Despite increasing money for placements, the agency has struggled to recruit and retain enough foster parents and group homes have struggled to stay open or staff their beds with qualified workers.
That has already resulted in children being shuffled nightly among “hot line” homes that provide last-minute, short-term stays, or in dire cases, sleeping in offices where DCF staff work overnight shifts. When children in DCF care end up in emergency departments for services like psychiatric evaluations, the state has sometimes kept them there while awaiting an appropriate placement, such as DCF group homes, foster homes or residential programs contracted with the Department of Mental Health.
Some extended stays in hospitals are classified as “administratively necessary” for other reasons, like patients waiting for home services to be set up. But for children who get services from DCF or are in DCF custody, a primary reason is they are still waiting for placements and have no other options.
That placement process has also become more difficult as social workers have seen more children with intensive needs during the pandemic, said David Foley, the president of SEIU Local 509, which represents many DCF workers around the state. “Social workers are navigating a complex system.”
In the hospital, at least, children are guaranteed a bed and meals, workers say. But living in emergency room conditions can also be deeply traumatizing to already traumatized children.
They’re rarely allowed to go outside and sometimes limited to foods like fries and chicken fingers that can be eaten without utensils. Many rooms have no windows, meaning kids often fill the days watching TV or scrolling through cellphones, if they have them.
The conditions they are subject to also affect hospital workers who want to help but are overextended, said Katie Pirri, an emergency department nurse at Steward Morton Hospital in Taunton.
“This is every hospital,” said Pirri, who said she’d personally seen a dozen such children in DCF custody since she started working in the emergency department six years ago. “They’re missing school, the nutrition is awful, they have nothing to do. Basically we’re baby sitters — but we have other patients who are really sick too.”
Hospital beds are also at a premium as hospitals around the state are being squeezed to capacity. Emergency departments have regularly reported hours-long waits for patients. In the last few months, more than 90 percent of hospital beds have been routinely filled, according to a state tracker.
Meanwhile, mental health services of all kinds, but particularly for children, can’t keep up with demand. Wait lists for therapy around the state have stretched to months. It is a crisis state lawmakers moved to address last year, allocating millions in new funding to improve resources and insurance coverage. Erasing the shortfall in care is sure to cost millions more.
Few places feel those cuts more acutely than Worcester County, where James grew up.
His mother, Marie, struggled early on with her own mental health issues — mood swings, depression — and James’s early years were a carousel of different relatives’ homes and some DCF involvement, she said. But as a young kid, he was quick to crack a joke or a smile for the people he loved most.
“If he loved you and got attached to you, you couldn’t go nowhere,” she remembered.
As James got older, he began to retreat into himself: skipping school, spending late nights out, mouthing off. At first Marie wondered if it was just the kind of acting up you might expect from a teenager. Then, she said, she heard about James getting into fights with other kids. The school he attended would report an ever-growing tally of absences. Some days, he wouldn’t listen to her entreaties at all.
She started worrying about her son getting mixed up with the wrong crowd. He “thought he was untouchable,” she remembered. “I was worried I was going to end up burying this kid or that he’d end up in jail.”
In December 2021, Marie decided she had no other choice: she filed a petition to involve the state in James’s care. The arrangement, she thought, might get him some therapy and set him straight.
But such petitions, called “child requiring assistance” cases, go through the juvenile court system. Despite several reforms made a decade ago, the process has gaps in linking children with behavioral health resources they need, according to a report late last year from the Office of the Child Advocate.
But Marie said she thought it was her only option.
“I just wanted him to have anger management classes. I wanted him to go to therapy, I wanted him to go to school,” she said. “But we never saw the services happen. We never got to see the therapy.”
Though James had been assigned social workers at home, he continued to skip class and argue with his family. Then in April, while at the courthouse for a hearing about his mother’s petition, James fought with a probation officer. A judge turned custody over to DCF, which placed James in a group home several miles north.
For a few months, Marie said, the new arrangement seemed to help. When James came home for occasional weekend visits, she’d see flashes of her son’s old self. They’d go out to eat or order takeout. Sometimes, Marie’s mother would cook. They’d watch TV while Oreo, James’s cat, would nuzzle his forehead and stay glued to his side.
Then at the end of August, DCF revoked his visiting privileges, citing concerns that his home setting was not safe. Marie said the decision came after she criticized James’s social worker and asked again about getting therapy for her son.
Cut off from home visits and struggling with school, James spiraled. In early October, he argued with staff at his group home and threw a rock through a car window, according to records reviewed by the Globe. His group home called the police, who escorted James to the hospital in Leominster.
When Marie got the call from the hospital, she was surprised and furious — after all, she had asked the state for help. She felt she deserved a say in his care.
When she was able to visit him, after he had been at the hospital for a week, she was ushered through security and a metal detector and was startled to find James isolated in a tiny hospital room barely wide enough for him to stretch his arms out. Thin blue scrubs rustled against his lanky frame. He looked every inch a patient — except that he wasn’t sick.
“I was like, of course he needs help. But a psych hold? Come on now,” she remembered.
She agonized over whether to take him home; she worried she wasn’t legally allowed to leave with him since he was in DCF custody. And she wondered: What happened to the therapy she’d sought for James?
She said James was happy to see her, chattering about underwhelming hospital food and asking if she could bring him his phone or something else to eat. Marie tried to reassure herself — perhaps this would only be for a few days, she thought.
She began driving almost every other day to visit him for a few hours after work, sometimes with his favorite McDonald’s sandwiches or coloring books to pass the time. Each day, she thought she’d hear an update about how much longer he would have to stay in the ER. But another week went by with no word.
Then Taylor Henley, one of James’s lawyers, e-mailed DCF asking for an update on James’s status. The agency was still looking for new placements, a social worker replied. New psych beds? No, the answer came back — James wasn’t in need of medical care anymore. Because his old group home wouldn’t take him back, DCF was leaving him in the ER until they could find somewhere else for him to go.
In e-mails, Marie demanded to understand how the state could leave her son behind — and keep her in the dark. “If I did the things DCF has done, I would [have] had my kids taken away from me for NEGLECT,” she wrote in a group e-mail chain that included his social worker.
“I completely understand the frustration but this is out of my control,” the worker wrote back, describing the lack of open beds for James. “There is a foster care crisis as well as a mental health crisis in Massachusetts and we cannot create placements out of thin air.”
For another three weeks, while James languished in the hospital, Marie and her son’s lawyers worked the phones, looking for answers. Henley said she turned to both the DCF ombudsman’s office and the Office of the Child Advocate. The ombudsman’s office, she said, offered to look at his file. The Office of the Child Advocate, she recalled, told her to call the ombudsman’s office.
Maria Mossaides, the director of the Office of the Child Advocate, declined to comment specifically on James’s case, but said when contacted that her office tries to connect people to the appropriate state agencies. The Office of the Child Advocate, she said, is also focused broadly on identifying gaps in the system for policy makers.
What ultimately sprung James after a month and a half wasn’t a new home to go to — it was a court date, requiring James to show up in person to discuss his custody situation and his delinquency case.
At the hearing, Marie said, she asked the court how to get DCF out of James’s life. She wanted to bring him home, but James couldn’t stay in Worcester County, she said, worrying that his being back in the neighborhood and around the wrong crowd could trigger his anger issues again. What, she wondered, if he stayed for a while with her adult daughter out of state?
The judge agreed. In a matter of minutes, she and James stepped out of the courtroom together, her son back in her custody.
James was “ecstatic,” Marie remembered. “All he cared about was he got to sleep in a real bed that night.”
The DCF worker at the hearing gave them a curt goodbye, Marie said. “He just high-tailed it out of there,” Marie said.
Two nights later, she said, she drove James to his sister’s house, hoping for a fresh start.
Elizabeth Koh can be reached at email@example.com. Follow her on Twitter @elizabethrkoh.