Suicide by Security Blanket, and Other Stories From the Child Psychiatry Emergency Service: What Happens to Children with Acute Mental Illness

  • Laura M. Prager and Abigail L. Donovan
  • Praeger
  • 110 pp.
  • October 3, 2012

These gripping stories of young people in crisis underline the tragedy of shortchanging our mental health services.

Reviewed by Miranda Carter

When I dropped my son off at college a few weeks ago, I met his roommate, Jack, for the first time. As we lugged duffle bags and backpacks into the small, cluttered room, I saw a desk with a stapler, tape dispenser and calculator arranged at precise right angles. “I like things to be neat,” Jack explained, adding a shiny new pencil sharpener to the lineup.

Suddenly I felt transported to my own freshman dormitory, which closely resembled my son’s room in size and layout. I’m sure watching a child start college often reminds parents of their own experience with higher education. But it wasn’t just the bunk beds and battered furniture that triggered my recollection. One of my roommates had organized her belongings as meticulously as Jack. She couldn’t put on a pair of jeans until she’d ironed a perfect crease into them. Then she started changing her sheets every day and washing her hands every time she touched anything. After a few months, she stopped being able to leave the room, and ended up withdrawing from school to get treatment for what turned out to be obsessive-compulsive disorder.

Chances are that my son’s roommate is just particular about his possessions. After reading Suicide by Security Blanket, I certainly hope so. The book tells the stories of a dozen children — their identifying details carefully concealed — who have ended up in the emergency room in what are or seem to be mental health crises. The authors, who work in the child psychiatry emergency service at Massachusetts General Hospital (MGH, as they call it) must determine the reasons for the visits.

These tales are riveting. In the book’s introduction, Prager acknowledges a fascination with the children’s stories. Clearly she understands how to listen carefully and, more important here, portray a character in a few well-chosen phrases. Readers hear, see and smell the tiny interview rooms where psychiatry residents speak to their patients. You can feel the tension rise as a child careens around the room, kicking and screaming as nurses and security guards try first to calm, then to restrain him.

Discovering what brought the child to the emergency department requires listening to the child — a critical but often ignored first step. Sometimes that is all that’s necessary. For example, in one story, a second-grader is sent to the emergency room after his teacher sees a picture he has drawn of himself attacking her with a knife. The vice principal, without speaking to the child, demands that he obtain a doctor’s note certifying that it is safe for him to return to class. When a psychiatrist asks the boy what happened, the answer turns out to be simple and benign. The boy can go back to school right away.

In many of the narratives, though, the child’s problems remain unresolved despite the attention from the experts in the emergency service. A solution or even ongoing treatment too often seems out of reach. Over the years the book’s authors have seen hundreds of children arrive in the emergency room, brought by distraught parents, referred by the court system or simply left with no place else to go. They know that, as Prager puts it in her introduction, “our current mental health system [is] one that consistently fails to meet the needs of children because to do so is too expensive and too time-consuming.” She laments the fact that, while insurance may cover inpatient mental health treatment, it often will not pay for the type of reliable ongoing care that might keep the child out of the hospital altogether. The results can be frustrating, frightening or catastrophic.

Parental denial or obstruction can make it impossible to make a proper diagnosis, let alone offer appropriate treatment. There is the 17-year-old girl who claims that a special fluid located deep in her brain brings with it a “perfect power” that makes her a star soccer player and a straight-A student — even if her coach and teachers think she’s underperforming. Although the girl also tells the emergency room doctor that she can hear what other people are thinking, her mother is adamant that she simply has an ear infection and needs antibiotics. When the doctor steps out of the room to consult with the child psychiatry fellow, mother and daughter flee the hospital without any further examination.

In “We Ain’t No Delinquents, We’re Misunderstood,” a 16-year-old boy is a human football. His mother claims that a judge has ordered the boy’s admission to a psychiatric unit at MGH, although she cannot explain why she waited until almost midnight to bring him to the hospital. He has been an inpatient at other psychiatric hospitals, has a history of drug and alcohol abuse, and is on probation for burglarizing an electronics store. The criminal justice, mental health and social service systems have all been involved in his life, but there’s never been a comprehensive or continuing plan to address his many problems. Instead, as the chapter title’s reference to “West Side Story” implies, he is kicked from counselor to social worker to cop. And like the Jets who taunt Officer Krupke in that fictional tale, this teen seems destined for a tragic ending.

As the book makes abundantly clear, ambiguity can lead to a terrifying outcome in the child psychiatry emergency service. A 5-year-old girl who arrives with intricate ballpoint drawings covering her inner thighs insists that a ghost is responsible. Her mother seems to blame the estranged father, even though all his visits with the girl have been carefully supervised. No one can be sure who drew sophisticated designs on parts of a little girl that should remain private. Everyone in the emergency department is concerned about possible abuse. They refer the matter to the Department of Children and Families for investigation, but there’s no definitive answer.

Threaded through these dramatic accounts are examples of the maze of obstacles the authors must navigate in carrying out their work. Despite the best of intentions, sometimes it seems that everything and everyone is arrayed against both child and physician. It’s hard to imagine anyone trying to treat acutely ill children under such conditions.

And that seems to be the point of this insightful and disturbing book. Putting a human face on a problem can help people comprehend it, and ideally motivate them to act. Suicide by Security Blanket presents a particularly disturbing set of faces with an especially powerful claim to attention. May it yield the kind of action its subjects so urgently require.

Miranda Carter is a consultant and parent who lives near Washington, D.C.

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