Editor’s note: This story discusses suicide and self-harm.
The slight 13-year-old in an oversized white shirt sits at a round table in a sparse conference room in his school on Chicago’s Southwest Side.
Randy Sadler, a paramedic of sorts for kids in emotional distress, sits across from the boy and explains he has some straightforward questions. The boy’s dark brown bangs hang over his eyes. His mother and two adults from his school are there too.
“Do you feel suicidal at this moment?” Sadler asks, telling the boy it’s okay no matter the answer.
He has in the past, the boy admits, but not right now. On this fall day, Sadler probes a little deeper, knowing the boy told the counselor he had been suicidal. He asks: “Do you have a plan? Are you anxious?”
The weight is on Sadler to make a potentially life or death decision: Is this child safe to go home?
Every day in Illinois, specialists like Sadler are called into schools, hospitals and homes to make these heart-wrenching decisions. They’re on the front lines of the state’s mental health crisis among children. It’s been simmering for years, but was supercharged by the COVID-19 pandemic.
In Illinois, the percentage of children who arrived in hospital emergency departments with suicidal thoughts climbed nearly 60% over a nearly six-year period ending in 2021, according to a study involving Lurie Children’s Hospital of Chicago.
Twenty years ago Illinois developed a safety net for children from low-income families — like the 13-year-old in the oversized shirt — who are in mental health crisis and have Medicaid health insurance or none at all. The state works with more than two dozen nonprofits, including Ada S. McKinley Community Services, where Sadler works, to try to quickly assess and find help for these children after a call is made to a hotline. The program is called Screening, Assessment and Support Services, or SASS.
Illinois mental health providers call the program an essential lifeline, a godsend for families at a difficult moment. But a six-month investigation by WBEZ, involving dozens of interviews and a review of hundreds of documents and state records, finds the state is failing to ensure thousands of children are getting any follow-up help, let alone the type of intensive behavioral health support many need.
WBEZ found this vital safety net is riddled with holes. It’s buckling under the weight of a youth mental health crisis that is grappling with staff shortages and greater need. SASS workers can be a real help, but they are hamstrung — they don’t have enough places to send kids in distress.
As one provider put it, SASS is like a Cadillac driving nowhere.
“This is all being funded by all of our tax dollars, and it’s a total mess,” said Cook County Public Guardian Charles Golbert, who represents children in the foster care system, some of whom have gone through SASS.
Complaints that children in crisis are waiting hours just for a SASS assessment — a response is required within 90 minutes — are up 50% in the last year, even though state officials say they track this and hold SASS providers accountable. That’s according to WBEZ’s review of state records and data obtained through public records requests. Last year, about 46,000 SASS calls from across Illinois required a quick response.
And the state doesn’t even know if all children in crisis screened by a SASS worker were connected to mental health support, typically inpatient or outpatient care, let alone whether they actually received treatment. After months of asking, the state couldn’t provide screening outcome data for about 40% of the cases that required the 90-minute response over five years. More than 220,000 calls required a quick response during that time period, from 2018-22.
In fact, state officials say they are just starting to hold insurance companies responsible for making sure children have a follow-up appointment scheduled after a SASS crisis intervention, or after a child is discharged from a hospital. Illinois largely outsources the SASS program to private insurers with Medicaid contracts.
What we do know is that many children are cycling through the system: One in three children are typically frequent fliers to SASS, with at least two calls made on their behalf in one year. State officials say the Medicaid insurers follow these children closely.
Still, Kristine Herman, bureau chief of behavioral health for the Illinois Department of Healthcare and Family Services, which oversees SASS, and other state officials say they need to do better.
In December, the state launched Pathways to Success, a program that funds organizations to provide more intensive care coordination and supportive services to children in their communities.
Herman hopes this fills some holes within SASS, even as some of these services are what SASS providers — and the private Medicaid insurers — are supposed to offer already. The state has proposed spending nearly $150 million for Pathways in the next budget year that starts July 1, and an estimated $300 million a year when the program is fully implemented.
“It’s one of the reasons why we’re pushing to get these additional services into the community, because those are really the types of follow-up services that they need that they don’t have right now,” Herman told WBEZ.
That reality was painfully clear as Sadler struggled to decide last fall whether the 13-year-old boy in the oversized shirt could safely go home.
Near tears, the boy’s mother explains through a Spanish interpreter that she’s run out of ideas on how to help her son. He’s been anxious for months, not sleeping and not wanting to go to school.
Sadler asks the boy, “What is making you so anxious?”
The boy says he feels a lot of pressure to grow up, to do well in school. After doing a thorough mental health assessment, Sadler says he is going to recommend regular outpatient counseling. But he hesitates.
“There’s a waiting list,” he says with a deep sigh. His agency, which covers most of the South Side and parts of the West Side, wanted to hire 15 to 20 more workers last fall but couldn’t keep up with the need.
Sadler tells the mother to call every week until they find him a therapist.
“Call again and again,” he says. “Tell them that your son is not well. Do you understand, be the squeaky wheel.”
SASS crisis program was designed to be an equalizer
As Sadler leaves the school, he’s feeling frustrated.
“That baby needs someone to check up on him every day. Ideally that would be the school, but I get it the school is under-resourced,” he says. In fact, the counselor said he had no idea the boy was struggling. In a school of more than 900 students, the boy did not stand out.
As soon as Sadler looks at his phone, he sees another call. A school a few miles away is calling about three children experiencing what the school sees as a mental health crisis.
Sadler is a teddy bear of a man with chubby cheeks, dimples and kind eyes. He’s in his early 40s, but when he talks he can sound like a worried grandma. He almost always calls children “babies” in an endearing way. He said parents, schools and hospitals want him to work magic for their babies, but there’s no magic to be worked.
“We are not the cure-all,” he says.
SASS is supposed to be an equalizer of sorts, a gateway to help give kids from low-income families a better chance at getting mental health treatment — and to prevent unnecessary hospitalizations. Kids with private insurance typically have more doctors willing to treat them. This comes down to money: Private insurance tends to pay better.
WBEZ interviewed parents, school counselors and mental health providers around the state to see how this plays out.
For one Chicago mother, Melina, turning to SASS was more a hindrance than a help. A year ago, her son had been threatening suicide. “He started crying and saying he wanted to kill himself, that he didn’t have a point in life.” Melina said. WBEZ is not using her last name to protect her son’s privacy.
His West Side school called SASS for help. For families with Medicaid, this is the main way to get urgent inpatient care. Melina was told it might take hours for a SASS worker to arrive. Not wanting her son to wait at the school, Melina, who didn’t have a car, used an Uber to pick him up from school and then to get to a psychiatric hospital on the western edge of the city.
They spent five hours in the hospital’s cold, unwelcoming waiting room. By the time a SASS worker finally arrived to assess the boy, he was no longer in visible crisis and didn’t say much. They were sent home with a referral for outpatient therapy. “My head was pounding,” she said. “It was like a nightmare.”
Melina felt abandoned and scared: “He’s saying he wants to kill himself. Maybe he’s gonna do it, maybe he’s not … I don’t know what to do.”
She told him to keep his door open while he slept.
When Melina called about therapy, she faced waitlists. She eventually landed a weekly spot on her own. But even today, Melina worries her son is not getting enough treatment.
Chasing the same hospital beds
Once SASS providers assess children, the wait begins — whether waiting for a bed in a hospital or a weekly therapy appointment.
Inside St. Bernard Hospital on Chicago’s South Side, at least once a week a child in a mental health crisis arrives in the busy emergency room. This small community anchor doesn’t have psychiatric beds for adolescents, or a pediatric unit at all. In fact, on the entire South Side, where there are vast health disparities compared to richer parts of Chicago, there’s not one pediatric psychiatric bed.
So children wait at St. Bernard for days, sometimes more than a week, for a bed someplace else. Sadler is one of the crisis interventionists that works to get them placed. He’s a familiar face at the hospital, building rapport with these young patients.
Without anything to do, many children linger outside their exam rooms, hoping to strike up a conversation with staff. They’re exposed to all the trauma that comes to the ER — people who are shot, in labor or suffering heart attacks. They see police officers guard patients’ rooms.
Dr. Ashley Magda, a senior physician in St. Bernard’s ER, is frustrated.
“When will the government finally realize that if we don’t help these kids as kids, we’re just going to have a bunch of very troubled adults,” she said.
What’s unfolding at St. Bernard is happening across Illinois. For the most vulnerable kids who need immediate help, there are only around 30 hospitals in the entire state — making up about 15% of all hospitals — that have pediatric psychiatric beds. And not all take a large portion of Medicaid patients. Hospitals with the most psych beds for children are concentrated in the suburbs and near Chicago’s West Side, according to 2020 state data, the most recent year available.
Here’s the ripple effect: Children across Illinois are crisscrossing the state chasing the same beds, traveling perhaps hundreds of miles from their homes.
Kelsey Di Pirro, with Community Counseling Centers of Chicago, known as C4, illustrates the capacity crunch. SASS workers fax referral packages to hospitals all over Illinois to find a bed, faxing forms as far away as Iowa and Tennessee. They do this every 12 hours until they get a bed.
If a child winds up in Missouri, they take an ambulance there, but they need to find a way home.
Di Pirro says a child can wait in the ER anywhere from 24 hours to five days. In the last year, some have waited longer than a month.
“We’ve gotten to the point with some kids, the hospitals are like, ‘We’re not going to accept them. Please stop calling us,’ ” said Carrie Ray with Heritage Behavioral Health Center in downstate Decatur.
Children with autism or aggressive behavior are hard to place. And finding a bed for a foster child is one of the biggest challenges. Hospitals want a commitment from the state they have a placement when treatment is over. The answer is often there’s nowhere for them to go. So these kids languish in the ER.
There’s no public real-time window into how many beds are actually available. Even the Illinois Department of Healthcare and Family Services, which oversees the SASS program, doesn’t have a clear picture.
Kristine Herman from HFS said the state brings together a team from multiple agencies to help stabilize children having trouble finding a bed.
State Medicaid claims illustrate how difficult it is for Medicaid patients in particular. Over the last roughly five years, one hospital and its providers submitted far more payment claims for treating pediatric Medicaid patients than another hospital with a similar number of beds — almost $37 million at one hospital versus around $2.5 million at the other, WBEZ found. In other words, one hospital is treating a lot of Medicaid patients. The other is not.
“It does not make me feel good when someone asks me, ‘What’s the race of the person,’ because it doesn’t matter,” said Melissa Coleman, a senior intervention specialist with Metropolitan Family Services, whose SASS territory covers the south suburbs and part of the South Side. “Some hospitals will ask you what the person’s ZIP code is. Why? I don’t even understand that part. And then they’ll ask you, ‘Which kind of [Medicaid] managed care is it?’ ”
In statements, spokespeople for hospitals explained why they might not admit a child. Some cited a workforce shortage — in rural areas in particular. That means taking on fewer patients if they have to staff private rooms or provide one-on-one monitoring. Others said how sick or aggressive a patient is are the main factors in whether they can be safely cared for in the hospital. In some cases, this puts other patients at risk.
SASS crisis workers on the front lines say the struggle to get children the care they need leaves them feeling defeated and angry — not just for the youth, but for the system they’re in.
Listen to the full series:
The struggle to find mental health care
The shortage of treatment options — and where care is located — comes into play in Sadler’s most difficult assessment of the day.
It’s after 4 p.m. when Sadler sees a call from a West Side elementary school. A 12-year-old told a counselor he plans to kill himself with knives in his kitchen while his parents sleep.
Ada S. McKinley, which generally focuses on the South Side, expanded onto the West Side at a time when another SASS provider left the program. That leaves Ada S. McKinley doing West Side assessments over the phone. The boy’s mother only speaks Spanish so Sadler brings a translator onto the phone.
It creates an awkward situation: a vulnerable boy in an office with his mother and a counselor in a near-empty school speaking to two strange men on a speaker on a phone.
As Sadler begins asking questions, the boy immediately starts sobbing.
In a small high-pitched voice, he admits he did want to kill himself. Then, he can’t say anything because he’s crying too hard. The counselor says the boy had said he’s “getting sadder and sadder,” and, “Sometimes, I want to get out of this world and never get back.”
Sadler immediately decides the boy should be admitted to a hospital for psychiatric care.
The mother wants Rush University Medical Center, where her son previously did an intensive therapy program and is relatively close to home. But Rush no longer has a pediatric psychiatric unit. The school counselor says the best option is Riveredge Hospital in the west suburbs.
Sadler tells the mother the hospitalization could be as long as 14 days.
Suddenly the mother’s voice is shaking and she is crying. Neither she nor her son wants this, she says.
Sadler is forced to step in: “I need mom to know … she has the legal right to say no. However, I will be immediately contacting DCFS and someone will be at the home today, and this can impact her and if she has any other children as well,” Sadler says, referring to child protective services.
The counselor says the boy is becoming increasingly upset as he listens. Sadler tries to refocus the situation. “The goal is to get him help,” he says.
Still the mom says she will look for help elsewhere. The counselor asks if, at the very least, they should recommend mom remove the knives from the home.
“Remove everything sharp: knives, scissors and glass,” Sadler says.
Searching for solutions
The state has known for years that SASS doesn’t deliver on its promises. In a 2019-20 report, an outside agency contracted by the state called for “immediate quality improvement efforts” related to children’s behavioral health, including SASS. Medicaid insurers have tried to improve by expanding access to treatment through telehealth and partnering with behavioral health providers to reserve appointment slots.
Still, Gov. JB Pritzker wants more done to fix the mental health fabric for children across the state. He’s tapped Dana Weiner, a senior policy fellow at Chapin Hall at the University of Chicago, to create a roadmap.
One recommendation is to launch a portal for parents, a one-stop shop to learn what mental health services are available and where to find them. In his proposed 2024 state budget, Pritzker included $10 million to create this portal. The idea is to eventually link families with appointments — a potential solution to a frustration echoed statewide.
Weiner also provides a blueprint for eventually having any provider that does business with the state — from hospitals to community organizations — be transparent about whether they have beds or appointments available. This could be a tough sell among hospitals in particular. They’re notoriously private about sharing capacity information.
“We’ve been doing this as if it’s like a poker game where everybody has their cards, but … we can’t see what they are,” Weiner said during a presentation in December. “If we can see it, we can more effectively both distribute resources and work to get kids placed.”
She also wants more services to prevent children from winding up in the hospital.
Weiner envisions it would take three to five years to build up the health care workforce, knowing having enough staff is integral to her plan.
For now, the state is piloting Pathways to Success, the program Kristine Herman from HFS touted that aims to provide more support for children with serious mental illnesses in their homes and communities. Ada S. McKinley, where Sadler works, is one of the agencies that will offer the program.
Vice President Nestor Flores said he has been working on hiring and the salaries are competitive, so he’s hopeful.
“We are going to try to make sure that clients don’t fall through the cracks,” he said.
Sadler thinks this could open up some services. But he worries it will be hard to staff up.
One of Sadler’s common refrains is, “It would be great if …” or, “It would be beautiful if …”
He has a long list of wishes — from schools with more emotional support, to communities with more mental health providers, to more hospitals with psychiatric beds in neighborhoods so families wouldn’t have to send children so far away.
But at the end of the day, Sadler, the paramedic of sorts for children in emotional distress, is not all that hopeful.
“The resources just aren’t there,” he says.
Sarah Karp covers education for WBEZ. Kristen Schorsch covers public health and Cook County for WBEZ.
WBEZ’s Susie An and Kate Grossman contributed reporting to this story.