Children who lash out in homes and protective placements are increasingly being dropped off at the M Health Fairview Masonic Children's Hospital, prompting the creation of a makeshift shelter in an ambulance garage.

While hospitals have always been a place of last resort for children in emotional or behavioral crises, Fairview leaders said counties and social service providers are using their pediatric emergency room at an unprecedented rate. Normally expecting one or two such cases a month, the Minneapolis pediatric hospital has taken in 145 children since September — with most staying about 15 days and one staying 97 days.

Hospitals already are strained by children suffering from heightened anxiety, depression and other mental health issues and needing inpatient care amid the pandemic. A few of the children being sheltered in the ambulance bay are in that category — needing mental health evaluations and awaiting open inpatient psychiatric beds. The rest have behavioral disorders or long-standing developmental disabilities, such as autism, but no acute medical issues for the hospital to treat.

"They are not appropriate for admission. They have no medical concerns … but yet we can't safely discharge them because there is no place to discharge them to," said Lew Zeidner, director of clinical triage and transition services for M Health Fairview, which operates the pediatric hospital on the University of Minnesota's West Bank. "They are too vulnerable to just put on the street."

The result was on display Monday afternoon as eight children sat and watched "Zootopia" in the large ambulance bay on concrete floors and the narrow windows of the garage doors for natural light. Other children were too unstable to join the group and kept in separate rooms. Beds lined one wall of the garage along with recliners moved out of hospital rooms.

Outbursts or violent incidents draw staff alerts daily. Half the children 10 and older are homeless. Most have one-on-one supervision all day and are seen by nurses and psychiatric aides.

Many of the children have traumatic histories and attachment issues, which aren't helped when exasperated parents or providers drop them off at the hospital, said Stacy Rivers, an M Health Fairview clinical manager with a supervisory role over the makeshift transitional unit.

The classic case "is a child who is no longer a child and is 12, 14, 16 years old — large, now aggressive, with chronic destructive thoughts or behaviors," she said.

State and county mental health officials described a chain of problems that have ultimately fallen on Masonic and other hospitals. They mostly stem from staffing shortages and financial struggles that have reduced Minnesota's residential treatment programs' capacity and other placements that are more therapeutic for children than hospitals.

The number of licensed children's residential facilities in the state has declined from 122 at the beginning of 2019 to 106 at the beginning of 2022, according to the Minnesota Department of Human Services. That total includes detention facilities and shelters as well as psychiatric residential treatment centers. Capacity has dropped at an even faster rate, meaning existing providers are using fewer of their beds.

The pandemic and related school closures and stay-at-home restrictions triggered new mental health crises in some children and made others with long-standing behavioral problems harder to handle, said Cynthia Slowiak, a Hennepin County human services manager for children with mental and behavioral disorders. The county is responsible for one-fifth of the 145 children dropped at the U hospital since September, according to M Health Fairview.

"Families were often left alone to deal with the challenges that already were there if their youth had mental health needs prior to COVID," she said. "But also a lot of families for the first time were being asked to respond to things that were coming of left field in terms of their child. They weren't prepared for it."

The right solutions?

Expansion of inpatient psychiatric capacity for children could help. Children's Minnesota is set to open a 22-bed inpatient psychiatric unit on its St. Paul campus this fall and has asked the Legislature to grant a moratorium exception for the hospital expansion. PrairieCare received legislative permission last year to add 30 inpatient beds at its pediatric psychiatric hospital in Brooklyn Park.

Bipartisan support has emerged for other child mental health solutions. Gov. Tim Walz visited Edison High School in Minneapolis on Wednesday to advocate the use of some of the state's budget surplus to expand school mental health and crisis prevention services. State Sen. Rich Draheim, R-Madison Lake, has gained support for legislation to expand a variety of child mental health services and ensure providers have enough trained staff.

Fairview leaders said many of the solutions address the minority of kids in the temporary shelter needing mental health care but that counties and the state also need to address the problem of children with behavior issues left at the ER doors despite their lack of medical needs.

The Minnesota Department of Human Services first responded in November to the crisis situation at Masonic, diverting $2.5 million in emergency state funding to psychiatric residential treatment facilities to prevent the loss of any more beds and staff members and to expand capacity. Another $360,000 paid for state staff to work with families and social service providers to fix problems that led to the removal of children from their homes or placements in the first place.

"This is very sad that our children, who really don't need to be hospitalized, have to be there," said Neerja Singh, interim director of DHS's Behavioral Health Division.

The support hasn't eased problems at Masonic, though, which converted the ambulance bay into temporary shelter late last month because of the rising demand.

Rivers defended the use of the garage as a temporary shelter. Confining kids for weeks to isolated and cramped emergency room bays can increase their agitation. In comparison, the ambulance bay is spacious and allows for group programming and more supervision.

The hospital provides psychiatric support to the children and also reaches out to their relatives to see if any family problems can be addressed so they can be discharged. It's a "point of pride" when some of the toughest children are no longer aggressive and even make improvements despite the unusual living conditions, she said.

"Within a few days or maybe weeks, we don't see [emergency] codes or issues any more," she said, "and they're talking about their feelings and making connections to family members who they were refusing to talk to when they first came in."

Correction: An earlier version of this story misstated Children’s Minnesota’s expansion plan.