Finding placement for vulnerable youth suffering from difficult combinations of physical, mental and behavioral challenges has become an impossible burden for counties across Pennsylvania.

Lawmakers in the House Children and Youth Committee recently sought to better understand the complex cases that have grown in both severity and number in recent years.

“We need your help,” said Jean Foschi, a commissioner in Cumberland County and member of the County Commissioner Association of Pennsylvania’s Complex Case Work Group.

She noted that the situation has “become untenable.”

The needs for these children are varied, but they have some commonalities. They require skilled care with training to respond to both medical and mental health needs.

“All of these children have experienced some sort of trauma,” said Johnathan McVey, special assistant to the secretary on complex needs planning in the Department of Human Services. He cited institutional abuse and neglect as just two examples of the kind of trauma the agency often sees.

The commission’s six-month survey of 45 out of 67 Pennsylvania counties found that 255 youth spent more than two years in unlicensed facilities like offices, hotels and hospitals waiting for appropriate placement for their unique situations. Another 175 youth spent more than seven years in hospitals beyond their discharge dates because they had nowhere else to go.

In circumstances where children are not in appropriate placement, adults like department staff and county sheriffs who are required to monitor them work extra hours at great expense to the counties up to $2,200 for a single night. Shelter costs for children with special needs and high risks can be upwards of $1,200 per night for short-term placement.

“Placement for juvenile females, I’ve been told, is like finding a unicorn,” said Committee Chair Charity Grimm Krupa, R-McClellandtown.

Some children are ultimately forced to go out of state. Others, according to Foschi, do not have a suitable placement anywhere within the United States. Others still received no care at all when their needs could not be met, while hundreds more received a lower level of care than they needed.

Among recommendations from the commission is the formation of a “no eject/no reject” program for children with nowhere else to go, something that already exists within the youth delinquency system but not for those outside of it. This recommendation has been taken up by those in the department creating the blueprint to move forward.

Lawmakers sought to determine how the situation has gotten so out of control and were met with a familiar refrain. The staffing crisis across healthcare has left county agencies without an inadequate workforce to address the level of need. Testifiers saw the COVID-19 pandemic as an escalating factor.

Foschi noted that county mental health services are underfunded, saying that even with the competitive pay offered in Cumberland County, it’s difficult to attract and retain necessary staffing. Providers are also strained by the cost of risk and liability insurance required to take kids with complex cases. In the last year, the agencies saw a net loss of 300 caseworkers across the state.

“The things people see are terrible,” Foschi said, comparing the traumas witnessed by case workers to the experiences police and other first responders have on the job.

When asked what factors lead to these complex cases, the experts noted that many stem from cycles of trauma created or exacerbated by circumstances like housing insecurity, parental incarceration and lack of access to other essential resources.

“The overall mental health system is extremely complicated, and for many parents, it’s a real challenge for them to be able to get their kids the needed services,” said Brian Bornman, executive director of Pennsylvania Children and Youth Administrators.

“Prevention is one of the major features that we really need to be looking at,” he said. “If we can’t stop what’s coming in the front door, we’re never going to be able to kind of catch up in providing the day to day care.”