In February, the Trump administration established the Make America Healthy Again Commission, which aims to “assess the prevalence of and threat posed by the prescription of selective serotonin reuptake inhibitors, antipsychotics, mood stabilizers, [and] stimulants.” If we really want to help America’s kids facing psychiatric crises, the last thing we need is to spread fear regarding well-researched, reasonably safe medications like anti-depressants. Instead, we need to improve access to pediatric mental health treatment. We need to ensure that children in dire need of psychiatric care no longer spend days or weeks in an emergency room, waiting for help.
As a pediatric emergency physician, I regularly see vulnerable children and teenagers struggling with suicidality, homicidal thoughts, or severe behavioral outbursts spending long periods of time waiting in emergency departments until an inpatient bed becomes available in a center providing specialized mental health treatment.
Smith Collection/Gado/Getty Images
These waits—known as emergency department “boarding“—can be astonishingly long, sometimes days or even weeks. Trapped in the confinement of their rooms, these struggling children and teens are forced to sit and wait—if they’re lucky enough to have a room. Often, when no rooms are available, they end up boarding in beds in hospital hallways.
Boarding is precisely the opposite of what these kids need. Trapped in bed, in a noisy room or hallway, under the fluorescent lighting of the hospital all day and night, these children experience more stress, dissatisfaction, fear and distrust of the system. Worse, these conditions can lead to a vicious cycle of behavioral escalations, increased medication use, longer stays, and sometimes even physical restraints resulting in psychological trauma. Paradoxically, the kids with the greatest needs often end up boarding the longest because they require a higher level of care than many treatment centers can provide.
As a society, we force children to endure these circumstances across the country every single day because we do not have better options.
To be clear, the blame does not fall on emergency departments or their staff. Emergency departments must pick up the pieces of our broken health care system by providing a safe place for kids until more specialized care is available. My coworkers labor tirelessly to provide the best care possible to these children and adolescents despite these appalling circumstances. Our emergency departments are a safety net, but one too small and underequipped for the volume of kids in need. Our health system suffers a dire shortage of suitable preventative, short-term, and long-term treatment options for kids with mental illnesses. Until more treatment beds become available, children and adolescents in crisis will continue to board without the ongoing treatment they need to stabilize their mental health.
These are not extreme or unusual cases. Today, one in seven children has a diagnosed mental or behavioral condition. For kids who get stuck boarding in the emergency department or an observation unit, the average length of time hovers between three and four days. Rather than expand services for children needing more intense treatment, many states are stuck with stagnant or even shrinking options. A 2023 report demonstrated that 30 states reported shortages of inpatient psychiatric beds for patients of any age. For children specifically, 89 percent of available psychiatric beds are located in urban areas, placing a huge travel burden on families in rural areas whose children require inpatient care.
Solving the problem of pediatric boarding will require efforts on many fronts. First, we need more available spots for inpatient pediatric care. To make this feasible, private insurers and public insurers (Medicaid) alike would need to expand the coverage for kids facing mental health crises.
Additionally, we need more community-based resources providing mental health treatment for kids before they need emergency or inpatient care. We need more therapists, psychiatrists, intensive outpatient programs, and crisis response teams, among other outpatient treatment options. Such resources could help children before their mental health needs escalate to the point that they require inpatient treatment. Thankfully, many emergency departments are also expanding the resources they offer for kids who are boarding, such as trained behavioral health nurses and consultations with social workers and child life specialists—practices which should certainly be encouraged.
Until then, those of us working in the emergency department will continue to do our best, knowing that sometimes, we might be the only hope for children who have been deprived of the care they deserve.
Dr. Alexis Cordone is a board-certified emergency physician at Yale-New Haven Health and a Public Voices Fellow of The OpEd Project.
The views expressed in this article are the writer’s own.
