A growing number of children in mental health crises are spending days, sometimes nearly a week, in hospital emergency rooms because there is nowhere else for them to go, a new study has found.
In a report published Friday in JAMA Health Forum, researchers at Oregon Health & Science University examined Medicaid claims data from 44 states covering more than 255,000 pediatric emergency room visits for mental health conditions in 2022. They found that about 12% of those visits, or over 30,000, resulted in children being “boarded” in the emergency room for three to seven days while waiting for placement in proper treatment programs.
Dr. John McConnell, director of OHSU’s Center for Health Systems Effectiveness and lead author of the study, said he was surprised at how frequently children in crisis spent three or more days in the ER.
“It points to a big gap in getting timely, appropriate care,” he said.
That wait time is far from recognized best practice. The Joint Commission, which sets health care benchmarks, recommends that pediatric patients in mental distress be stabilized and moved out of the ER within four hours, as extended stays can jeopardize patient safety, slow the start of treatment and pull critical resources away from other urgent cases.
The study found boarding was most common for children with suicidal thoughts, attempts or severe depression — conditions that have become more prevalent in recent years. The number of suicides among U.S. children and young adults rose 62% from 2007 to 2021, according the Centers for Disease Control and Prevention.
Boarding rates also varied dramatically, from 2.7% in Arkansas to 27.3% in Iowa.
Oregon’s rate was just above the national average.
McConnell said the findings confirm years of anecdotal reports that psychiatric boarding is a nationwide problem, particularly for children covered by Medicaid, which insures nearly half of all U.S. kids.
“It’s clear there aren’t enough places for kids to go, both in terms of inpatient beds and outpatient services,” McConnell said. “There’s also no single source of accountability for Medicaid patients having a mental health crisis. When these kids show up in the emergency department, it’s not clear who’s responsible for making sure they get timely care.”
The shortage of treatment options has left emergency departments — historically designed for broken bones, infections and acute injuries — as the fallback for pediatric mental health crises.
That reality is evident at OHSU Doernbecher Children’s Hospital. Psychiatric visits to the pediatric ER have nearly tripled since 2016, from 150 to 453 last year, said Dr. Rebecca Marshall, who leads the hospital’s pediatric psychiatry consult service.
Marshall, who was not involved in the study, said the patients are evenly split between Medicaid and private insurance, a sign the problem extends far beyond the Medicaid-only snapshot in McConnell’s analysis.
“These aren’t just numbers,” she said. “They represent real kids, real families and the hospital staff trying to help them in a space that was never meant for this.”
Often, those kids arrive after telling a parent or guardian about suicidal thoughts, severe depression, or another struggle — only to be told there’s no psychiatric bed available, Marshall said.
“It’s often disorienting and disappointing for youth and families,” she said. “They’re in limbo, in a place that’s not designed to be therapeutic, and sometimes it can make things worse.”
In the ER’s confined environment — often without fresh air or activities — children can feel trapped, irritable or more depressed, Marshall said, adding that some become agitated enough to lash out or try to leave, even when it isn’t safe.
At times, Marshall said, as many as half of the hospital’s pediatric emergency beds are occupied by children boarding for behavioral health reasons, forcing staff to improvise space for other emergencies.
“You can train staff and add activities, but you can’t turn an ER into a therapeutic psychiatric space,” she said. “If we want kids to get better, we have to put them in the right environment.”
Oregon has taken steps to expand behavioral health services, including a $130 million investment in 2021 to increase community-based residential facilities for people with severe mental illness. But Marshall said those efforts haven’t kept pace with demand, in part because of how the state’s fragmented and often short-term approach to funding behavioral health.
“The challenge has been scaling it up quickly enough,” she said.
The state has also fallen short on some key mental health commitments. The state’s much-touted parity law, which required insurers to cover mental health on par with physical health, failed to deliver, and stricter reporting requirements passed in 2021 remain largely unenforced. Likewise, a 2013 plan to expand in-home care for Medicaid patients led to new support for people with developmental disabilities, but nothing comparable for children and young adults needing intensive psychiatric care — despite their inclusion in the original plan.
McConnell, who led Friday’s study, said the deeper problem is a fragmented health care system that has long treated mental health as an afterthought, giving it far less attention and funding than high-profile conditions like cancer or heart disease.
“Even if we add beds or other resources, I worry there won’t be real change until someone is clearly accountable,” he said. “That responsibility is tied to measurable outcomes, whether that’s boarding rates or patient well-being.”
— Kristine de Leon is a reporter for The Oregonian/OregonLive focusing on consumer health and data enterprise stories. Contact her at kdeleon@oregonian.com.
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