The average emergency department (ED) is set up for medical emergencies and is not well-equipped to handle patients’ mental health needs, explained Jennifer Hoffmann, MD, MS, a pediatric emergency physician at Ann & Robert H. Lurie Children’s Hospital of Chicago.

“These environments can be loud, chaotic, and overly stimulating, especially for children experiencing an acute mental health crisis,” Dr. Hoffmann said. 

Unfortunately, an increasing number of children experiencing mental health emergencies are finding themselves boarding in EDs. Dr. Hoffmann and colleagues recently conducted a retrospective study of more than five million mental health ED visits for children aged five to 17 and found that about one in three visits that resulted in admission or transfers saw children in the ED for more than 12 hours.¹

Dr. Hoffmann

“One in eight visits exceeded 24 hours,” Dr. Hoffmann added. The stays exceeding 24 hours were more likely to occur in certain patient populations including the youngest children, non-Hispanic Black children, and those with public insurance.¹ 

Although this is not a new issue, it does appear to be getting worse. Prior to the COVID-19 pandemic, data had begun to indicate that the total number of visits to the ED for children with mental health disorders was increasing, and in the years since, monthly rates of hospitalizations and ED visits have continued to put a strain on available resources.^2,3

Fewer Resources, More Patients

The reasons for the increase in pediatric mental health boarding are multifactorial, and vary by state, according to Moshe D. Bitterman, MD, an attending psychiatrist in the ED at Lurie Children’s Hospital.

Dr. Bitterman

“The amount of inpatient beds available to these populations has decreased, and there has also been a decrease in community resources over time,” Dr. Bitterman said. 

For example, in its 2023 report, Mental Health America found that more than 2.7 million children and adolescents are living with severe major depression, with more than half receiving no mental health treatment at all.⁴  

“It is a stress on the system,” said Sandy Herman, MD, an emergency physician who recently retired from a position with the Tennessee Department of Mental Health. “We are seeing an increased use of psychiatric services by pediatric patients, and more patients at a younger age.”

Appropriate Treatment

Dr. Herman

Most pediatric patients presenting to the ED with acute mental health crisis will fall into one of two categories, Dr. Bitterman said. First is internalizing patients with thoughts or intention of self-harm; second is externalizing patients who may be harmful or aggressive towards others. 

Dr. Bitterman is one of two attending psychiatrists hired at Lurie in the last few years who splits his time between the ED and medical floors. 

“My colleague, Dr. Jonathon Wanta, and I are able to start a behavioral assessment immediately and use a framework to see how we can intervene to decrease a patient’s risk,” Dr. Bitterman said. “That includes behavioral analysis, medical evaluations or recommendations, and interventions.”

Starting this process in the ED and then continuing another day or two if a patient is boarding on the medical floor, allows some patients to go home without the need for in-patient hospitalization. Since they took on this role, Dr. Bitterman said about two-thirds of pediatric patients who arrive to the ED for mental health issues who were placed in behavioral health observation were discharged home before the need for inpatient psychiatric admission.

Dr. Snow

In contrast, in EDs where there is no psychiatrist available, emergency physicians may more frequently be forced to use involuntary medication or restraints to manage behavior. “These physicians are doing what they need to do to keep the patients and themselves safe,” Dr. Bitterman said, but these interventions may unintentionally exacerbate issues.

Even if a patient leaves the ED and is admitted to the hospital, pediatric patients in acute mental health crisis are often still not getting the care they need.

Kathleen D. Snow, MD, MPH, an attending physician in hospital medicine at Boston Children’s Hospital, described this decision to keep a kid boarding in the ED or boarding on the hospital floor as a “push-pull challenge faced by many hospital administrators.” Dr. Snow and colleagues recently studied pediatric mental health boarding across EDs and inpatient medical units at 40 children’s hospitals and found the median length of stay had increased from three days in 2017 to four days in 2023, with a range of two to 589 days.⁵

“Key factors associated with prolonged boarding were kids with underlying medical complexity, and those with underlying psychiatric complexity,” Dr. Snow said, adding that the level of boarding that is occurring is probably “unimaginable to the majority of the population.”

What Can Be Done?

Emergency physicians can tell their patients about the 988 Suicide & Crisis Lifeline, which offers 24/7 judgment-free support for mental health, substance use, and thoughts of suicide. Text or call 988, or chat at 988Lifeline.org for confidential support, offered at no cost.

There is no one-size-fits-all solution. At least part of the solution will be to decrease the number of children presenting to the ED for mental health crises. 

“We need to ensure that youth are aware of a new national 988 crisis hotline,” Dr. Hoffmann said. “Many children could be linked to community services and not require emergency visits.”

There are also emerging models of mobile mental health services that physically go to the location where a child is in crisis, whether that is at home or at school. 

“These are only available in certain geographic areas but hold a lot of promise to reducing ED visits,” Dr. Hoffmann said. “There are also emerging models of psychiatric urgent care or walk-in clinics where patients can receive same-day services that could reduce emergency visits.” 

Additionally, Dr. Hoffmann said there are emerging ED diversion models in which ambulance crews have pre-set criteria to bring patients directly to freestanding psychiatric facilities instead of the ED.

Once a patient is in the ED, emergency physicians must try to improve and not exacerbate mental health symptoms. Dr. Herman said an important step in minimizing the issue will be an increase in psychiatric training for emergency physicians. “Emergency physicians will have to become more comfortable initiating treatment in the ED,” Dr. Herman said. This might include obtaining training in verbal de-escalation or trauma-informed care. 

Use of brief interventions, such as the Safety Planning Intervention, have been shown to be effective in adult EDs, reducing return visits by as much as 43 percent, with emerging evidence showing they may be effective for children as well.^6,7

“There is also a move toward self-guided digital mental health interventions deployed within the ED,” Dr. Hoffmann said. 

Dr. Snow said that Boston Children’s has an in-patient psychiatric unit embedded within its hospital and has opened two additional off-site locations with psychiatric beds. 

“Obviously that requires a ton of additional hiring, training, and support to create those facilities,” Dr. Snow said. Within the hospital, a lot of additional staff has been added including psychiatrists, social workers, and others who can help triage these admissions and at least do some level of check-in everyday while they board. 

One thing remains clear, though. More attention on the problem and more potential solutions are sorely needed. Indeed, incoming ACEP President L. Anthony Cirillo, MD, said that the health care community “cannot continue to celebrate getting a 59-year-old STEMI patient to the cath lab in less than 30 minutes when a nine-year-old suicidal patient has been sitting in the ED for 30 days waiting for an inpatient psychiatric bed.”

Ms. Lawrence is a freelance health writer and editor based in Delaware.

References

1. Hoffmann JA, Foster AA, Gable CJ, et al. Pediatric mental health boarding in us emergency departments, 2018-2022. J Am Coll Emerg Physicians Open. 2025;6(4):100180.
2. Lo CB, Bridge JA, Shi J, et al. Children’s mental health emergency department visits: 2007-2016. Pediatrics. 2020;145(6):e20191536.
3. Valtuille Z, Trebossen V, Ouldali N, et al. Pediatric hospitalizations and emergency department visits related to mental health conditions and self-harm. JAMA Netw Open. 2024;7;(10):e2441874.
4. Mental Health America. The State of Mental Health in America. https://mhanational.org/the-state-of-mental-health-in-america/. Accessed July 22, 2025.
5. Snow KD, Mansbach JM, Cortina C, et al. Pediatric mental health boarding: 2017 to 2023. Pediatrics. 2025 Feb 13:e2024068283.
6. Boudreaux ED, Larkin C, Sefair AV, et al. Effect of an emergency department process improvement package on suicide prevention: The ED-SAFE 2 cluster randomized clinical trial. JAMA Psychiatry. 2023;80(7):665-674.
7. Itzhaky L, Stanley B. The Safety Planning Intervention for Children (C-SPI): rationale and case illustration. Cognitive and Behavioral Practice. 2024;31(2):250-258.