On a rainy Thursday evening last spring, a 15-year-old girl was rushed by her parents to the emergency department at Boston Children’s Hospital. She had marks on both wrists from self-harm and a recent suicide attempt, and earlier that day she confided to her pediatrician that she planned to try again.
At the ER, a doctor examined her and explained to her parents that she was not safe to go home.
“But I need to be honest with you about what’s likely to unfold,” the doctor added. The best place for adolescents in distress was not a hospital but an inpatient treatment center, where individual and group therapy would be provided in a calmer, communal setting, to stabilize the teens and ease them back to real life. But there were no openings in any of the treatment centers in the region, the doctor said.
Indeed, 15 other adolescents — all in precarious mental condition — were already housed in the hospital’s emergency department, sleeping in exam rooms night after night, waiting for an opening. The average wait for a spot in a treatment program was 10 days.
The girl and her family resigned themselves to a stay in the emergency room while she waited. But nearly a month went by before an inpatient bed opened up.
The girl, being identified by her middle initial, G, to protect her privacy, spent the first week of her wait in a “psych-safe” room in the emergency department. Any equipment that might be used for harm had been removed. Her door was kept open night and day so she could be monitored.
It was “padded, insane-asylumlike,” she recalled recently. “Just walls — all you see is walls.”
She grew “catatonic,” her mother recalled. “In this process of boarding we broke her worse than ever.”
Mental health disorders are surging among adolescents: In 2019, 13% of adolescents reported having a major depressive episode, a 60% increase from 2007. Suicide rates, stable from 2000 to 2007, leaped nearly 60% by 2018, according to the Centers for Disease Control and Prevention.
Across the country, hospital emergency departments have become boarding wards for teenagers who pose too great a risk to themselves or others to go home. They have nowhere else to go; even as the crisis has intensified, the medical system has failed to keep up, and options for inpatient and intensive outpatient psychiatric treatment have eroded sharply.
Nationally, the number of residential treatment facilities for people under age 18 fell to 592 in 2020 from 848 in 2012, a 30% decline, according to the most recent federal government survey. The decline is partly a result of well-intentioned policy changes that did not foresee a surge in mental-health cases. Social-distancing rules and labor shortages during the pandemic have eliminated additional treatment centers and beds, experts say.
Absent that option, emergency rooms have taken up the slack. A recent study of 88 pediatric hospitals around the country found that 87 of them regularly board children and adolescents overnight in the ER. On average, any given hospital saw four boarders per day, with an average stay of 48 hours.
“There is a pediatric pandemic of mental health boarding,” said Dr. JoAnna K. Leyenaar, a pediatrician at Dartmouth-Hitchcock Medical Center and the study’s lead author. She extrapolated from her research and other data to estimate that at least 1,000 young people, and perhaps as many as 5,000, board each night in the nation’s 4,000 emergency departments.
“We have a national crisis,” Leyenaar said.
This trend runs far afoul of the recommended best practices established by the Joint Commission, a nonprofit organization that helps set national health care policy. According to the standard, adolescents who come to the ER for mental health reasons should stay there no longer than four hours, as an extended stay can risk patient safety, delay treatment and divert resources from other emergencies.
Yet in 2021, the average adolescent boarding in the ER at Boston Children’s Hospital spent nine days waiting for an inpatient bed, up from three and a half days in 2019; at Children’s Hospital Colorado in Aurora in 2021, the average wait was eight days, and at Connecticut Children’s Medical Center in Hartford, it was six.
Doctors and hospital officials emphasize that adolescents should absolutely continue to come to the ER in a psychiatric emergency. Still, many emergency room doctors and nurses, trained to treat broken bones, pneumonia and other corporeal challenges, said the ideal solution was more preventive care and community treatment programs.
“Frankly speaking, the ED is one of the worst places for a kid in mental health crisis to be,” said Dr. Kevin Carney, a pediatric emergency room doctor at Children’s Hospital Colorado. “I feel at a loss for how to help these kids.”
The challenge was evident one day in late February when Carney arrived for his shift at 3 p.m. The children’s hospital has 50 exam rooms in its emergency department, which fill with patients who have gone through an initial screening and need further evaluation. By midafternoon, 43 of the rooms were full, 17 of them with mental health cases.
“It’s breathtaking,” Carney said as he stood in the hallway. “Forty percent.”
On clocking in, Carney had inherited a block of 10 exam rooms from a doctor who was clocking out. “Seven are mental health issues,” Carney said. “Six are suicidal. Three of them made attempts.”
Throughout the day, staff members at the hospital had called eight inpatient facilities in the region, looking for available slots in treatment centers where the 10 young boarders, as well as 17 other adolescents boarding at three smaller Colorado Children’s Hospital campuses around the state, could be placed.
Colorado is struggling with the same shortage of services that has hit hospitals nationwide. The state has lost 1,000 residential beds serving various adolescent populations since 2012, according to Heidi Baskfield, vice president of population health and advocacy for Children’s Hospital Colorado.
The emergency department “is just a collection of rooms where patients are expected to stay in their rooms and comply with rules,” said Lyndsay Gaffey, director of patient care services at Children’s Hospital Colorado. In the inpatient ward, she said, the aim instead was to stabilize patients by having them work through trauma, receive therapy and interact with peers.
For adolescents like G, who stayed in the emergency room of Boston Children’s Hospital last spring, the experience can be wrenching.
G lives in a Boston suburb with a teenage brother, father and mother. The family has a history of anxiety and depression, the mother said, but G had been a happy and adventurous child. In middle school she started talking back and acting somewhat obsessively, behavior that her mother figured was typical for a teenager.
What G’s mother did not know was that her daughter had been cutting herself for two years, since seventh grade, before the pandemic began.
As the pandemic set in, G withdrew, and her grades fell. “Then came April 29,” her mother said. “We had a life before April 29 and a life after April 29.”
That day, she picked up G at school for a routine visit to the pediatrician. As G got into the car, her mother saw the marks on her wrists.
At the emergency room, G told the medical team she had tried to overdose a few weeks earlier and had regretted the next morning that she was still alive.
Admitting to her pain and self-harm provided her “with kind of a little bit of relief,” she said. “After two years of cutting and trying to kill myself, I was finally going to get some help. But I didn’t really get help.”
Dr. Patricia Ibeziako, a child psychiatrist at Boston Children’s Hospital, said that adolescents do, in fact, receive some treatment while boarding in the emergency department, including basic counsel aimed at “crisis stabilization” that is “all geared to safety.”
“Boarding is not a great thing, but it’s still care,” Ibeziako said. “We’re not just putting a kid in a bed.”
Finally, 29 days after G arrived, a bed was located for her at an inpatient facility in an outlying suburb. She spent a week there but did not find the experience all that helpful.
“We learned the same coping skills over and over,” she said.
In the fall, she told a counselor at school that she planned to kill herself; she was quickly readmitted to the same inpatient unit, given priority as a former patient, and spent two weeks there. When her stay ended, G went into an intensive outpatient program. But a counselor there told her mother that G needed more intensive care because she had described a plan to kill herself.
“They told me, ‘This kid is on fire; she’s too acute to be here,’” G’s mother recalled. This time, the family went to the emergency room at a different Boston-area hospital, Salem Hospital, where G boarded only one night and, this time, was lucky to get a bed in that hospital’s inpatient unit, where she spent three weeks, until mid-October.
G’s mood these days is “better than it was, but it still sucks,” she said recently. And, she added, “I’m better at covering things up more.”
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