A 15-year-old girl was rushed by her parents to the emergency department at Boston Children's Hospital on a rainy Thursday evening last spring. She had marks on her wrists from self-injury and a recent suicide attempt, and she told her doctor that she was going to try again.
The doctor told her parents that she was not safe to go home.
I need to tell you what's likely to unfold, the doctor said. 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 help them get back on their feet. The doctor said there were no openings in the treatment centers.
15 other adolescents were already housed in the hospital's emergency department, sleeping in exam rooms night after night, waiting for an opening. There was an average wait of 10 days for a spot in a treatment program.
The girl and her family decided to stay in the emergency room. It took nearly a month before the bed opened up.
The girl, being identified by her middle initial, G, spent the first week of her wait in the emergency department. Equipment that could be used for harm had been removed. She was forbidden to use electronics because she wanted to commit suicide or ask a friend to smuggle in a sharp object. She could be monitored because her door was kept open all the time.
She recalled in an interview that it waspadded, insane-asylum-like.
Her mother said that she grew catatonic.
A 60 percent increase in the number of adolescents reporting having a major depressive episode is a sign of a surge in mental health disorders. According to the Centers for Disease Control and Prevention, the suicide rate went up by 60 percent by the year 2000.
One of the starkest manifestations of the crisis is described by G's story. Hospitals across the country have become boarding wards for teenagers who pose too great a risk to go home. Even as the crisis has intensified, the medical system has failed to keep up, and there are no other options.
According to the most recent federal government survey, the number of residential treatment facilities for people under the age of 18 fell by 30 percent. Policy changes that did not anticipate a surge in mental-health cases are to blame for the decline. Experts say that social-distancing rules and labor shortages have eliminated additional treatment centers and beds.
Emergency rooms have taken up the slack without that option. The study found that 87 of the 88 hospitals board children and adolescents overnight, with an average stay of 48 hours.
The lead author of the study said that there is a children's mental health boarding epidemic. She estimated 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.
Dr. Leyenaar said that there was a national crisis.
The Joint Commission, a nonprofit organization that helps set national health care policy, has recommended best practices for this trend. Adolescents who come to the E.R. for mental health reasons should stay no longer than four hours, as an extended stay can risk patient safety, delay treatment and divert resources from other emergencies.
At Boston Children's Hospital, the average wait for a bed was nine days in 2021, up from three and a half days in 2019.
Emergency-department boarding has gone up at small, rural hospitals with no mental health specialists.
Adolescents should continue to come to the E.R. in a psychiatric emergency, according to doctors and hospital officials. Many emergency-room doctors and nurses said the ideal solution was more preventative care and community treatment programs.
The E.D. is one of the worst places for a child in a mental health crisis to go.
One day in February, the challenge was obvious when Dr. Carney arrived for his shift. The children's hospital has 50 exam rooms in the emergency department, which are used by patients who have gone through an initial screening and need further evaluation. 17 of the rooms had mental health cases by the afternoon.
As he stood in the hallway, Dr. Carney said it was breathtaking.
A block of exam rooms was given to Dr. Carney by a doctor who was leaving. Three of them tried.
The adolescents who were deemed to be at physical risk to themselves or others could be easily identified, because their exam room doors were open so they could be monitored and they wore maroon-colored scrubs instead of their own clothes. No shoelaces, belts, or zippers.
The staff at the hospital had been looking for available slots in treatment centers in the region 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.
Jessica Friedman, a social worker, said that there are no beds for adolescents in Aurora.
Ms. Friedman told a reporter that she had only had two conversations that day.
The interim clinic manager in the emergency department stood nearby and said that the flood of boarders was crushing the staff.
Hospitals across the country are struggling with a shortage of services. The state has lost 1,000 residential beds since 2012 for various adolescent populations. Ridgeview, a 500-bed facility for at-risk young people, was closed by the state because of poor quality and abuse. The chief executive officer of Excelsior said at the time of the facility's closing that reimbursement rates were not high enough to support ongoing operations.
Ms. Baskfield said that the low reimbursement rates paid by Medicaid was a major cause. The daily Medicaid rate in Colorado was $400 for a therapeutic residential bed from 2006 to 2021, less than some families spend to send their kids for a night to sleepaway camp.
It was hard to hire experienced staff because of the low rates. Colorado has raised its reimbursement to $750 per day by using money from the American Rescue Plan, but new beds have yet to open, and that source of money is temporary.
The Association of Children's Residential and Community Services, a nonprofit advocacy group, noted that the closing of facilities and the loss of beds was the result of many factors. She said that the intended replacements were never funded and remained largely unavailable.
The capacity for patients was reduced because of labor shortages and social-distancing guidelines.
On that February day in Colorado, one bed finally opened up. It was in the 12-bed inpatient ward of Children's Hospital Colorado, just a short walk from the E.R.
The hallways are wide, the walls are green, and the lighting is bright. Each bedroom has windows that look outside and a glass panel that allows hospital staff to peer inside.
Four adolescents in maroon scrubs sat on blue chairs and couches in a small room. One listened to headphones and sang aloud to the soundtrack of Encanto. Two people chatted with a person.
The emergency department is just a collection of rooms where patients are expected to stay in their rooms and comply with rules, according to the director of patient care services at Children's Hospital Colorado. She said the aim was to have patients work through trauma, receive therapy and interact with peers in the inpatient ward.
They must be watched here as well. A staff member swept up the pen when the reporter rested it on the countertop.
In severe cases of mental distress, emergency-room doctors can compel an adolescent to board in the E.R. Parents return home with their child to try to manage while waiting for a treatment opening. The option requires family and doctors to work through a difficult question: Is the adolescent safe to go home?
In early February, a 12-year-old boy was in the emergency room of the Highlands Ranch campus of Children's Hospital Colorado. He is being identified for privacy reasons.
He arrived with his mother that morning after she discovered that he had been searching the internet for ways to commit suicide. He was asked several times how safe he was to go home. The mother said one exchange.
The doctor asked if he thought he could go home.
J asked what the other option was.
You would be in the emergency room.
J said that he could go home with his mom.
The doctor said that he would come back to the emergency room.
Understand the signs. Depression and anxiety are different issues, but they share some indicators. Look for changes in the behavior of a youth. A teen in distress may express worry or profound sadness.
Approach with sensitivity. If you want to start a discussion with a teen who might be struggling, be clear and direct. Don't shy from hard questions, but also approach the issue with compassion and not blame.
The correct diagnosis should be obtained. Ask for recommendations to find the right doctor for your child. Ask the specialist if she uses the measurement tools to make medical assessments and if she has treated specific conditions in children.
Carefully consider the effects of your medication. If you want to know if a medication is working and how hard it is to wean off of it, you need to know the doctors experience treating children with specific drugs.
Don't forget the basics. Young people with developing brains need eight to 10 hours of sleep to promote mental and physical health. Lack of sleep can affect development. Physical activity is important.
She said that J's mother took him home and kept every medicine and knife. J asked her if she could start tomorrow.
His mother told him he would have to wait. A spot for J opened in an intensive treatment program after 16 days. She said it was the scariest two weeks of her life.
The experience of being in the emergency room of Boston Children's Hospital can be difficult for adolescents like G.
G lives with his family in a Boston suburb. The mother said that G had been a happy and adventurous child despite the family's history of anxiety and depression. Her mother thought she was typical of a teenager when she started acting crazy in middle school.
G's mother didn't know that her daughter had been cutting herself for two years. She said that self-injury was a mechanism to deal with inner pain. She hid the activity with sweaters, hoodies, and foundation.
G withdrew and her grades fell.
She picked up G at school to go to the doctor. G's mother saw marks on her wrists as she got into the car.
G told the medical team at the emergency room that she had tried to overdose a few weeks earlier and regretted it the next day. She told them that she was thinking about drinking the hand sanitizer.
She said that admitting to her pain and self- harm gave her some relief. I didn't get help.
She was moved for safety reasons to a room with a bed and a rollaway. It was difficult to sleep with the door open.
The mother and daughter played a number of games. G was given Ativan on three of the next four nights and then was prescribed Trazodone for chronic anxiety.
Some adolescents can be overwhelmed in an emergency department. She heard screaming while she was treating an infant with a respiratory illness. It came from a boy with attention-deficit disorder who was threatening to kill himself and was boarding down the hall.
The girl hit her head against the wall when other patients started escalating.
She said that some teens tell her that boarding in the emergency department made them more suicidal.
According to Dr. Ibeziako, adolescents receive some treatment in the emergency department, including basic counsel aimed at crisis stabilization.
Ibeziako said that boarding is not a great thing, but it is still care.
There were no inpatient beds available in the region when May 7 arrived. A bed opened in the hospital, upstairs in the medical unit, with a window and a private bathroom, and a person who was watching G around the clock.
Her mother said that she was very depressed and depressed.
After 29 days, a bed was found for G in an outlying suburb. She did not find the experience helpful.
She said they learned the same skills over and over. She worked a fast-food job and continued to cut herself, but she hid it better.
In the fall, she told a counselor at school that she planned to kill herself; she was quickly re-admitted to the same inpatient unit, given priority as a former patient, and spent two weeks there. G went into an outpatient program after her stay ended. G needed more intensive care because she had described a plan to kill herself.
They told me that the child was too young to be here. This time, the family went to the emergency room at a different Boston-area hospital, Salem Hospital, where G boarded only one night and was lucky to get a bed in that hospital's inpatient unit, where she spent three weeks, until mid-October.
She said recently that her mood is better than it was, but still sucks. She said that she was better at covering things up.
She said you have to say no when people ask you a question.
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