In this issue of Pediatrics, McEnany et al1 performed a meta-analysis to better understand pediatric mental health boarding in emergency departments and patient and hospital characteristics that increase the likelihood of boarding. Visits to pediatric emergency departments for mental health–related complaints have steadily increased over the past decade,2,3 resulting in significant delays in care for patients, increased resource use in emergency departments, and significant inpatient costs. McEnany et al1 highlight the need for additional research, particularly on the national level and in rural and general hospital settings, to inform policy decisions to help address this problem.
A better understanding of the mental health resources available nationally in both rural and urban centers is essential. This includes patient access to hospital-based psychiatric resources, inpatient interventions, community-based psychiatric treatment centers, and psychiatric stabilization units. Significant disparities in mental health services continue to exist, with many communities in the United States lacking regionally coordinated pediatric psychiatric care. The lack of pediatric psychiatric care facilities directly contributes to the increased use of emergency departments for psychiatric care and, consequently, children experience delays in receiving emergent psychiatric assessment and treatment.
Disparities in care have also contributed to the growing problem of pediatric boarding in emergency departments.4 Children of younger age with mental health problems are found to have a higher likelihood of boarding in emergency departments.1 In addition, because of the fact that children are disproportionately affected by poverty, with the increased risk for mental health disorders and decreased access to mental health services,3,4 it becomes clear that there are multifaceted risk factors leading to barriers in accessing mental health care. Those facing challenges in accessing mental health care also have high readmission rates, further stressing hospital systems. Other risk factors, such as identifying as lesbian, gay, bisexual, or transgender; rural residence; and substance abuse, and their association with mental health and boarding need to be further investigated on the national level. More research is needed to investigate the association of sociodemographic and clinical characteristics and mental health.
For regions of the United States that do have access to pediatric psychiatric services, methods for determining prehospital diversion when possible should be developed. Trivedi et al5 identified that ∼10% of adult regional emergency medical service transports were for patients placed on involuntary mental health holds, and with the use of an emergency medical service–directed screening protocol, patients can be safely diverted to an inpatient psychiatric facility and bypass medical clearance in emergency departments. Preliminary data on pediatric patients from the same region of the United States indicate that diversion of pediatric patients on mental health holds is safe. These upstream efforts can provide potential interventions for expediting assessment, safe diversion, and treatment of these patients.5
The need for additional research to understand pediatric mental health boarding and access to care in urban and rural settings throughout the United States is fundamental to creating a mental health system of care that mitigates the need for boarding. McEnany et al1 lay out the critical information needed to continue to develop proven mechanisms for getting children the care they need in a timely fashion and to continue to explore other potential barriers to care. This in turn can help to fuel the change in pediatric mental health policy and to strive for a more balanced provision of psychosocial services in the United States.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/2020-1174.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.