It is difficult to imagine a child with a medical emergency staying in an ED for several days waiting for an inpatient bed. Yet, it happens routinely to children and adolescents with psychiatric emergencies.

“In terms of parity, which represents justice in healthcare, this is unequal treatment,” says Claire Zilber, MD, DFAPA, ethics committee chair for the Colorado Psychiatric Society. “Long waits in the ED can exacerbate agitation or psychosis, necessitating the use of restraints, which would otherwise not be needed.”

The shortage of psychiatric inpatient beds is well-known. But Zilber argues simply accepting this as the status quo is ethically unacceptable. “Ethical care means adequately funded care,” she says. “Our society undervalues the importance of mental health, and, thus, underfunds mental health services.”

Major gaps in resources for child and adolescent mental healthcare “tend to play out in EDs,” says Gail A. Edelsohn, MD, MSPH, co-chair of the American Academy of Child & Adolescent Psychiatry (AACAP) Ethics Committee. Pediatric psychiatric visits increased by 28% between 2011 and 2015, according to the authors of a recent paper, with the largest increases in adolescents, African American, and Hispanic patients.1 Researchers also found a large increase in suicide-related visits among adolescents and noted that just 16% of patients were seen by a mental health professional.

“Many youths and their families experiencing a mental health crisis wait hours or days waiting for discharge or transfer to a psychiatric hospital,” Edelsohn notes.

Another study found that of 1,746 mental health visits to a pediatric ED in 2016, 386 stayed longer than 24 hours.2 Presenting with private insurance, physical or chemical restraint use, autism or developmental delay comorbidity, and prior psychiatric hospitalization were associated with pediatric mental health ED boarding.

“EDs do their best to meet the needs of youth and their families,” says Maria E. McGee, MD, MS, MPH, also co-chair of the AACAP Ethics Committee. However, not all EDs can provide adequate specialized mental health staffing. Not all include calming space to meet the needs of vulnerable, distraught youth who sometimes exhibit dangerous behaviors. “This means youth might be lacking necessary mental healthcare while they are waiting,” McGee notes. Prolonged boarding in the ED can result in lower quality care for psychiatric patients. It is not just lack of available inpatient beds that is the problem. “The creation of more pediatric psychiatric beds is a one-dimensional solution to a multidimensional problem,” McGee adds.

Various unmet mental healthcare needs, which might precede a mental health crisis, also must be considered. “Prolonged ED boarding is a reflection of deeper gaps in the availability and accessibility of outpatient mental healthcare resources,” McGee says. Certain interventions are vital, such as early support of children’s developmental needs, early detection and interventions addressing psychiatric illnesses in children and adolescents in school and clinical settings, and addressing adverse childhood experiences.

The average length of stay for mental health visits in pediatric EDs was more than 11 hours, according to the authors of a 2015 study.3 A prolonged ED stay “translates to ethical concerns revolving around autonomy, beneficence, nonmaleficence, justice, and fidelity,” McGee says.

In some cases, patients or family want to leave the ED against medical advice (AMA) because of the long wait for an open bed at a psychiatric facility. In this case, says McGee, “the physician must make a decision that has significant clinical, ethical, and risk management implications.” The ED provider either creates a therapeutic alliance so that the patient receives timely and quality psychiatric care, initiates an involuntary commitment proceeding, or faces an AMA discharge.

“A hospital ethicist has multiple roles in the case of psychiatric boarding,” McGee says. An ethicist can help to assess issues involving distributive justice, including the scarcity or lack of mental health resources and ED crowding. “An ethicist can assist in elevating the constellation of ethical concerns that arise from psychiatric boarding to hospital leadership,” McGee offers. These leaders are responsible for institutional policy, practice, and budget allocation that can enhance the training, staffing, expertise, safety, and physical accommodations for the ED.

“An ethicist’s expertise can also be utilized to advocate for systemic changes to address the mental healthcare needs and psychosocial challenges that culminate into an ED visit,” McGee notes.

Ethical challenges arise when the recommended treatment or discharge plan is not acceptable to all the key stakeholders. Child welfare agencies, juvenile justice entities, and parents can disagree on what is in the child’s best interest. “These differences can quickly become quite heated,” Edelsohn observes.

The physician may recommend community-based services, but the family may want a residential setting. “Ethicists can help address these conflicts by teaching clinicians specific mediation techniques to achieve consensus around treatment decision-making in the ED,” Edelsohn says.


  1. Kalb LG, Stapp EK, Ballard ED, et al. Trends in psychiatric emergency department visits among youth and young adults in the US. Pediatrics 2019;143. pii: e20182192. doi: 10.1542/peds.2018-2192. Epub 2019 Mar 18.
  2. Hoffmann JA, Stack AM, Monuteaux MC, et al. Factors associated with boarding and length of stay for pediatric mental health emergency visits. Am J Emerg Med 2018; Dec 23. pii: S0735-6757(18)31003-9. doi: 10.1016/j.ajem.2018.12.041. [Epub ahead of print].
  3. Sheridan DC, Spiro DM, Fu R, et al. Mental health utilization in a pediatric emergency department. Pediatr Emerg Care 2015;31:555-559.