Study uncovers disparities in boarding rates of children with severe mental health symptoms

A new study led by researchers at McLean Hospital and Harvard Medical School, in collaboration with researchers from Massachusetts General Hospital and Cambridge Health Alliance, has uncovered concerning disparities in boarding rates of children and adolescents with severe mental health symptoms in emergency departments.

When reviewing more than 4,900 boarding episodes of youth under 17 years old in Massachusetts over an 18-month period, the researchers found there were numerous racial and gender disparities: Black youth were less likely to be admitted to inpatient psychiatric care than White youth. Additionally, transgender and nonbinary youth experienced longer boarding times in the Emergency Department and lower admission rates to inpatient units compared to cisgender females. Nearly half of the boarding episodes did not result in inpatient admission.

Youth who must board in the emergency department for days or weeks at a time without transitioning to inpatient care typically receive less mental health care than they would have received in an inpatient setting, which potentially puts them at risk of even worse outcomes, according to the authors.

Our study found that several non-clinical factors, including statewide demand for inpatient care, appear to play a role in the admission decision, and that racial and gender disparities permeate the process. Boarding is a culmination of problems and lack of access throughout the mental health care system, not just inpatient care. Solving it will take resources and interventions at many levels."

Nicole M. Benson, MD, MBI, senior study author, associate chief medical information officer at McLean Hospital and assistant professor of psychiatry at Harvard Medical School

Benson and lead study author Lindsay Overhage, BA, an MD/PhD student and researcher in the department of Health Care Policy at Harvard Medical School, led a review of data collected across Massachusetts on all youth 5 to 17 years of age who were boarded in Emergency Departments for three or more midnights while awaiting inpatient care, from May 2020 to June 2022. The researchers utilized a comprehensive dataset from the Expedited Psychiatric Inpatient Admission database, maintained by the Commonwealth of Massachusetts.

The study revealed Black youth were more than 4 percentage points less likely to be admitted for inpatient treatment than their White counterparts, despite similar clinical presentations and needs for psychiatric care. Transgender and nonbinary youth were more than 9 percentage points less likely to receive an inpatient admission compared to cisgender females and boarded in the Emergency Department for approximately two days longer, on average.

A secondary analysis found statewide demand was strongly correlated with individual outcomes, which can play a role in the decision for inpatient admission. For every 100 additional youth boarding across Massachusetts on the day a child or adolescent was assessed with a psychiatric emergency, the percentage of youth admitted was more than 19 percentage points lower and boarding times were on average three days longer.

The study's authors call for policy reforms, in addition for targeted interventions to address the root causes of disparities in psychiatric care access for youth. They point out that efforts are underway in Massachusetts to implement a roadmap for behavioral health reform, focusing on crisis intervention teams, enhanced community support and improved access to psychiatric beds.

"The experience of boarding – of being stuck in one Emergency Department room, under 24-hour, one-on-one supervision, for days or weeks at a time, with little definitive mental health treatment and not knowing how long you'll be stuck there – is detrimental to children's wellbeing," said Overhage. "In fields other than psychiatry, the sickest person in the Emergency Department gets admitted first for inpatient care. But many inpatient units don't feel equipped to deal with kids who have the most severe psychiatric symptoms, so by default these kids end up languishing in Emergency Departments."