A Healthy Blog

Massachusetts health care — wonky, with a healthy dose of reality

Psychiatric “Boarding”

Psychiatric “Boarding”

May 10, 2018

By Kate Ginnis, MSW, MPH, Director of Behavioral Health Advocacy & Policy, Boston Children’s Hospital


Children in Crisis

One in five children suffers from a diagnosable mental health disorder.  Half of all lifetime cases of mental illness are diagnosed by age 14.[i]  The prevalence of mental health disorders among children and adolescents indicates the need for a robust treatment system that allows families to access appropriate care for their children when and where they need it.  Any parent who has tried to get care for their child knows that it is not that simple.

Kids and Families in Crisis

Children with mental and behavioral health disorders and their families across Massachusetts are in crisis. Nowhere is it more evident than in Emergency Rooms throughout the Commonwealth, where parents and caregivers bring their children when they are having a behavioral health emergency.  As with any patient in the ER, children are evaluated by professionals who make recommendations about the best next step, which may include inpatient psychiatric care, an intermediate level of care, or outpatient care.  The similarity between what happens in the ER for youth with physical health conditions and those with behavioral health conditions stops there.  For children with physical health conditions, more complex conditions with more acute symptoms warrant the most immediate and most intensive care.  For children with behavioral health conditions, the most complex patients are more likely to spend days or even weeks in the ER awaiting care.[ii]  Psychiatric “boarding,” was first observed in 2000,[iii] and has been a problem for youth and their families ever since.  Most days in Massachusetts, there are children sleeping in EDs because they cannot access the care that they need.

Why is there a boarding crisis?

Psychiatric boarding is the most severe and apparent symptom of the inadequacies in access to behavioral health care that the Children’s Mental Health Campaign (CMHC) has prioritized for more than a decade.  In 2006, the CMHC was launched with the publication of a paper entitled, “The Time is Now,” which laid out a set of recommendations to improve children’s mental health care in Massachusetts.  Since that time, the CMHC, a coalition of advocates led by the Massachusetts Society for the Prevention of Children, Boston Children’s Hospital, the Parent-Professional Advocacy League, Health Care for All, Health Law Advocates and, more recently, the Massachusetts Association for Mental Health, has advocated with leaders in Massachusetts to make substantial policy changes to improve access. 

Though we understood that boarding was indicative of a larger system failure, the CMHC leadership realized that in order to advocate for much-needed change, we needed to better understand what was driving the problem. Over the past three years, the CMHC embarked on a research project funded by the CF Adams Charitable Trust to look at boarding from the perspective of hospitals, families, and the community.  We knew that this problem was multi-faceted and that we needed a multi-pronged solution.  We wanted to make sure that we understood both the data and the family experience in order to identify essential policy changes that would have real impact. 

Our research elucidated a trend that we knew existed but for which we previously had mostly anecdotal evidence: youth with more complexity board longer.  In December 2016, the CMHC brought together key stakeholders at a pediatric boarding “summit,” to present project outcomes and to get feedback from key stakeholders which enabled us to develop a plan for next steps in legislative, administrative, and budget advocacy to eliminate boarding.  At the same time, the Executive Office for Health and Human Services, with the leadership of Secretary Marylou Sudders, embarked on a statewide workgroup to solve the boarding problem for both children and adults.  CMHC leaders have been delighted at the attention paid to this critical issue and have been engaged at every step of the way.  Perhaps the most immediate result of our collective work is the creation of inpatient units to treat youth with Autism Spectrum Disorders who are in psychiatric crisis, the first of which will open later this year.

What’s next?

Boarding as a symptom allowed the CMHC leadership to unpack several other advocacy priorities that we believe will improve access at all levels of the mental health care system, and that you can read about on the CMHC website or by subscribing to our monthly newsletter. New issues are brought to our attention by the advocacy of our engaged providers and families, and we depend on your insight, expertise, and activism to combat the inequities that exist in the children’s behavioral healthcare system. Contact the CMHC or you may contact me directly at kate.ginnis@childrens.harvard.edu.


This blog is part of HCFA’s Children’s Mental Health Week series.


[i][i] Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005 Jun;62(6):617-27.

[ii] Wharff, E. A., Ginnis, K. B., Ross, A. M., & Blood, E. A. (2011). Predictors of psychiatric boarding in the pediatric emergency department: implications for emergency care. Pediatric emergency care27(6), 483-489.

[iii] Mansbach, J. M., Wharff, E., Austin, S. B., Ginnis, K., & Woods, E. R. (2003). Which psychiatric patients board on the medical service?. Pediatrics111(6), e693-e698.