Why early mental health intervention is essential to prevent pediatric boarding
A 12-year-old boy arrives at the emergency department (ED) in a mental health crisis. His immediate needs are stabilized within hours, but finding an appropriate psychiatric bed proves nearly impossible. Eighteen hours later, he’s still there, along with his exhausted parents. Meanwhile, an overwhelmed nursing staff is doing their best to provide mental health support in a space designed for medical emergencies.
This scenario plays out daily across American hospitals. Recent data from the Journal of the American College of Emergency Physicians shows that approximately one in three pediatric mental health ED visits now exceeds 12 hours, with 13% lasting 24 hours or longer.
These statistics represent children in crisis, families in anguish, and a system that’s treating emergency departments as the default solution for a problem that should be addressed much earlier.
The question that keeps me focused isn’t how we can make EDs handle mental health crises more efficiently, though that’s important work. Really, it’s, “How many of these crises could we prevent entirely?”
The Problem: When Emergency Becomes the Norm
Emergency departments across the country are seeing more children in mental health crisis than ever before. Hospitals report a 24% spike in mental health ED visits for children aged 5 to 11 and a 31% increase for adolescents aged 12 to 17.
Furthermore, these children spend a considerable amount of time in the ED. Our research found that children may wait anywhere from 8 to 34 hours for psychiatric care — a range that reflects how unpredictable and prolonged these emergency department stays have become, as well as the shortage of psychiatrists, PMNHPs, and psychologists across the country. Facilities also report spending upwards of thousands of dollars per admission on these extended stays. The projected cumulative cost of mental health inequities across all healthcare settings is estimated to amount to $14 trillion by the year 2040, with emergency department psychiatric care representing a growing portion of this burden.
The human cost runs deeper. Emergency departments weren’t designed for extended mental health care, yet children in crisis often spend hours or days in these sterile, chaotic environments during their most vulnerable moments. Staff without specialized behavioral health training struggle to provide appropriate support, while the departments themselves become crowded and overwhelmed.
Perhaps most troubling, many of these children return within weeks, suggesting that emergency-based interventions often fail to address the root issues driving their crises.
Why It Happens: The Upstream Failures
The emergency department has become the mental health safety net by default, not by design. Three critical gaps create this downstream crisis.
- Outpatient access remains severely limited.
The average wait time for a child psychiatrist appointment can stretch to weeks or months, assuming one exists within driving distance. Rural areas face particular challenges, with some regions having no pediatric mental health specialists within a 200-mile radius. - Our current scheduling systems prioritize speed over severity.
Most behavioral health practices operate on a first-come, first-served appointment booking system. A child experiencing suicidal ideation might wait weeks for care, while someone seeking routine medication management gets seen sooner because they called first. - Primary care providers often lack the tools and training to identify escalating mental health conditions early.
Without proper screening and triage systems, warning signs go unnoticed until a crisis forces families to seek emergency care.
Unfortunately, EDs end up shouldering the burden of a problem that can often be prevented with earlier, more targeted intervention.
Iris POV: Prevention Through Smart Intervention
The most effective psychiatric care often happens before a crisis hits. At Iris Telehealth, we’ve seen how strategic upstream interventions can dramatically reduce ED volumes and boarding times.
Our Virtual Clinic model demonstrates this prevention-focused approach. Rather than waiting for children to reach crisis levels, we embed psychiatric expertise directly into primary care settings and ambulatory care locations. When a pediatrician notices concerning behavioral changes or identifies a patient at risk, they can connect with our full pod of providers — psychiatrists, PMHNPs, and therapists — for comprehensive, longitudinal care.
This immediate access changes everything. A 10-year-old showing signs of severe anxiety can receive proper assessment and treatment planning before missing weeks of school or ending up in an emergency department. A teenager experiencing depression gets connected to ongoing care quickly rather than cycling through crisis interventions.
We’ve partnered with health systems to show measurable results. Texas Health Resources launched a Virtual Clinic program that reduced average wait times for behavioral health appointments from 17 days to 7 days, while serving over 3,600 patients in the first year alone. This 60% reduction in time from referral to first visit means children and families get the support they need before conditions escalate to emergency department visits.
The technology exists. The clinical expertise is available. What’s needed is the commitment to intervene early rather than react late.
Building a Better Path Forward
ED overload is preventable with smarter upstream support. When we shift our focus from crisis response to early intervention, we can spare children and families the trauma of extended boarding while reducing costs and improving outcomes.
At Iris, we help health systems build these prevention-focused programs with smooth and straightforward implementation. Our Virtual Clinic solution integrates seamlessly across care settings, providing full-scope behavioral health support before conditions reach crisis levels. Once established, pediatric patients receive comprehensive mental health care when and where they need it most, reducing the burden on emergency departments.
If you would like to learn more about how you can prevent pediatric mental health crises before they reach your emergency department, contact us today.
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About the Author
Dr. Tom Milam serves as Chief Medical Officer at Iris Telehealth and President of Iris Medical Group – guiding their team of providers in telemedicine and industry best practices. He received his undergraduate degree from WVU in Anthropology, where he graduated summa cum laude and Phi Beta Kappa. He went on to earn his Master of Divinity Degree from Yale, where he was a Yale’s Associate Scholar, followed by receiving his Doctorate of Medicine (MD) from the University of Virginia. His residency training in psychiatry took place at Duke and UVA. Dr. Milam has practiced in North Carolina, Virginia, and New Zealand and is an Associate Professor of Psychiatry and Behavioral Medicine at the Virginia Tech Carilion School of Medicine and Research Institute in Roanoke, VA.
