The Podium

Some emergencies need more than the emergency room

“I’m a frog, I’m a frog,” yelled the7-year-old with matted hair as she hopped around the holding room, a secure area buried in the middle of the emergency department. The room contained only a mattress on the floor, a crumpled sheet, and a plate of half-nibbled chicken nuggets that a nurse had ordered from the cafeteria thinking that the child might be hungry. A school guidance counselor had brought the girl to the hospital directly from her second-grade classroom after she began bouncing and screeching uncontrollably. All attempts to calm her had been unsuccessful.

The counselor reported that all the school knew was that the girl was likely neglected as her mother struggled with narcotic addiction. At that moment, a man’s ear-piercing shriek echoed in the corridor, followed by a string of curses. Attracted by the noise, the girl stopped hopping and tried, unsuccessfully, to wriggle her way out of the room.

Outside in the corridor, four burly security guards rushed by, moving quickly into the holding room adjacent to the one in which the girl was secluded, to manage the patient, an older man who had just lunged at a nurse. Soon the man began yelling more loudly, threatening to take out everyone in sight. The little girl hopped her way into a corner of her room and put her head down.


This story, distressing as it is, does not surprise me; events like this one happen almost every day at hospitals around the country. As the director of the Child Psychiatry Emergency Service at Massachusetts General Hospital, I know what can happen when children and families end up in an emergency room with a psychiatric crisis. I’ve seen a suicidal 10-year-old boy spend days locked for his own safety in a small room with no windows while doctors, nurses ,and social workers tried to persuade a third party payer to authorize an inpatient hospital stay. That boy knows fear, desperation and loneliness, as does the twelve-year-old who learned how to sniff glue from his older cousin and then couldn’t stop doing it, the seven-year-old girl who broke all of the glassware in her apartment and then tried to cut a younger sibling with a shard of glass, and the 15-year-old high school athlete brought in by the paramedics after his father found him trying to hang himself in his closet. Each of these children landed in an emergency room because he or she had nowhere else to go for help.

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An appalling lack of access to mental health services across the nation has created a crisis that sends an ever-increasing number of children to hospital emergency rooms with urgent psychiatric problems. In the emergency room where I work, the number of children presenting with psychiatric crises has doubled over the last decade. Why is it so difficult to recognize that paying for consistent, community-based, developmentally appropriate outpatient psychiatric care might prevent such crises and obviate the need for emergency room visits?

Even the best commercial health insurance plans offer only limited coverage for behavioral health. State-based programs remain underfunded and inadequate to the task. Instead, the system allows children with psychological difficulties to remain undiagnosed and untreated until they shatter. Then, when the “lucky” ones somehow make their way to an emergency room, they find another system that is poorly designed and ill-equipped to help them—a system that sometimes forces a youngster who thinks she is a frog to stay in a room adjacent to one that contains a terrifying and potentially dangerous adult.

Colleagues often ask me how I can stand worrying about all the children who show up in my emergency room with their unsolvable problems. Ironically, I am a bit less worried about the kids in my emergency room — at least I know where they are. I am more concerned about those kids whom we don’t see, those out there who have not yet done whatever it takes to attract someone’s attention, but who continue struggling alone with internal conflicts or external chaos or both. If we don’t look, we won’t see trouble brewing.

Ignoring the pressing need to identify those vulnerable to mental illness and provide them access to treatment puts both children and society at risk. Anyone who understands development knows that it’s crucial to intervene early. Problems in childhood often predict problems in adulthood. Children are often sent to the emergency room directly from school because, like the seven-year-old hopper, their behavior or emotions have overwhelmed their teachers’ ability to cope. But those children should have been identified much, much earlier and offered access to, for example, consistent and affordable community-based services. Sometimes hopping is akin to jumping for joy, but sometimes it’s a harbinger of other, more serious problems. In this post-Columbine, Virginia Tech, and Aurora world, we should know that it may be way too late to catch a child after he or she has already pulled a knife on a classmate.


All over the country, children with mental health problems suffer from neglect born of stigma, poverty, and ignorance. Meanwhile our current system of care fails them at every level — lack of available outpatient resources coupled with insurers’ reluctance to pay for such services, overburdened emergency rooms where children wait for hours or days often witnessing things they shouldn’t, and extremely limited inpatient or residential options for those who need more intensive services. Children with mental health problems are just as needy and deserving of care as those with other health problems. If we wait for these children to become young adults before we pay attention, we will continue to reap the whirlwind.

Dr. Laura M. Prager is director of the Child Psychiatry Emergency Service at Massachusetts General Hospital and assistant professor of psychiatry at Harvard Medical School. She is also coauthor of “Suicide by Security Blanket and Other Stories from the Child Psychiatry Emergency Service.