Inside Boston’s Youth Mental Health Crisis

Illustration by Benjamen Purvis

They are the words that no parent wants to hear from their child: I need help. I feel like I’m going to hurt somebody or myself.

Yet that was exactly what David told his mothers one night in February. Concerned for their son’s safety, they drove him straight from Medford to the emergency room at Cambridge Hospital. They were promised an inpatient psychiatric bed by the morning for the 17-year-old, but when morning came, they say, the hospital had given it to someone else who had been languishing in the ER for 10 days.

David, a pseudonym to protect his privacy, and the other patient were by no means alone. On the night David arrived, there were countless desperate children waiting—doctors call it “boarding”—in ERs across the state because there was not a single inpatient psychiatric bed available for any of them in all of Massachusetts. Earlier that week, the number of boarders statewide totaled 221. And so David, who according to his parents suffered from bipolar disorder and PTSD, was left to lie in bed in a windowless room, along with a six-year-old kid also waiting for help. Left to lie for six long days.

With no inpatient beds available, the hospital wanted to discharge David and suggested a partial hospitalization program an hour away—a program with a weeks-long waiting list. Clearly, his parents said, that was not a plan. His private therapist—who had been working with David for five years—wrote a letter to the hospital noting that David was showing signs of destabilization, or warning signs that he could harm himself and others. The therapist did not agree that he was ready to go home.

On day seven, the hospital discharged David. The parents say there was no follow-up plan.

Ten days later, David’s parents say, their son blew up, locking himself in his room. When David’s mother decided to call the police, her son turned combative. He ran. A group of cops chased and finally wrangled him. Screaming and spitting in what his parents describe as a full-blown PTSD trauma response to the fire trucks, ambulances, and cruisers, he was like a wild animal. At Mass General’s ER, where the police transported him, doctors chemically sedated David and tied his arms and legs tight to the hospital bed with leather straps as his parents looked on with horror.

There were, once again, no inpatient adolescent psychiatric beds available anywhere. With no other options available, David was moved into the belly of the hospital to a locked area reserved for psychiatric emergencies. His parents say there were no windows and no fresh air, and the door needed to remain shut tight. He stayed up all night mindlessly playing on an iPad, slept all day, and had to be put in four-point restraints three separate times when he became agitated. It was, his mom says, inhumane. “We’ve had ER waits in the past,” she says. “But this was a new level of horrible.”

He stayed there for 19 days.

During that time, David’s parents—furious and desperate—called and emailed politicians, advocates, and the Department of Mental Health. “There were no more alarms that you can pull than we did,” his mom says.

For years, David’s family had tangled with the broken system Massachusetts offers children like David, and they—along with David’s school and treatment team—still couldn’t get David the help he so desperately needed. “There are so many stories that are even worse than our story, which I think is pretty up there. And these parents have lost hope,” David’s mom says. “There are people out there who, bless their hearts, think that if their child needs help, that they’re going to receive it. It is not true.”

Cambridge Hospital said in an email that “while we cannot speak to individual patient care issues, we are constantly working to balance access to care with our limited resources,” adding that it has doubled its youth inpatient mental health capacity in the past two years. MGH couldn’t comment on David’s case either, though the hospital did say in an email that it made “significant investment” in building a new unit in the hospital for acute psychiatric care that opened in April 2021. Rooms in this unit are designed to be therapeutic environments, and for privacy and infection control, doors to these rooms can remain shut. The email also said that when children are receiving acute psychiatric care within the MGH Emergency Department, they are seen daily by a psychiatric care provider—often a child psychiatrist—and can also see a psychologist twice weekly.

By now, nearly everyone has heard about the mental health crisis ravaging young people across the state and country. Late last year, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association joined together to declare a national state of emergency in children’s mental health, citing soaring rates of depression, anxiety, trauma, loneliness,
and suicidality.

The real crisis, though, is not solely that children are in desperate need of help, but that our healthcare system seems incapable of responding to them. Ours is just as much a mental health crisis as a mental healthcare crisis. In Massachusetts, we have sat idly by for decades, ignoring the red flags alerting us that we are ill-equipped to serve children struggling with mental health problems. “I was on the front page of the Globe more than 10 years ago talking about this same situation,” says Meri Viano, associate director of the Parent/Professional Advocacy League, an organization that advocates for improved access to mental health services. “And it hasn’t been figured out yet.”

Underfunding by the government and under-reimbursing by insurance companies have left not only a critical shortage of psychiatric beds but also a critical shortage of mental health professionals to monitor them. Child counselors and psychologists—the people who might be able to keep those kids out of beds to begin with—are also in short supply. And while Beacon Hill is attempting to address the issue with recently passed legislation and earmarked funding, the wheels of government are creaking slowly as our children suffer. “The healthcare system is literally imploding,” says state Senator Cindy Friedman (D-Arlington), a longtime youth mental health advocate. “Between the cost, the issues of access, and the incredible workforce burnout, we are in an enormous and very serious crisis. And I do not believe that there is the sense of urgency that is needed to address these problems. That worries me.”

Long before children become so desperate that they need an unavailable inpatient bed, they need therapy, and many times, they don’t get it.

Ever since the pandemic struck, we have been inundated with information about the toll COVID and the related shutdowns have taken on our kids’ mental and emotional well-being. While that makes for eye-catching headlines, it is not an entirely accurate portrayal. Yes, the pandemic made kids’ general well-being worse, but experts are quick to point out that it was being pounded for quite a while. “I think it’s exceedingly important not to frame the current crisis as primarily a pandemic-related issue,” says Patricia Ibeziako, the associate chief for clinical services at Boston Children’s Hospital’s Department of Psychiatry and Behavioral Sciences. “Because by doing so, we will be ignoring more than a decade of data preceding COVID that unambiguously shows that the emotional well-being of our youth has been declining.”

Nationwide, rates of childhood mental health problems and suicide rose steadily between 2010 and 2019. Today, according to the Centers for Disease Control and Prevention, suicide is the second-leading cause of death among 10- to 14-year-olds. And a truly heartbreaking report from the CDC found that 44 percent of teens reported that they “persistently felt sad or hopeless” last year. That number is up from 26 percent in 2009.

Here in Massachusetts, we are seeing the same grim panorama, specifically with huge increases in anxiety, depression, and eating disorders. More than half the children who walk into the emergency room at Boston Children’s in crisis have attempted suicide, are having thoughts about it, or are behaving in such a way that doctors believe they might try it, according to Ibeziako. “It’s pretty acute,” she says. “I don’t think people understand the severity and gravity of illness that we’re dealing with.”

There are many reasons why our kids are feeling worse than ever—from the effects of social media to a loss of community to academic stress—but the fact that dizzying numbers of children are showing up in such dire straits to emergency departments that are ill-equipped to handle them or offer them any meaningful help is reflective of a system that has broken down at every step of the way.

Long before children become so desperate that they need an unavailable inpatient bed that turns into a protracted ER stay, they need therapy, and many times, they don’t get it. “The demand for therapy is definitely greater than the supply of therapists,” says Liana Shelby of the Massachusetts Psychological Association. While there are no hard statistics underscoring this shortfall, even before the pandemic, many children’s therapists already had waitlists, and those have only grown exponentially longer since then. Today, Shelby says, the average wait time for a therapy appointment is about six months. If a child requires specialized treatment for, say, autism or trauma, the wait can be up to a year.

When it comes to outpatient care at hospitals, the situation is equally dire. The waitlist is up to 10 months at Boston Children’s, Ibeziako says. A report this past February from the Natick-based Association for Behavioral Healthcare (ABH), an advocacy group representing community-based mental health and addiction-service providers in Massachusetts, pointed out that while “fast, easy, and ongoing access to outpatient mental health services can help people avoid costlier, higher levels of care, including inpatient stays and Emergency Department visits,” most people were not able to access it.

A survey of its members found that 3,015 children were waiting an average of more than 13 weeks for initial assessment, and 3,221 kids were waiting more than 15 weeks for ongoing therapy.

Further cutting off children’s access to mental healthcare is the fact that many outpatient psychiatrists, psychologists, and social workers—up to 50 percent—don’t accept insurance, says Amara Anosike, the director of behavioral health policy and advocacy at Boston Children’s Hospital. Sometimes therapists take only one or two kinds of insurance. As a result, many kids simply go without help.

The reason why accepting insurance is so unpopular among therapists is that reimbursement rates for their services are notoriously low. Mental healthcare providers, for instance, have historically been reimbursed at lower rates than primary care or other healthcare providers. According to one 2017 report, the average in-network reimbursement rates for Massachusetts primary care providers were nearly 60 percent higher than for behavioral care providers.

Low reimbursements also affect staffing in inpatient behavioral health settings. “The inpatient behavioral health system has primarily been funded based on historic rates rather than on current cost-based methodologies,” explains Leigh Simons Youmans, Senior Director of Healthcare Policy at the Massachusetts Health & Hospital Association. “Because there’s never really been a true assessment of what it costs to deliver behavioral healthcare, those historic under-reimbursements have just perpetuated.” These low reimbursements mean that inpatient clinics can’t pay competitive wages to workers. The result? Many employees are forced to take jobs on the side to make ends meet, or leave the field altogether.

Laura Ivy was having a terrible morning. And her terrible morning was wholly unrelated to the crutches she was hobbling around on—although they did serve as a pretty apt metaphor.

The 28-year-old master’s-level clinician, who has been providing in-home therapy to children through the mental healthcare provider Advocates in Marlborough for the past three years, woke up to a call from one of the eight families she works with. Their child was in crisis, unable to gain control of their emotions or say they wouldn’t hurt themself or someone else.

Ivy sped to their house to have a conversation about hospitalization. “The only time I will advocate for a hospitalization is an immediate safety concern. No parent wants to make that agonizing decision,” she says, because part of that decision is saying, I cannot keep my kid safe without help. When they do seek care, and the hospital can’t help them, they call Ivy back, begging for direction. What do we do? “The number of times I’ve had to say, I don’t know,” Ivy says with a resigned shake of her head.

Her cell phone is on all day, every day of the week—nights, too. She spends at least four hours a week with each child, with a goal of getting them to a place where they don’t need her anymore, usually in about nine months. Sometimes, Ivy spends time during the therapy sessions working with caregivers, just trying to help them navigate a fractured and confusing system so they can get the help their child needs. “It’s very intense,” she says. “This is not something that you do unless you love it.”

Loving it, though, is not enough for many mental healthcare professionals to keep doing it. Ivy’s office has had “massive turnover,” she says, with only three people remaining from her original team of 14. That tracks with the findings of the ABH report from February of this year, which found that for every 10 clinicians with master’s degrees hired in Massachusetts in 2021, approximately 13 left, with nearly half of the survey’s respondents reporting that it took nine months or more to fill each vacant position.

Burned out, stressed out, and underpaid, Ivy knows well why people are leaving the field. “I love the kids. I love what I do,” she says, but she doesn’t know how long she can keep doing it. She has a second job selling vegetables for 16 hours on weekends just so she can pay her bills. “Unless something changes with insurance compensation and the system as a whole, the chances of me being able to do this work and start a family are not great,” she says. “I gave everything to my job, I busted my butt, and I can’t pay to live.”

Governor Charlie Baker tried to address this pressing workforce issue when he allocated $400 million for mental health from the federal American Rescue Plan Act (ARPA) a year ago, one of the largest funding amounts to be put toward behavioral health in decades. “The good news is there’s $400 million that the legislature appropriated,” says David Matteodo, the executive director of the Massachusetts Association of Behavioral Health Systems, a trade group for inpatient psychiatric and addiction treatment facilities. “The bad news is we haven’t seen a dime of it yet.”

Part of the ARPA funds—$110 million—will go toward a loan repayment program for mental health professionals. “We have to get more providers into the system, and we have to do that through loan repayments,” Senator Friedman says. “Social workers are being paid $35,000, and psychologists are getting $60,000, with huge loans. So we’ve got to make it easier for people to come into the system and work. We’ve got to build the pipeline.” The problem? At press time, that program was still in the design phase and far from becoming a reality.

Then there’s the $198 million set aside for a Behavioral Health Trust Fund, to be disbursed throughout the mental health system to fund a broad array of programs all aimed at building up that workforce pipeline. But while the money has been allocated, it remains on hold. “The trust fund is subject to the recommendations of a commission created by the legislature before it can be dispersed,” says Matteodo, who is a member of the commission. As of press time, the commission hadn’t even met yet. “That’s a source of frustration to advocates like myself,” he adds. All of it will fall to the new governor’s administration.

Meanwhile, staffing vacancies continue to result in longer waitlists and fewer kids served, according to the ABH report. A survey included in the report revealed that there are a total of 640 vacancies at their members’ mental health clinics.

This is certainly the case at Advocates, which has locations throughout the state and 67 children on its approximately five-month waitlist for in-home therapy alone. Cara Colavito, the clinical director at Advocates, has the unenviable job of managing the list, which has experienced a sharp increase in wait times over the past few years. She says parents were shocked and furious at first, but now they are “hopeless and helpless,” as it has become the sad norm. “I’m hearing about all these really horrific and traumatic things that they’re going through, and I don’t even have someone to assign them,” she says. “I get a pit in my stomach as I go to make these calls. I’m going to be speaking to people who are really struggling, and all I want to do is help, but I don’t have the help to give them.”

The struggling kids can’t even get evaluated until they are assigned to a clinician, which takes months. When they finally get through their doors, Colavito says, “we’re also managing all of the crises that have happened while waiting.” Many times, that includes an emergency ER visit.

Just before the pandemic in early 2020, Amanda’s rising ninth grader was a happy, social teenager, excited about school and her friends. When fall rolled around, and she entered high school, Amanda (a pseudonym to protect her child’s privacy) noticed her daughter’s demeanor suddenly take a dramatic turn. Sullen and withdrawn, she was a broken shell of a child who refused to leave the house. But Amanda couldn’t find a therapist or a program that would take her. “I called every hotline I could find; I put myself on every waitlist I could find,” she says. Her daughter wound up in the ER and at crisis centers six times in five months.

Amanda’s experience is common. “What we hear from the hospitals, both on the emergency department side and the inpatient psychiatric side, is that patient care has been deferred because of an inability to access it. And so kids are also more acute when they reach the inpatient level,” says Youmans from the Massachusetts Health & Hospital Association. “And they’re waiting essentially for care in an environment not designed to treat psychiatric needs.” In addition, Boston Children’s Ibeziako notes that some 2,000 kids a year come to the hospital while experiencing a mental health emergency. “What’s really striking is the severity of illness that we’re seeing…kids with more suicidal attempts, kids with multiple psychiatric diagnoses, not just one,” she says.

This spring, some 250 kids were boarding at emergency rooms on any given day at hospitals across the state. Boston Children’s, the only freestanding pediatric provider, has had an average of 39 boarders every single day this year, and they are waiting for an average of nine days—up from three in 2019—in the emergency room or on medical floors where they aren’t getting the care they need. “They are being kept safe,” Ibeziako says. “But they are not getting the right care in the right setting.”

Even longer stays are common, according to Boston Children’s Anosike, who says she recently advocated for a child stuck in the hospital’s emergency room for 200 days. Even when those kids make it to an available psych-unit bed, however, they can languish there for months at a time because there is no availability in less-acute settings when they are ready for it. “I have a meeting later today with our inpatient psych services, and they have kids that have been there 60 days, 100 days, 170 days,” she says. These long stays create a bottleneck that affects other children. One child taking an inpatient bed for 160 days, Anosike says, represents 10 kids who now need to board in the emergency room.

Even before the pandemic, Massachusetts hospitals, assisted by the state government and the behavioral health community, worked to increase the number of inpatient psychiatric beds in an attempt to meet the ever-growing demand. But while the number of beds has increased, a large percentage of them sit empty. The sole reason? Because there are not enough workers to staff them. As of mid-September, more than a quarter of available beds in the state were offline for this very reason. It was only 9 percent in February 2021.

When kids do get into an inpatient program, they are often rushed out too soon, either because insurance only covers a certain number of days, or the facility simply determines that they no longer qualify for higher-level care. Sometimes those kids wind up back at the ER. If they are lucky.

When Cindy (a pseudonym to protect her family’s privacy) saw her 18-year-old son—who had a history of crippling anxiety and a diagnosis to go along with it—having delusions and experiencing intense paranoia, she rushed him to the ER at a hospital in Boston and found a placement for him in a private facility just before the pandemic. After a two-week stay, during which doctors diagnosed Cindy’s son with possible psychosis and gave him a new prescription for a powerful drug, they told his mom to pick him up. They were discharging him.

As Cindy’s son paced in front of the discharge desk, tears running down his face, he said over and over again, “Am I ready to go home?” Cindy says staff assured her he was safe, even though they had only recently upped the dose of his new anti-psychotic medicine.

Cindy complains that the institution offered no plan for aftercare, instead suggesting various places that she discovered did not have any openings. Cindy had already put her son on all those waitlists, hoping something would work out. “But he didn’t wait,” she says.

After making cookies with his family that night and hugging his younger brother—
calling him his best friend—her son snuck out of the house, drove to the center of town, and stepped in front of a commuter train.

In the wee hours of the morning on August 1—just before the legislative session ended—the House and Senate in Massachusetts passed the Mental Health ABC Act: Addressing Barriers to Care. The omnibus bill, says Representative Adrian Madaro (D-Boston), the House Chair of the Joint Committee on Mental Health, Substance Use, and Recovery, is arguably the most significant reform to the mental health landscape in Massachusetts in decades. And yet it is still not enough. “I would never say this is the panacea to all of the behavioral health woes,” he says. “But it is certainly an enormous step in the right direction.”

The legislation aims to tackle a whole host of important issues—from guaranteeing annual mental health wellness exams to creating an online portal to search for open inpatient beds in real time. But perhaps the biggest reform is attempting to tackle insurance coverage.

For years now, there have been state and federal laws requiring so-called parity—meaning that health plans’ behavioral health coverage must be on par with their medical coverage. But those laws haven’t been properly enforced. This bill aims to change that. “Basically, we’ve allowed insurance companies to self-report and allowed them to do it at a very aggregated level,” Senator Friedman says. “Now they have to prove to the Division of Insurance that they are actually following the laws.” The bill provides better tools to enforce parity laws by creating a clear structure for the Division of Insurance to investigate parity complaints and ensure their timely resolution.

The law also tries to address the problem of lower reimbursement rates for mental healthcare by requiring they be on par with primary care. But Diane Gould, the president and CEO of Advocates, says when it comes to both reimbursing adequately for services and also expanding the scope of what is reimbursable, there is still “a long way to go.”

While the legislation is a huge step in the right direction, advocates know it certainly won’t provide an overnight fix. “It will take years—decades—to build the comprehensive infrastructure necessary to adequately care for children with mental health needs,” Ibeziako says. “So many people are hoping for quick solutions. But if you rapidly build a system by cutting corners, you’re going to end up with a very subpar infrastructure in the long run.”

In the meantime, kids continue to struggle. Senator Friedman still gets calls from parents whose kids are languishing in the emergency room for months on end. She picks up the phone, makes calls, and uses her influence. “And then, of course, something happens,” she says, adding that it shouldn’t take a politician’s call to make things happen. “The Department of Mental Health’s job is to ensure that there’s a system in place for taking care of people in need of treatment. Why aren’t they screaming and yelling? Why aren’t they coming into the legislature advocating for what they need? That’s not happening. And that doesn’t ever happen,” she says. (Boston reached out to the Department of Mental Health and was told commissioner Brooke Doyle was unavailable for comment.)

Anosike thinks that, at this point, everyone should be screaming and yelling. “It’s not just one part of the system that needs to step up. All of us—providers, payers, parents, advocates, policymakers—have a part,” she says. “A one-time infusion of resources will not undo decades and decades of underinvestment. This crisis will require a comprehensive and sustained effort to address the systemic and ongoing access issues that we are experiencing. These [new] resources are great, but they are too little and too late.”

As a result, parents continue to hit brick walls trying to get their kids the help they need. A few years after the tragic loss of her son to suicide, Cindy is heartbroken for other parents who are in the same situation as she was when she struggled to get him the help he needed. “People should know there’s nothing out there,” Cindy says. “In fact, it’s worse than having nothing because you’re putting faith in something that is just so broken. I hate to say it for all those people whose kids are struggling right now with their mental health: God help them.”

Illustration by Benjamen Purvis

The Kids Are Not All Right

A look at our children’s mental healthcare crisis, by the numbers.

44

Percentage of teens across the nation who reported that they “persistently felt sad or hopeless” in 2021.

6

About how many months it takes to get a therapy appointment for a child
in Massachusetts.

30

Percentage of children who went to Boston Children’s this year in crisis who were not in active mental health treatment.

441

Number of licensed psychiatric beds for kids in the state as of mid-September.

27

Percentage of those beds that are offline and unavailable due to shortages in staff.

250

Average number of kids “boarding” on any given day in emergency rooms at hospitals across the state this spring.

3

Average number of days children boarded at Boston Children’s Hospital’s ER in 2019.

9

Average number of days children boarded at Boston Children’s Hospital’s ER in 2022.

Illustration by Benjamen Purvis

Not Sure If Your Child Has a Problem?

Daniel Dickstein, chief of the division of child and adolescent psychiatry at McLean Hospital, shares five signs to keep an eye out for.

Consider it a problem if these behaviors last for more than two days in a row or start to become more common than not:

1

Isolating themselves alone in their room.

2

Cutting ties with friends or a recent breakup.

3

Either sleeping far more or far less than usual.

4

Loss of interest in social activities—dropping out of sports or youth groups or not going to school.

5

Greater anger, irritability, fighting, or volatility.

First published in the print edition of the December 2022 issue, with the headline “Broken.”