Across the country, there are children confined to hospital rooms -- missing school, cut off from peers, unable to even step outside -- for no medical reason.
There's simply nowhere else for them to go.
The ongoing pandemic has caused mental health crises among the young to skyrocket. An increasing number of these children and adolescents are admitted to emergency rooms, where they are assessed and stabilized.
And then they wait.
One child at St. Louis Children's Hospital has been waiting for somewhere to go for nearly six months, according to Trish Lollo, president of the hospital.
"This is something that is not only a Children's issue. This is a national crisis that we are going to have to contend with immediately," Lollo said. She was one of four St. Louis-area hospital presidents who wrote an open letter sounding the alarm about this catastrophe.
"On any given day, our emergency department rooms are home to significant numbers of kids with mental health concerns, most of whom languish for days for access to a treatment facility," the letter said. "When we get to the point that there is no hope of transfer to an appropriate facility after holding these children for multiple days in our emergency departments, we end up admitting them to a hospital room."
Imagine a child, already suffering from severe mental health problems, stuck in an emergency department -- which is not at all equipped to provide what they need -- for days or weeks.
In some situations, the child needs a "step-down" alternative from a hospital, like an intensive outpatient program. Or the child might need a therapeutic bed in a residential facility that can provide treatment in a social setting, or perhaps a foster home placement -- but nothing is available in the state. In other cases, the parents or caregivers may refuse to bring a child back home after he or she is stabilized because they believe the child will again become a danger to themselves or others.
"This has been a particularly heartbreaking component of the crisis," Lollo said.
While they are waiting in the ER, these children are known as "boarders." There have always been a few cases like this, even prior to the pandemic, but now there may be up to 50 children boarding in ERs across Missouri during COVID-19 surges, according to Kyle John, vice president for Behavioral Health at Mercy Hospital St. Louis. Children who test positive for COVID-19 must be quarantined in the hospital before another facility will accept them. There are fewer residential beds for children and adolescents available in the state than there were before the pandemic, because some facilities have shut down.
John said Mercy has a child staying in the hospital who was transferred from a neighboring state. She is medically cleared to return, but the state won't take her.
"The home state can't find a shelter, foster placement or residential bed," John said. The consequences of lingering in an ER or hospital bed for weeks can be devastating for patients, who may start to regress and act out.
It can also be dangerous for the staff who care for them.
"It's a very challenging situation to keep our staff safe," Lollo said.
Alyssa Harrell, a nurse and clinical instructor at SSM Health Cardinal Glennon Children's Hospital, has seen the toll it takes on patients and nurses. A handful of times during the pandemic, she worked a full day shift, then came back from 3 a.m. to 7 a.m. to serve as a one-on-one behavioral health "sitter" for a child, which involves watching the patient constantly and documenting their status every 15 minutes. Once that was over, Harrell would then work another full nursing shift.
Heather Dolce, spokeswoman for the Missouri Department of Social Service, said the Children's Division is in the process of securing a 15-bed emergency shelter facility in Jefferson City to provide temporary housing for some of these children. She could not provide a date for when the shelter might open.
"Facility build-out and staffing efforts are well underway. We assure you that the Children's Division has made moving forward with this as soon as possible a priority," said Dolce in an email.
It will take a multipronged effort to address a crisis that has been building for years. The state needs to pay a living wage to the caregivers who would be staffing these additional beds in order to attract and retain workers. Additionally, there needs to be a financial incentive for hospitals and facilities to open additional pediatric behavioral health units.
Lollo said she often thinks about the societal costs of children who need care but cannot get it, and about the long-term impact of boarding on a child's ability to recover and thrive.
The child who has been waiting at Children's for 160 days had had an earlier long-term admission there, too.
"He's been with us almost an entire year, in a hospital room," she said.
Waiting for a place that will take him.