When the Emergency Department Is Not Enough


When the Emergency Department Is Not Enough

A new inpatient pediatric facility will answer an urgent need to help children and teens experiencing psychiatric emergencies

By Matt Purcell and Ginger Skinner

A child entering an emergency department (ED) with a complex fracture or an acute case of pneumonia can expect to be hospitalized promptly. But for a child experiencing severe depression or paranoid delusions, the wait can take days or even weeks.

“Just about every day, there’s a child we see in the emergency department who needs inpatient psychiatric care,” says Michael deCastro Cabana, M.D., M.P.H., professor of pediatrics and the Michael I. Cohen, M.D., University Chair of Pediatrics at Einstein and physician in chief at the Children’s Hospital at Montefiore (CHAM). “The need for more inpatient mental health resources for kids is an increasingly urgent one.”

While EDs are frequently the first point of care for children’s mental health emergencies, they aren’t designed to provide the appropriate support. According to a 2017 study published in the Journal of the American Academy of Child & Adolescent Psychiatry, the ED is designed for acute help, delivered over hours, not days, and there is little continuity of care.

Just about every day, there’s a child we see in the emergency department who needs inpatient psychiatric care.
—Dr. Michael deCastro Cabana

Jonathan Alpert, M.D., Ph.D., left, and Michael deCastro Cabana, M.D., M.P.H., at the Children’s Hospital at Montefiore. (Photo by Jason Torres)

Due to a lack of inpatient psychiatric beds, children are sometimes transferred from the ED to nonspecialized pediatric units. “But general pediatrics floors are already overextended, and they’re not geared to provide specialized mental health services,” says Jonathan Alpert, M.D., Ph.D., professor and chair of psychiatry and behavioral sciences, professor in the Dominick P. Purpura Department of Neuroscience and of pediatrics, and the Dorothy and Marty Silverman Chair in Psychiatry at Einstein and Montefiore. “In addition, the environment of care may pose hazards, such as dangling cords or sharp objects, for suicidal youth.”

Parents worry about the distance, about being able to visit their child during one of the most challenging times they’ve encountered as a family.
— Dr. Jonathan Alpert

Nowhere to Go

This heartbreaking scenario at hospitals across the country is even more acute in the Bronx, where an estimated 25 inpatient beds serve an area that includes 400,000 people under the age of 18—about a third of the borough’s population. 

“For all the cases that show up in our ED, there’s maybe room for one or two that can be transferred to a Bronx facility,” says Peter Semczuk, D.D.S., M.P.H., senior vice president and executive director of Montefiore’s Moses Campus and Montefiore Faculty Practice Group. As a result, administrators frequently engage state agencies to find placement in other areas of New York, such as Westchester County or Long Island, or even other states.

That reality, notes Dr. Alpert, underscores the importance of having local inpatient capacity.

“These parents worry about the distance, about being able to visit their child during one of the most challenging times they’ve encountered as a family. It’s very important to us that we have inpatient beds that are accessible to families geographically, culturally, and linguistically, and that also provide high-quality, evidence-based treatments,” he says. 

Now, pediatric specialists hope a new inpatient psychiatric unit at Montefiore will bring some much-needed relief. 

Years in the Making

Experts at Montefiore identified the need for such a unit more than 20 years ago. “When we opened CHAM, we talked a lot about creating an inpatient psychiatric unit,” says Dr. Semczuk, “but we were so oversubscribed with other patient demands that we had to prioritize all of the other specialty services.” And with on-campus space and outside financing in short supply, an inpatient pediatric facility remained on the drawing board.

Until COVID-19.

Experts say the crisis increased the urgency for inpatient psychiatric beds for children and adolescents and added a layer of stress for doctors and nurses working in already overextended EDs across the country. But even before the pandemic the number of children and adolescents in need of a higher level of care had been rising steadily. Research published in the December 2022 edition of JAMA Pediatrics showed that mental health visits to pediatric EDs increased 8% every year for five years starting in 2015, with 13% of patients revisiting within six months.

Montefiore’s new, 21-bed inpatient psychiatric facility for children will be housed in the Bronx Psychiatric Center complex near Einstein.

With a burgeoning demand for beds, and a renewed commitment from Gov. Kathy Hochul to address New York’s mental health challenges, Montefiore leadership charted a path forward. Meetings with the New York State Office of Mental Health resulted in strong support for the partial redevelopment of the New York City Children’s Center in the Bronx—and the prospect of significant state funding.

Taking Action 

Still, one key element was missing: philanthropic support. 

Construction of the Montefiore Einstein Center for Children’s Mental Health of the Children’s Hospital at Montefiore Einstein was made possible in part thanks to a $1 million gift from Montefiore Trustee David B. Keidan, who joined the institution’s board two decades ago because he was attracted to the hospital’s mission of service. He says it aligns with the Jewish concept of tikkun olam—taking action to repair and heal the world. 

“I was shocked to learn that a child who is experiencing severe mental issues may have to wait as long as three months to get an available psychiatric bed in the Bronx,” says Mr. Keidan. “To me, charitable work, particularly for children, is of prime importance. And I can’t think of anything more horrifying than not being able to get help for a child who has substantial mental health issues.”

Building the new unit is also about removing invisible barriers to care. 

“Today, there’s greater recognition of conditions like depression, anxiety, and eating disorders in youth, and less stigma,” says Dr. Alpert. “And therefore a greater willingness for families to pursue mental health services.”

I was shocked to learn that a child who is experiencing severe mental issues may have to wait as long as three months to get an available psychiatric bed in the Bronx.
— Montefiore Trustee David B. Keidan

As increased attention is brought to the crisis, more children are recognized as in need of treatment; financial support for such care must keep pace. In January 2024, the New York State Office of Mental Health designated Montefiore a Behavioral Health Center of Excellence and awarded funding to support a separate, completely outpatient children’s psychiatry clinic in the South Bronx. In March, Montefiore received a nearly $6 million appropriation for the new inpatient unit spearheaded by New York State Assembly Speaker Carl Heastie and Assemblyman Michael R. Benedetto. 

“Montefiore’s focus on growing inpatient mental and behavioral health treatment for children and adolescents in the Bronx reflects a commitment to reducing care inequities, addressing the community’s specific needs, and providing leadership in the realm of urban pediatric mental healthcare,” says Assemblyman Benedetto. “I’m grateful for their dedication to leading the charge on an issue impacting the Bronx youth, and I’m hopeful that with adequate approvals and resources, we will be successful in improving mental and behavioral health outcomes for children and adolescents in our communities.”

Despite efforts by the state and others to boost the profile of mental health, however, raising philanthropic funds for psychiatry remains challenging. “It’s still very much the case that it takes a certain amount of courage for people to come out in support of mental health, especially when provided a menu of other options that are also meaningful,” says Dr. Alpert.

An architect's rendering of the Montefiore Einstein Center for Children's Mental Health of the Children's Hospital at Montefiore Einstein.

Widening Access to Specialized Care

The new, 21-bed unit will provide care for children ages 5 to 17 and will offer them many of the things the ED can’t: their own bathrooms, rooms with windows and TVs, access to child-life services, specialized nursing care, space to walk and interact with patients their own ages—even a basketball court, which they will share with an adjacent school.

Children and adolescents admitted to the new inpatient unit will receive regular psychotherapy and essential medications tailored to their conditions, in addition to other care such as arts therapy and education. Philanthropic support and $5.7 million in New York State funding will help cover the costs. 

Plans are in place to break ground for the facility this year. It will also offer resources for parents and other caregivers, both during and after their children’s stays, including parent support groups and meetings with psychotherapists and social workers. “It’s important for the parents to be involved in the treatment and be given the skills and enhanced support they need,” says Dr. Alpert. “No matter how caring and knowledgeable parents are, no parent is fully equipped to navigate how to support a child through a mental health crisis severe enough to warrant inpatient treatment.”

The holistic nature of the unit and the continuum of care it will provide are by design. “We have recognized—increasingly so over time—the need to position CHAM and the Montefiore Health System to be in a better place to take care of pediatric mental health,” says Dr. Cabana. “The new unit is a great example of pediatricians collaborating with those in other disciplines and other specialties to evaluate kids and exchange new ideas about better ways to take care of them, for now and in the future.” 

Once a child is released from inpatient care, an intensive outpatient program, or IOP, continues for four to six weeks for children and families who need it. Montefiore has received a license from the Office of Mental Health to open a new IOP for youth on the Wakefield campus; this will be one of only a few IOPs in New York State licensed by the Office of Mental Health. It’s considered an important midway point between the inpatient program and outpatient treatment. 

“We see the entire program as marshaling all the resources we have to intervene when mental health issues first present,” says Dr. Alpert, “and change the child’s trajectory toward a healthier life. It’s an enduring contribution to be able to have a unit of this kind.”

Click here to donate

Let's Connect!

"*" indicates required fields


More From Einstein

Class of 2024 Celebrates Match Day
Einstein Community Enjoys Pi Day
Graduate Students Win Marmur Award
Empowering Einstein Women in Science
Einstein Secures $192M in NIH Grants
Training the Next Cancer Researchers
Bringing a Novel Drug to Market
A Promise to Rwandan Genocide Survivors