Abstract
Background: Access to inpatient psychiatric care for children and adolescents has become an increasingly urgent health services concern in the United States. Rising rates of pediatric mental health crises, suicidality, and emergency department utilization have intensified pressure on pediatric behavioral health systems, contributing to prolonged psychiatric boarding, delayed transfers, and concerns regarding inpatient psychiatric capacity. This scoping review synthesized contemporary literature addressing pediatric inpatient psychiatric access from a systems-level perspective, including psychiatric boarding, inpatient capacity limitations, utilization pressures, workforce constraints, reimbursement environments, policy conditions, and related drivers of access to care.
Methods: A scoping review was conducted in accordance with PRISMA-ScR and Joanna Briggs Institute guidance. Searches of PubMed and Scopus identified studies published between 2010 and 2025 addressing pediatric inpatient psychiatric access, psychiatric boarding, capacity, utilization, workforce limitations, reimbursement factors, policy conditions, and related systems-level issues. Following deduplication and screening in Covidence, 48 U.S.-based studies met inclusion criteria. Data were extracted using a standardized charting framework and synthesized using descriptive and thematic approaches.
Results: Across eight thematic domains identified during synthesis, psychiatric boarding and emergency department strain emerged as the dominant themes in the literature. Studies consistently identified inadequate pediatric inpatient psychiatric capacity as a major contributor to prolonged emergency department stays, transfer delays, and medical unit boarding. The COVID-19 pandemic appeared to intensify existing pediatric psychiatric access challenges through increasing psychiatric utilization, acuity, and boarding duration. Multiple studies additionally identified disparities affecting publicly insured youth, transgender and gender-diverse adolescents, justice-involved youth, and children with developmental disabilities. Systems-level interventions, including psychiatric liaison services, crisis stabilization models, discharge coordination programs, and telepsychiatry, demonstrated potential to improve psychiatric throughput and reduce boarding pressures in selected settings.
Conclusions: Pediatric psychiatric boarding and inpatient psychiatric access strain appear to reflect interconnected structural, operational, workforce, financial, and policy-related limitations within pediatric behavioral health systems. Existing literature suggests that emergency departments and medical units increasingly function as de facto psychiatric care environments because of insufficient psychiatric infrastructure. Addressing pediatric psychiatric access strain will likely require coordinated investment in psychiatric capacity, workforce development, behavioral health infrastructure, standardized reporting systems, and operational redesign strategies to improve timely and equitable access to care.