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Where pediatric hospital boarding lands: Black foster youth

Black Health Editorial team
8 min read

Evidence-based

Written by the Black Health editorial team. Last updated . How we source.

Empty hospital corridor at night with treatment-bay doors lining both sides, an EXIT sign overhead, a parked medical cart, and a wheelchair in the distance; fluorescent strip lighting casts a dim blue-green glow down the hallway.
Empty hospital corridor at night with treatment-bay doors lining both sides, an EXIT sign overhead, a parked medical cart, and a wheelchair in the distance; fluorescent strip lighting casts a dim blue-green glow down the hallway. Photo: Sandy Torchon / Pexels
KFF Health News documented children boarding in hospitals long after they were cleared for discharge. The peer-reviewed literature names which children carry the heaviest exposure.

Missouri's Department of Social Services reimbursed $16.3 million to 19 hospitals for 9,943 days of pediatric boarding last fiscal year, more than $1,600 a night, according to KFF Health News reporter Cara Anthony's May 18 piece. Illinois's child welfare agency logged 304 cases of youth held in psychiatric hospitals beyond medical necessity in its last fiscal year, with roughly 43% in the 13-to-16 age band. In Minnesota, per-day boarding for a child with a complex medical condition cost $3,932 in 2017, the most recent figure Anthony cites for that state.

Anthony's piece names what the practice costs taxpayers and what it costs the families. Her case study centers on a mother identified only as Quette, whose teenage son was paralyzed in a 2023 shooting and spent months at a St. Louis children's hospital after being medically cleared. He remains in state custody. The reporting does not break out boarding patients by race because state agency tallies do not stratify the boarding population that way. The peer-reviewed literature does.

Three peer-reviewed numbers KFF's reporting does not name

A 2024 JAMA Pediatrics cohort of 4,942 pediatric psychiatric boarding episodes across Massachusetts hospitals between May 2020 and June 2022 found that Black youth waiting for an inpatient psychiatric bed were admitted to inpatient care at 51% versus 56% for White youth (Overhage et al., PMID 38976283). That is a 5-point absolute admission gap. The remainder of Black boarding episodes ended with some disposition other than inpatient psychiatric care, even after the child was medically cleared to leave the emergency department.

A 2025 Hospital Pediatrics single-site analysis of 683 Behavioral Emergency Response Team activations at a US children's hospital between 2018 and 2020 found that Black pediatric inpatients had 2.1 times the adjusted odds of a BERT call relative to non-Black peers, with the 95% confidence interval running 1.6 to 2.8 (Peterson et al., PMID 40122110, P<.001). The model adjusted for insurance status and mental-health diagnosis. The authors note that BERT activation reflects staff clinical judgment, which is the disparity-mediating variable in the cohort. Insurance overlapped with race; the adjustment isolates the race effect partially, not completely.

A 2026 JAMA Network Open cohort of 1,572 pediatric mental-health encounters at Mayo Clinic Rochester's emergency department between 2021 and 2024 found that children with a history of out-of-home placement, which includes foster care, group homes, and residential treatment, spent 24% longer in the ED than peers without that history, with the 95% confidence interval running 12% to 36% (Kelly et al., PMID 41575744). Kelly's cohort did not publish a Black-specific subgroup. A 2025 JAACAP Open scoping review by Mroczkowski and colleagues explicitly named child-welfare-involved youth as a published-disparity-data gap (PMID 40109489).

Foster overrepresentation feeds the boarding population

Black children represent 22% of US foster-care entrants and 14% of the US child population, according to AFCARS 2023 data carried in the Annie E. Casey Foundation KIDS COUNT Data Center and last updated November 2, 2025. The total US foster-care population in 2023 was 360,531. That is a 1.6-fold over-representation of Black children in the population from which placement history accrues.

Read together, AFCARS and Kelly compose into one statement. AFCARS establishes that Black children are over-represented among youth with an out-of-home-placement history. Kelly's 2026 cohort establishes that placement history adds 24% to ED length of stay among youth presenting for mental-health care. Combined, they say Black children are disproportionately represented in the population for whom hospital boarding lasts longer, before any race-stratified analysis of placement-history youth is ever published. The two findings come from independent cohorts, and the structural argument that links them rests on triangulation rather than on a single race-stratified placement-cohort paper. That gap in the published literature is real.

What happens inside a boarding episode then layers onto that exposure. Peterson 2025 documents that staff are more likely to call a behavioral-emergency team on Black pediatric inpatients during a stay. Overhage 2024 documents that when boarding ends, Black youth are admitted to inpatient psychiatric care at a lower rate than White peers. Tyler Rainer and colleagues, writing in Hospital Pediatrics in 2023, named adultification bias and trauma misdiagnosis as the proximate clinical mechanisms in a case-narrative paper centered on a Black first-grader's repeated pediatric ED boarding (PMID 37066672). The clinical pattern that produces lower inpatient-psychiatric admissions and higher behavioral-emergency activations is the same clinical pattern Rainer documented at the case level.

The Rainer team defined adultification bias as the clinical tendency to read Black youth behavior as fixed-pattern conduct disturbance rather than as normative reactions to trauma or other adverse childhood experiences. The case child Rainer presents carried documented exposure to poverty, domestic violence, and Child Protective Services involvement; the clinical teams treating her used involuntary emergency medications, physical restraints, and hospital security at the bedside during repeated ED boarding episodes that began in first grade. Trauma misdiagnosis, in the Rainer framework, is the second mechanism: presenting behavior generated by an adverse-experience exposure ends up coded as a fixed-pattern behavioral diagnosis rather than as a trauma response. Both mechanisms operate before disposition. By the time Overhage's data records a Black-vs-White admission gap, the clinical chart has already named the wrong cause for the presenting behavior.

A separate 2025 Pediatrics scoping review by Efrem and colleagues reported that 43 of 50 reviewed studies, or 86%, found that racially marginalized pediatric patients experienced unequal treatment in emergency departments versus their non-Hispanic White peers (PMID 40628405). The boarding literature sits inside that broader pattern.

Five questions to put to the care team

Parents, guardians, and court-appointed advocates for a Black child who is boarding in a pediatric ED after medical clearance can put the following to the attending team and the hospital social worker:

  1. Is my child being boarded waiting for an inpatient psychiatric bed, a community-based placement, or a foster placement? Which is the disposition goal, who owns the timeline, and what is the documented hour-by-hour benchmark for transfer?
  2. Has a Behavioral Emergency Response Team alert been activated during this boarding stay? If so, what triggered it, who decided to call it, and is there a written de-escalation plan in the chart that the family and the case manager have seen?
  3. If my child is in foster care or has placement history, who is the assigned child-welfare case manager, what is the backup contact when they are unavailable, and who is the hospital's child-welfare-liaison social worker?
  4. What is the discharge plan if no inpatient bed opens up in the next 24, 48, and 72 hours? What is the alternative disposition under each scenario and which one has the team prepared paperwork for?
  5. If the hospital is reporting daily costs to the state, who is paying for this stay, and is my child's placement status affecting where the bill goes or how long they wait?

You can search for Black-serving child and adolescent mental health providers in your area on the blackhealth.org provider directory. Federal accountability data on foster-care entrants and exits by race is public at the AECF KIDS COUNT Data Center and the HHS Administration for Children and Families Children's Bureau. State child-welfare ombuds offices exist in most states and can receive complaints about extended hospital boarding when the placement system is the obstacle.

Citations

Medical Disclaimer

This content is for informational and educational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about a medical condition.

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