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In Limbo

May 28, 2021
by Sarah Barbara Abdallah and Jelena MacLeod

Dr. Abdallah: In late summer of 2020, as a pediatric intern in the The Solnit Integrated Training Program, I spent a month working with the child psychiatry consult liaison team that serves patients on the pediatric wards at Yale New Haven Children’s Hospital. Our supervising physician commented on an uptick in recent eating disorder cases, which she attributed to the stressors of the pandemic. At that time, we had two patients with eating disorders on our list.

By the time I switched to working in the pediatric emergency department (ED) in November, that uptick had grown in magnitude and became more apparent in other psychiatric presentations, namely suicide attempts. The number of children warranting psychiatric admission was consistently exceeding the number of available inpatient psychiatric beds. For days at a time, ten or more children sat in ED rooms waiting for an opening on one of the at-capacity inpatient psychiatric units. Some ED staff called the back hallway where many of them waited “Mini Wini” after the Winchester 1 child psychiatry inpatient unit.

Soon the backlog spilled onto the pediatric wards. Without the usual volume of winter respiratory cases, the floors could accept children with psychiatric presentations who initially required medical care and clearance. This group was mostly comprised of patients struggling with eating disorders and those with suicide attempts by toxic ingestion. Once these patients were medically cleared, it took days to weeks before a bed opened up on a psychiatric floor or eating recovery facility. They waited on the pediatrics wards in limbo, unable to move on to the next phase of treatment and too sick to safely go home.

The safety risk posed by their diseases meant that under the standard model of care, these patients required regular one-on-one monitoring. Over the course of my February pediatrics wards rotation, I watched nurses struggle to find enough sitters, often having to fill the role themselves for a half-hour at a time. I also watched my psychiatry colleagues on the child psychiatry consult-liaison service speeding around the wards with triple the usual census.

Drs. Abdallah & MacLeod: COVID-19’s toll on pediatric mental health is only beginning to manifest. Causes are multifactorial, ranging from decreased social connectedness to increased risk for domestic violence and child abuse.1-2 Preliminary studies have shown an overall increase in suicidality, substance use, and eating disorders among children, adolescents, and young adults since the start of the pandemic.3-5 Of particular concern, children and adolescents who already belong to disadvantaged and marginalized groups, whether due to race, socioeconomic status, preexisting mental health conditions, or any number of other factors, are disproportionally affected.1,6

There are several sorely needed systems-level changes that would allow for more prompt, appropriate and multifaceted care in this complex new landscape. Among them are funding to increase inpatient and outpatient capacity for children and adolescents seeking mental health services, med-psych units in pediatric hospitals that allow for simultaneous treatment of physical and mental health co-morbidities, and optimization of telehealth psychiatry to allow for broader access to treatment across pediatric settings.

In the meantime, pediatricians can play a pivotal role in supporting children and adolescents who are awaiting psychiatric services. While there is no perfect way to handle these impossible scenarios, engaging family members and encouraging social support is known to promote resilience in the face of acute and chronic stress.7 Validation, a smile, and a listening ear can go a long way towards promoting healing. Most importantly, providers must exercise self-compassion and maintain realistic expectations of their work in a non-psychiatric setting. It can be discouraging to observe patients in clinical limbo, without having the resources to address their primary illness. But helping children survive limbo, both physically and psychologically, while preserving their hope for the recovery ahead is a clinical win.

Further resources for families on helping children cope and adolescents with the COVID-19 pandemic can be found at the American Academy of Child & Adolescent Physiatry website.


Sarah Abdallah, MD, grew up in Ann Arbor, MI, as the oldest of four siblings in a lively Lebanese-American family. She moved to New Haven to attend college at Yale and hasn’t left since, although she is still a Midwesterner at heart! In college, she double-majored in Molecular Biology and Psychology, and along the way she discovered her passion for human genetics. Her longstanding research interest is in applying experimental and computational genomics approaches to better understand the etiologies of complex neuropsychiatric disorders. As a medical student at Yale, she spent one year as an HHMI-ASHG research fellow in the Fernandez lab, where she has since continued her work to identify genes and genetic variants that contribute to OCD. She is excited to train as a resident in the Albert J. Solnit Integrated Adult/Child Psychiatry/Research program and to keep working with the awesome people at the Child Study Center. Outside of medicine, she enjoys running, traveling and competing with the Yale grad touch rugby team, and working on various art and film projects.

Jelena MacLeod, MD, MHS, is a Clinical Fellow in the Albert J. Solnit Integrated Adult/Child Psychiatry/Research program. She is originally from Zagreb, Croatia, and has lived in Belgium as well as the Washington, D.C. area. At the Johns Hopkins School of Public Health, her master’s thesis explored the public health potential of incorporating epigenetics into our understanding of trauma, stress, and PTSD. She subsequently studied neuroendocrinological and behavioral correlates of pediatric anxiety disorders as a postgraduate at the Yale Child Study Center. During her time at the University of Connecticut School of Medicine, she founded and developed a Peer Support program to train medical students in basic mental health counseling skills. Her current work focuses on the optimization of mental health screening in pediatric primary care through systems design, healthcare data mining, and implementation science.



Submitted by Alexa Tomassi on May 28, 2021