Trends and shifting ecologies: Part I.

Ultimately, decreased hospital lengths of stay, endemic shortages of psychiatric hospital beds, lengthy waits for indicated outpatient services, and closing of residential treatment facilities, safe homes, and detention centers have led to what could be viewed as a children's mental health service "de-institutionalization." Only critical shifts in the underlying philosophy, practice, financing, and perceived role of hospital-based child and adolescent psychiatric emergency service will put the pediatric emergency department in a position to keep up with the accelerating service demands.