A young boy lays in a hospital bed, looking over to their left.
Research and Breakthroughs

Children With Behavioral Disorders Most Frequently Return to the Emergency Room for Mental Health Care

Parents have few alternatives for children in crisis when mental health care is lacking.

Families who lack access to mental health care services often must bring children in a crisis to the emergency room.

“The emergency room may not always be the best place for kids with mental health emergencies, but they don’t have anywhere else to go,” says Anna M. Cushing, MD, a Pediatric Emergency Medicine Fellow at Children’s Hospital Los Angeles. “Children with mental health emergencies often stay in emergency rooms for hours or even days while they wait for space in a dedicated psychiatric facility.”

To better understand which children are most likely to use the emergency room for mental health services and who is most likely to make repeat visits, a CHLA research team led by Dr. Cushing conducted a multisite, retrospective cohort study of 38 pediatric hospital emergency rooms across the nation. The study, which included over 200,000 pediatric patients between 3 to 17 years old who visited the emergency room because of mental health issues from 2015 to 2020, was published in the journal JAMA Pediatrics.

The team found that mental health visits to the emergency room had increased overall by about 8% a year, and revisits by 6%, compared with a 1.5% increase in visits for other conditions.  Many of the mental health emergency room revisits were within six months of the initial visit. “When kids come back to the emergency department multiple times for mental health reasons, it is a sign that we, as a healthcare system, are not giving them adequate care,” says Dr. Cushing. Previous studies also showed a national increase in pediatric mental health emergency department visits, likely due to both worsening mental health in children and limited availability of outpatient pediatric mental health providers.

Children with behavioral disorders revisited the most

The CHLA team found a surprising pattern. The kids at highest risk of returning to the emergency room within 6 months were not children who were depressed and suicidal or self-harmed or had substance use disorders – the most common diagnoses resulting in revisits were children with behavioral disturbances. Children with psychotic disorders were 42% more likely to revisit the emergency room; children with disruptive behavior or impulse control disorders 36% more likely, and those with neurodevelopmental disorders 22% more likely to come back compared with the children who had depression, suicidal thoughts or who harmed themselves.

“While suicidality and self-harm have been the focus of the national conversation on pediatric mental health, our research points to the challenges of a different problem – managing kids who have behavioral dysregulation,” says Dr. Cushing. “Studies like ours show that we need to broaden our focus and keep patients with other types of mental health disorders in mind when creating hospital interventions and making policy decisions.”

While mental health patients comprise only 4% of overall emergency room visits, Dr. Cushing noted that these patients may require one-on-one observation and generally spend more time in the emergency room, which impacts workflow and the capacity to care for other patients. “Patients with behavioral outbursts in the ED are considered code situations, meaning that they require a physician and a specialized behavioral response team to try to help them calm down and to order emergency medications if needed,” she says.

Some factors that can increase the chance that a child is brought to the emergency room for mental health treatment include the type of condition, if drugs are used to restrain behavior, if families have public, instead of private insurance, and if an inpatient psychiatric unit is available at the hospital.

“What’s important about this paper is that we looked at emergency department revisits on a national scale,” says Dr. Cushing. “It’s the first step in understanding the scope of the problem. Targeted interventions for these patients during their first visit would ideally improve their longer-term outcomes and prevent them from having to come back to the emergency department.” Additionally, she notes that solutions such as training more general pediatricians to manage mental health conditions or building mobile crisis units/centers in high-risk communities may help divert mental health patients from overburdened emergency rooms.

Additional authors on the study include: Danica B. Liberman, Ara Festekjian, Todd P. Chang, Pradip P. Chaudhari, of the Division of Emergency and Transport Medicine at Children’s Hospital Los Angeles and the Keck School of Medicine of USC, Phung K. Pham, of the Division of Emergency and Transport Medicine at Children’s Hospital Los Angeles; and Kenneth A. Michelson of the Division of Emergency Medicine at Boston Children’s Hospital.

Learn more about the Division of Emergency and Transport Medicine.