The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies.

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Using Hospital Incident Command Systems to Respond to the Pediatric Mental and Behavioral Health Crisis of the COVID-19 Pandemic.

ABSTRACT: Hospital incident command systems (HICS) were implemented to expand mental and behavioral healthcare (MBHC) services during the COVID-19 pandemic. Data on patient census, nurse vacancies, staff injuries, and staff perceptions were analyzed to quantify issues and track progress toward HICS goals. Data, environment of care, staffing, staff support, staff education, and communication resources were developed. After HICS implementation, 84% of nurses reported confidence in providing care to youth with acute MBHC needs. Nurse leaders should consider HICS for addressing other crises.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies.

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Mental Health Care Following Firearm and Motor Vehicle-related Injuries: Differences Impacting Our Treatment Strategies.

OBJECTIVE: To compare new mental health diagnoses (NMHD) in children after a firearm injury versus following a motor vehicle collision (MVC). BACKGROUND: A knowledge gap exists regarding childhood mental health diagnoses following firearm injuries, notably in comparison to other forms of traumatic injury. METHODS: We utilized Medicaid MarketScan claims (2010-2016) to conduct a matched case-control study of children ages 3 to 17 years. Children with firearm injuries were matched with up to 3 children with MVC injuries. Severity was determined by injury severity score and emergency department disposition. We used multivariable logistic regression to measure the association of acquiring a NMHD diagnosis in the year postinjury after firearm and MVC mechanisms. RESULTS: We matched 1450 children with firearm injuries to 3691 children with MVC injuries. Compared to MVC injuries, children with firearm injuries were more likely to be black, have higher injury severity score, and receive hospital admission from the emergency department ( P <0.001). The adjusted odds ratio (aOR) of NMHD diagnosis was 1.55 [95% confidence interval (95% CI): 1.33-1.80] greater after firearm injuries compared to MVC injuries. The odds of a NMHD were higher among children admitted to the hospital compared to those discharged. The increased odds of NMHD after firearm injuries was driven by increases in substance-related and addictive disorders (aOR: 2.08; 95% CI: 1.63-2.64) and trauma and stressor-related disorders (aOR: 2.07; 95% CI: 1.55-2.76). CONCLUSIONS: Children were found to have 50% increased odds of having a NMHD in the year following a firearm injury as compared to MVC. Programmatic interventions are needed to address children's mental health following firearm injuries.

Career Development in Pediatric Emergency Medicine: What Do We Need?

OBJECTIVES: The Women in Pediatric Emergency Medicine (PEM) subcommittee of the American Academy of Pediatrics Section on Emergency Medicine identified 2 top priorities for 2021: career development and mentorship/sponsorship. The objective of this study was to catalog and delineate the career development domains for women physicians in PEM. METHODS: After a review of the literature to identify the key areas for gaps for women in PEM, we used Q sort methodology to elicit domains for this subcommittee to address by survey of a national sample. RESULTS: One hundred fourteen discrete potential areas of interest for career development were identified by the working group based on salient themes from the literature and personal experiences. Forty-one Women in PEM subcommittee members (27%) completed the survey. The career development topics were sorted into the domains of personal (40.4%; n = 46), administrative (28.1%; n = 32), research (10.5%; n = 12), teaching (10.5%; n = 12), service (7.0%; n = 8), and clinical (3.5%; n = 4). CONCLUSIONS: This study demonstrates that the career development needs of women in PEM include a range of personal, teaching, research, administrative, clinical, and service domains. However, more than two-thirds of the career development topics were categorized into just 2 domains, administrative and personal.

Emergency Department Visits for Suicidal Ideation and Self-Harm in Rural and Urban Youths.

OBJECTIVES: To compare emergency department (ED) visit rates for suicidal ideation and/or self-harm among youth by urban-rural location of residence. STUDY DESIGN: This is a retrospective analysis of ED visits for suicidal ideation and/or self-harm by youths aged 5-19 years (n = 297 640) in the 2016 Nationwide Emergency Department Sample, a representative sample of all US ED visits. We used weighted Poisson generalized linear models to compare population-based visit rates by urban-rural location of patient residence, adjusted for age, sex, and US Census region. For self-harm visits, we compared injury mechanisms by urban-rural location. RESULTS: Among patients with ED visits for suicidal ideation and/or self-harm, the median age was 16 years, 65.9% were female, 15.9% had a rural location of patient residence, and 0.1% resulted in mortality. The adjusted ED visit rate for suicidal ideation/or and self-harm did not differ significantly by urban-rural location. For the subset of visits for self-harm, the adjusted visit rate was significantly higher in small metropolitan (adjusted incidence rate ratio [aIRR], 1.39; 95% CI, 1.01-1.90), micropolitan (aIRR, 1.46; 95% CI, 1.10-1.93), and noncore areas (aIRR, 1.39; 95% CI, 1.03-1.87) compared with large metropolitan areas. When stratified by injury mechanism, ED visit rates for self-inflicted firearm injuries were higher among youths living in rural areas compared with those in urban areas (aIRR, 3.03; 95% CI, 1.32-6.74). CONCLUSIONS: Compared with youths living in urban areas, youths living in rural areas had higher ED visit rates for self-harm, including self-inflicted firearm injuries. Preventive approaches for self-harm based in community and ED settings might help address these differences.

Pharmacologic Restraint Use During Mental Health Visits in Pediatric Emergency Departments.

OBJECTIVES: To evaluate the trends and hospital variation in the use of pharmacologic restraint among pediatric mental health visits in the emergency department (ED). STUDY DESIGN: We examined ED visits with a mental health diagnosis in patients aged 3-21 years at children's hospital EDs from 2009 to 2019. We calculated the frequency of pharmacologic restraint use and determined visit characteristics associated with restraint use. We calculated cumulative percent change for visits with restraints and for all mental health visits. We used logistic regression to test trends over time and evaluate hospital variation in the frequency of restraint use. RESULTS: We identified 389 885 mental health ED visits (54.9% female, median age 14.3 years) and 13 643 (3.5%) visits with pharmacologic restraint use. Characteristics associated with pharmacologic restraint use were late adolescent age (18-21 years), male sex, Black race, non-Latino ethnicity, public insurance, and admission to the hospital (P < .001). During the study period, both mental health ED visits increased by 268% and mental health ED visits with pharmacologic restraint use increased by 370%. The rate of pharmacologic restraint in this patient population remained constant. Hospital use of pharmacologic restraint for mental health visits varied significantly across hospitals (1.6%-11.8%, P < .001). CONCLUSIONS: Pediatric mental health ED visits with and without pharmacologic restraint are increasing over time. In addition, the overall number of pharmacologic restraint use has increased threefold. Significant hospital variation in pharmacologic restraint use signifies an opportunity for standardization of care and restraint reduction.

Pharmacologic Management of Acute Agitation in Youth in the Emergency Department.

ABSTRACT: When youth in the emergency department become acutely agitated, it can be dangerous and distressing to patients, families, and clinicians. Timely, effective, and patient-centered management is key to reducing the potential for patient and staff injury while preserving patient dignity. We review the definition of agitation and pharmacologic management for youth with acute agitation, including common classes of medications, indications for use, and adverse effects. We also discuss the need to integrate the use of medications into a comprehensive strategy for agitation management that begins with proactive prevention of aggressive behavior, creation of a therapeutic treatment environment, and verbal de-escalation strategies.

A Teenager With Acute Anterograde Amnesia.

Isolated amnesia is an uncommon presenting complaint in the pediatric age group. We report the case of an 18-year-old woman who presented with the acute onset of memory difficulty and an otherwise normal neurologic examination. Brain magnetic resonance imaging demonstrated inflammation in the bilateral temporal lobes. Serum and cerebrospinal fluid testing ultimately revealed a diagnosis of autoimmune encephalitis. Although rare, the acute onset of isolated amnesia deserves a prompt, comprehensive evaluation.

Factors associated with boarding and length of stay for pediatric mental health emergency visits.

OBJECTIVE: To determine demographic and clinical risk factors associated with boarding (length of stay ≥24 h) for pediatric mental health emergency department (ED) visits. METHODS: This is a retrospective cross-sectional analysis of mental health visits identified by diagnosis codes for children 5-18 years old presenting to a tertiary pediatric ED in 2016. We performed multivariate logistic regression to identify demographic and clinical factors associated with boarding. RESULTS: There were 1746 mental health visits and 386 (22%) visits had length of stay ≥24 h. In the multivariate logistic regression model, factors associated with boarding included: private insurance (OR 1.59, 95% CI 1.15, 2.19) and having both private and public insurance (OR 1.68, 95% CI 1.16, 2.43) relative to public insurance; presentation during a school month (OR 2.17, 95% CI 1.30, 3.63); physical or chemical restraint use (OR 4.80, 95% CI 2.61, 8.84); comorbid autism or developmental delay (OR 1.82, 95% CI 1.35, 2.46); prior psychiatric hospitalization (OR 2.55, 95% CI 1.93, 3.36); and reasons for presentation of agitation, aggression, or homicidal ideation (OR 2.76, 95% CI 1.40, 5.45), depression, self-injury, or suicidal ideation (OR 2.79, 95% CI 1.45, 5.40), and bipolar, mania, or psychosis (OR 5.78, 95% CI 2.36, 14.09) relative to anxiety. CONCLUSIONS: Insurance status, presentation month, restraint use, autism or developmental delay comorbidity, prior psychiatric hospitalization, and reason for presentation are associated with pediatric mental health ED boarding. Resources should be directed to improve the mental health care system for children with identified risk factors for boarding.

Evaluation and management of suicidal ideation and self-harm in children in the emergency department.

Suicide is a leading cause of death among youth, and the emergency department (ED) serves as the primary point of healthcare contact for many with suicidal ideation. As suicide-related presentations to the ED continue to rise, the implementation of time- and cost-effective care pathways becomes ever more critical. Evidence-based tools for the identification and stratification of suicide risk can aid in clinical decision-making and care linkage. This issue reviews best practices for suicide risk assessment of youth to guide evaluation, management, and disposition planning within the ED setting.

Characteristics of pediatric behavioral health emergencies in the prehospital setting.

OBJECTIVE: Approximately 10% of emergency medical services (EMS) encounters in the United States are behavioral health related, but pediatric behavioral health EMS encounters have not been well characterized. We sought to describe demographic, clinical, and EMS system characteristics of pediatric behavioral health EMS encounters across the United States and to evaluate factors associated with sedative medication administration and physical restraint use during these encounters. METHODS: We conducted a retrospective cross-sectional study of pediatric (<18 years old) behavioral health EMS encounters from 2019 to 2020 using the National Emergency Medical Services Information System. Behavioral health encounters were defined using primary or secondary impression codes. We used multivariable logistic regression to identify factors associated with sedative medication administration and physical restraint use. RESULTS: Of 2,740,271 pediatric EMS encounters, 309,442 (11.3%) were for behavioral health. Of pediatric behavioral health EMS encounters, 85.2% of patients were 12-17 years old, 57.3% of patients were female, and 86.6% of encounters occurred in urban areas. Sedative medications and physical restraints were used in 2.2% and 3.0% of pediatric behavioral health EMS encounters, respectively. Sedative medication use was associated with the presence of developmental, communication, or physical disabilities relative to their absence (adjusted odds ratio [aOR] 3.38, 95% confidence interval [CI] 2.93-3.91) and with encounters in the West relative to the South (aOR 1.23, 95% CI 1.16-1.32). Physical restraint use was associated with encounters by patients 6-11 years old relative to those 12-17 years old (aOR 1.35, 95% CI 1.27-1.44), the West relative to the South (aOR 3.49, 95% CI 3.27-3.72), and private nonhospital EMS systems relative to fire departments (aOR 3.39, 95% CI 3.18-3.61). CONCLUSIONS: Among pediatric prehospital behavioral health EMS encounters, the use of sedative medications and physical restraint varies by demographic, clinical, and EMS system characteristics. Regional variation suggests opportunities may be available to standardize documentation and care practices during pediatric behavioral health EMS encounters.

A Qualitative Assessment of Barriers and Proposed Interventions to Improve Acute Agitation Management for Children With Mental and Behavioral Health Conditions in the Emergency Department.

BACKGROUND: Mental health visits to the emergency department (ED) by children are rising in the United States, and acute agitation during these visits presents safety risks to patients and staff. OBJECTIVE: We sought to assess barriers and strategies for providing high-quality care to children who experience acute agitation in the ED. METHODS: We conducted semistructured interviews with 6 ED physicians, 6 ED nurses, 6 parents, and 6 adolescents at high risk for developing agitation. We asked participants about their experiences with acute agitation care in the ED, barriers and facilitators to providing high-quality care, and proposed interventions. Interviews were coded and analyzed thematically. RESULTS: Participants discussed identifying risk factors for acute agitation, worrying about safety and the risk of injury, feeling moral distress, and shifting the culture toward patient-centered, trauma-informed care. Barriers and facilitators included using a standardized care pathway, identifying environmental barriers and allocating resources, partnering with the family and child, and communicating among team members. Nine interventions were proposed: opening a behavioral observation unit with dedicated staff and space, asking screening questions to identify risk of agitation, creating personalized care plans in the electronic health record, using a standardized agitation severity scale, implementing a behavioral response team, providing safe activities and environmental modifications, improving the handoff process, educating staff, and addressing bias and inequities. CONCLUSIONS: Understanding barriers can inform solutions to improve care for children who experience acute agitation in the ED. The perspectives of families and patients should be considered when designing interventions to improve care.

Improving Documentation of Firearm Access During Pediatric Emergency Visits for Suicidal Ideation.

BACKGROUND AND OBJECTIVES: Approximately half of youth suicides involve firearms. The promotion of safe firearm storage in the home through lethal means counseling reduces suicide risk. We aimed to increase the documentation of firearm access and storage among children presenting to the emergency department (ED) with suicidal ideation or self-injury to 80% within 13 months. METHODS: We conducted a multidisciplinary quality improvement initiative to improve the documentation of firearm access and storage among children <18 years old seen in the ED for suicidal ideation or self-injury. The baseline period was February 2020 to September 2021, and interventions occurred through October 2022. Interventions included adding a templated phrase about firearm access to psychiatric social work consult notes and the subsequent modification of the note to include all firearm storage elements (ie, locked, unloaded, separate from ammunition). Statistical process control and run charts were generated monthly to monitor the documentation of firearm access and storage, which was measured through a review of keyword snippets extracted from note text. RESULTS: We identified 2158 ED encounters for suicidal ideation or self-injury during the baseline and intervention periods. Documentation of firearm access increased from 37.8% to 81.6%, resulting in a centerline shift. Among families who endorsed firearm access, the documentation of firearm storage practices increased from 50.0% to 78.0%, resulting in a centerline shift. CONCLUSIONS: The modification of note templates facilitated increased documentation of firearm access and storage practices for children with suicidal ideation in the ED. Future studies should assess whether improved documentation is associated with improved storage practices and reductions in firearm suicides after ED encounters.

Psychotropic Medication Administration in Pediatric Emergency Departments.

BACKGROUND AND OBJECTIVES: Visits by youth to the emergency department (ED) with mental and behavioral health (MBH) conditions are increasing, yet use of psychotropic medications during visits has not been well described. We aimed to assess changes in psychotropic medication use over time, overall and by medication category, and variation in medication administration across hospitals. METHODS: We conducted a retrospective cross-sectional study of ED encounters by youth aged 3-21 with MBH diagnoses using the Pediatric Health Information System, 2013-2022. Medication categories included psychotherapeutics, stimulants, anticonvulsants, antihistamines, antihypertensives, and other. We constructed regression models to examine trends in use over time, overall and by medication category, and variation by hospital. RESULTS: Of 670 911 ED encounters by youth with a MBH diagnosis, 12.3% had psychotropic medication administered. The percentage of MBH encounters with psychotropic medication administered increased from 7.9% to16.3% from 2013-2022 with the odds of administration increasing each year (odds ratio, 1.09; 95% confidence interval, 1.05-1.13). Use of all medication categories except for antianxiety medications increased significantly over time. The proportion of encounters with psychotropic medication administered ranged from 4.2%-23.1% across hospitals (P < .001). The number of psychotropic medications administered significantly varied from 81 to 792 medications per 1000 MBH encounters across hospitals (P < .001). CONCLUSIONS: Administration of psychotropic medications during MBH ED encounters is increasing over time and varies across hospitals. Inconsistent practice patterns indicate that opportunities are available to standardize ED management of pediatric MBH conditions to enhance quality of care.

Use of Electronic Health Record-Based Measures to Assess Quality of Care for Pediatric Agitation.

OBJECTIVES: Acute agitation during pediatric mental health emergency department (ED) visits presents safety risks to patients and staff. We previously convened multidisciplinary stakeholders who prioritized 20 proposed quality measures for pediatric acute agitation management. Our objectives were to assess feasibility of evaluating performance on these quality measures using electronic health record (EHR) data and to examine performance variation across 3 EDs. METHODS: At a children's hospital and 2 nonchildren's hospitals, we assessed feasibility of evaluating quality measures for pediatric acute agitation management using structured EHR data elements. We retrospectively evaluated measure performance during ED visits by children 5 to 17 years old who presented for a mental health condition, received medication for agitation, or received physical restraints from July 2020 to June 2021. Bivariate and multivariable regression were used to examine measure performance by patient characteristics and hospital. RESULTS: We identified 2785 mental health ED visits, 275 visits with medication given for agitation, and 35 visits with physical restraints. Performance was feasible to measure using EHR data for 10 measures. Nine measures varied by patient characteristics, including 4.87 times higher adjusted odds (95% confidence interval 1.28-18.54) of physical restraint use among children with versus without autism spectrum disorder. Four measures varied by hospital, with physical restraint use varying from 0.5% to 3.3% of mental health ED visits across hospitals. CONCLUSIONS: Quality of care for pediatric acute agitation management was feasible to evaluate using EHR-derived quality measures. Variation in performance across patient characteristics and hospitals highlights opportunities to improve care quality.

Pediatric mental health emergency department visits from 2017 to 2022: A multicenter study.

BACKGROUND: The COVID-19 pandemic adversely affected children's mental health (MH) and changed patterns of MH emergency department (ED) utilization. Our objective was to assess how pediatric MH ED visits during the COVID-19 pandemic differed from expected prepandemic trends. METHODS: We retrospectively studied MH ED visits by children 5 to <18 years old at nine U.S. hospitals participating in the Pediatric Emergency Care Applied Research Network Registry from 2017 to 2022. We described visit length by time period: prepandemic (January 2017-February 2020), early pandemic (March 2020-December 2020), midpandemic (2021), and late pandemic (2022). We estimated expected visit rates from prepandemic data using multivariable Poisson regression models. We calculated rate ratios (RRs) of observed to expected visits per 30 days during each pandemic time period, overall and by sociodemographic and clinical characteristics. RESULTS: We identified 175,979 pediatric MH ED visits. Visit length exceeded 12 h for 7.3% prepandemic, 8.4% early pandemic, 15.0% midpandemic, and 19.2% late pandemic visits. During the early pandemic, observed visits per 30 days decreased relative to expected rates (RR 0.80, 95% confidence interval [CI] 0.78-0.84), were similar to expected rates during the midpandemic (RR 1.01, 95% CI 0.96-1.07), and then decreased below expected rates during the late pandemic (RR 0.92, 95% CI 0.86-0.98). During the late pandemic, visit rates were higher than expected for females (RR 1.10, 95% CI 1.02-1.20) and for bipolar disorders (RR 1.83, 95% CI 1.38-2.75), schizophrenia spectrum disorders (RR 1.55, 95% CI 1.10-2.59), and substance-related and addictive disorders (RR 1.50, 95% CI 1.18-2.05). CONCLUSIONS: During the late pandemic, pediatric MH ED visits decreased below expected rates; however, visits by females and for specific conditions remained elevated, indicating a need for increased attention to these groups. Prolonged ED visit lengths may reflect inadequate availability of MH services.

Race, Ethnicity, Language, and the Treatment of Low-Risk Febrile Infants.

Importance: Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language. Objective: To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection. Design, Setting, and Participants: This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source. Exposures: Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English). Main Outcomes and Measures: The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes. Results: Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46). Conclusions and Relevance: Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.

Disparities in Pharmacologic Restraint Use in Pediatric Emergency Departments.

OBJECTIVES: Emergency department (ED) utilization by children with mental and behavioral health (MBH) conditions is increasing. During these visits, pharmacologic restraint may be used to manage acute agitation. Factors associated with pharmacologic restraint use are not well described. METHODS: This was a retrospective cohort study of ED visits from the Pediatric Health Information System database, 2010-2020. We included visits by children 3-21 years with a primary MBH diagnosis and identified visits with pharmacologic restraint. Regression models were used to analyze the association between patient- and hospital-level factors and restraint. RESULTS: Of 545 800 ED MBH visits over the study period, 22 194 visits (4.1%) involved pharmacologic restraint use. In multivariable analysis, restraint was associated with ages 18-21 years (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.59-2.22), male sex (OR, 1.25; 95% CI, 1.16-1.34), Black race (OR, 1.22; 95% CI, 1.09-1.35), visits starting overnight (OR, 1.68; 95% CI, 1.45-1.96), or the weekend (OR, 1.26; 95% CI, 1.22-1.30), and repeat ED visits (OR, 1.31; 95% CI, 1.17-1.47). Every 100-visit increase in average annual MBH volume was associated with a 0.09% decrease in restraint (95% CI, -0.15 to -0.04) with no significant association between average annual ED volume and restraint (95% CI, -0.25 to 0.25). CONCLUSIONS: For children in the ED with MBH conditions, ages 18-21 years, male sex, Black race, visits starting overnight or the weekend, and repeat ED visits were associated with pharmacologic restraint. These results can inform strategies to reduce restraint use and ensure safe and equitable ED care.