Several factors contribute to the decision to discharge a child with a mental or behavioral complaint from the ED versus admission for inpatient psychiatric care. Key factors associated with difficulty in safe ED discharge as well as predictors of ED revisit include: impulse control issues; neuro-developmental disorders; acute suicidality or psychomotor agitation; anxiety; mood disruption; and drug or alcohol intoxication.^13,14

In addition to this, patients are more likely to make a return visit to the ED if they did not have a mental-health follow-up within 30 days of the initial ED visit, although less than 50 percent of children with mental-health concerns do not receive proper mental-health follow-up within 30 days.¹⁵

Discharge planning for low-risk children during the ED visit is critically important, as evidence suggests that children who were not given a specific follow-up appointment with a mental-health professional were more likely to have an ED revisit within three months.¹⁶

In addition to providing timely followup, access to therapeutic interventions such as the Stanley Brown Safety Plan, lethal-means counseling education, and interventions help patients and families learn to identify triggers and coping skills so they can feel more knowledgeable, safe, and empowered to seek help when needed.^17,18 The Emergency Medical Services for Children Innovation and Improvement Center, funded by the Health Resources and Services Administration in collaboration with several professional societies including ACEP, has developed a series of resources for care of children with suicidality and agitation through its Pediatric Education and Advocacy Kits.^19,20

For children who are not deemed to be at low risk and who require inpatient care, the ED often serves as the boarding site, as the number of available inpatient pediatric psychiatric beds are far fewer than the number of children needing them. This results in ED beds and staff being allocated to mental-health boarding, which affects ED staffing and throughput. These children sometimes spend days and weeks in the ED, and their treatment needs (medications and therapeutic engagement) and daily activity needs such as food, hygiene, and entertainment must be met.²¹

However, there are resources, including free online toolkits such as the New England Behavioral Health toolkit developed by the New England Emergency Services for Children collaborative, that include a daily schedule template, free activities patients can do in the ED, and a safe-toy purchasing guide for pediatric ED patients who are boarding for a mental and behavioral health crisis.^22,23