Study examines rising use of emergency holds for youth in mental health crisis - Children's National

When a child or teenager is experiencing a mental health crisis, an emergency hold can allow authorities to bring the young person to a hospital for evaluation without consent when there is an immediate safety concern. These holds can be essential, but little pediatric research has examined how often they are used or how they may shape a young person's experience in the emergency department.

A new study led by researchers at Children's National helps fill that gap. Published in Pediatrics, the study reviewed 14,883 mental and behavioral health visits to an urban pediatric emergency department from January 2019 through December 2024. Researchers found that emergency holds became more common each year and were associated with longer emergency department stays and greater use of physical restraints.

The big picture

Of the visits studied, 2,219, or 15%, involved a young person who arrived under an emergency hold. Among those visits, 64% involved law enforcement transport, 20% involved a mobile crisis unit and more than 350 involved children aged 6 to 11.

Emergency hold status was associated with several patient and care factors, including Black race, male sex, a mental or behavioral health emergency visit during the previous 12 months, longer time in the emergency department and physical restraint use. The study population was largely Black and publicly insured, reflecting the community served by the hospital.

Physical restraint use also increased over the six-year study period and was associated with arrival under an emergency hold. Mobile crisis involvement, by contrast, was not associated with physical restraint use.

"We found that emergency hold use increased each year during the study period," said Christopher Gable, DO, an emergency medicine physician at Children's National and the study's corresponding author. "These patterns warrant closer examination of how emergency hold decisions are made for children and adolescents."

Why it matters

Emergency departments are an essential safety net for children and adolescents in crisis, particularly when community-based services are unavailable or difficult to access. But an emergency hold may also involve law enforcement contact, loss of control and restrictive care practices during an already difficult experience for young people and families.

The findings raise important questions about equity, crisis response and the use of restraints. They also underscore the need to understand how prehospital decisions and arrival pathways may influence what happens after a child reaches the hospital.

Because the study examined one emergency department, the results may not reflect practices in every hospital or community. The analysis also identifies associations, not cause and effect. It cannot determine whether an emergency hold itself led to restraint use or whether other features of a crisis contributed to both.

Moving crisis care forward

The study provides a starting point for improving how communities respond when children and teenagers need urgent mental health care. Future research should examine whether mobile crisis programs, specialized transportation, earlier outpatient support and other community-based services can help young people reach care safely while minimizing unnecessary detention and restraint.

The goal is not simply to reduce a single intervention. It is to build a crisis system that protects safety, preserves dignity and connects children with appropriate care as early as possible. The researchers call for further evaluation of strategies that reduce restrictive interventions, improve coordination between community and hospital-based services and provide compassionate, equitable and developmentally appropriate care.

Read the full study, Emergency Hold Use in Youth With Mental Health Concerns Presenting to the Emergency Department, in Pediatrics. Additional authors from Children's National include Mickey Emmanuel, MD, Sydney Meszaros, BA, Theresa Ryan Schultz, PhD, MBA, RN, Olivia Miller, PhD, BCBA-D, Monika K. Goyal, MD, MSCE, and Shilpa J. Patel, MD, MPH.