Factors Associated With Police Bringing Children to a Psychiatric Emergency Room

Over the 8-month index period (September 2017 through April 2018), 435 CPEP encounters occurred for 339 children ≤12.9 years; of the total number of CPEP referrals (N=11,447), child encounters constituted 3.8%. Additionally, 22% (N=96) of the 435 encounters during this period were revisits and 28% (N=121) were police arrivals.

Of the 339 children, 103 (30%) had at least one police arrival through March 2020, including 33 (10%) with a single police arrival; 25 (7%) with multiple CPEP encounters, which were all police arrivals; and 45 (13%) with both police and nonpolice arrivals. Of those with only nonpolice arrivals (N=236), 165 (70%) had a single encounter, and 71 (30%) had multiple nonpolice arrivals.

In addition to the 435 CPEP encounters during the index period, the children involved in these encounters had an additional 108 encounters that had occurred before the index period and 214 that occurred after (Table 1). The analysis of factors associated with a first police arrival was based on 548 CPEP encounters, up to and including the first police arrival, spanning the preindex, index, and postindex periods (Table 1).

Table 2 presents descriptive statistics for the full sample, including children with nonpolice arrivals and children with police arrivals. The latter group had significantly more CPEP encounters than children with only nonpolice arrivals. Children were referred to the CPEP by families (60%), school personnel (who either called the police or told parents to take the child to the CPEP) (32%), or a mental health or other medical professional advising that the family take the child to the CPEP (8%).

No significant differences in sex or age were found between children with or without police arrivals. Rates of ever having Medicaid insurance and coming from families without two parents were substantially higher for children with a police arrival than for children with only nonpolice arrivals.

Children who were brought by police showed significantly more aggressive and suicidal behaviors than children who never arrived with police, as evidenced by large statistically significant differences in most of the encounter-level binary measures. Outbursts of verbal and physical aggression or destruction of property were significantly more common in encounters among children with at least one police arrival (71%) than among those with no police arrivals (30%) (OR=5.63). Although most children with outbursts had calmed by the time police responded to the 911 call, according to the police reports, two boys and three girls continued to show aggression in the presence of the police officers. Finally, suicidal behavior, but not suicidal ideation, was more than twice as high among children with any police arrivals (23%) than those with only nonpolice arrivals (10%) (OR=2.56).

Compared with children with only nonpolice arrivals, children with a police arrival were more likely to have had either current or past treatment and to be hospitalized after their CPEP visits (Table 2). Police-arrived children were significantly more likely to have discharge diagnoses of ADHD and oppositional defiant/conduct disorder and were less likely to have a diagnosis of anxiety-related or adjustment disorder. Rates of depression and developmental disorder did not differ significantly between the two groups. Psychotic-like symptoms were rare, with only 13 instances of auditory or visual hallucinations reported; unspecified psychosis was diagnosed once.

Although Black children and Latinx children had significantly more police arrivals than White children and Asian or other children, the initial multilevel logistic regression model (Table 3, model 1) revealed that only Black race, older age, male gender, not living in a two-parent family, and having Medicaid insurance were independently associated with a first police arrival. With the addition of clinical factors (aggression and suicidal behavior severity, model 2) into the analysis, Black race and insurance status were no longer statistically significant factors. Table 4 shows that Black children were most likely to have multiple police arrivals and were least likely to have a two-parent family. Asian children and those from other race-ethnicities (i.e., Indigenous American) were most likely to have a single police arrival and were least likely to use Medicaid, compared with children in the other racial-ethnic groups. Black children were brought to the ER for outbursts or aggression more often than their peers, whereas Asian or other children were more often brought for suicidality.

Table 5 shows that young age at the time of a first police arrival predicted an increased likelihood of a future police arrival (model 1). Although the OR for age in model 2 was similar to that of model 1, age was not statistically significant in model 2 because of multicollinearity with the added variables. Severity of outbursts and aggression, severity of suicidality, and a history of treatment were the strongest predictors of a second police arrival.

In this study, we used police arrival data from the only psychiatric ER setting for children in the United States for which data were available at the time, finding that 28% of CPEP arrivals were brought in by police in response to a 911 call. This rate is higher than those reported in studies conducted in New York City and Michigan (9, 10), even for revisits (18%–19%). It is unclear whether this difference represents variation in police practices, samples, 911 call use, or treatment options. Moreover, comparison with previous literature is difficult because of disparate study goals; only one study of children and adolescents examined police arrivals (8). In other studies, aggressive behavior was not addressed in the clinical information examined (10, 17), settings included both inner cities and other environments (8–10), study periods ranged from the 1990s (8) to recent years (9, 10), and sample ages ranged from children (10) to adolescents (8, 10). Finally, police arrival data from studies of adults entail very different developmental considerations (e.g., parents and schools are not usually involved in arrivals) and diagnostic characteristics (e.g., intoxication, psychosis, disorientation, and involuntary commitment) (3–7).

The children in this study who arrived at the CPEP with police one or more times showed highly dysregulated behaviors and represented a socially marginalized group. Consistent with some of our hypotheses, important demographic correlates were Black race, Medicaid insurance, not living in a two-parent home, male sex, and older age. These associations were statistically significant before the clinical variables were added to the model. However, the clinical variables appeared to account for differences in police versus nonpolice arrivals and were associated with both first and subsequent police arrivals. This was especially true for aggressive outbursts, which prompted more police calls among Black families, who were more likely than families of other race-ethnicities to have the aforementioned demographic characteristics. In this sample, suicidality was a less common reason for police encounters than were aggressive outbursts, with suicidal behavior but not ideation differentiating police arrivals from nonpolice arrivals.

Although lack of previous treatment is often associated with excessive ER use (14, 17–19), treatment history was not significantly associated with a first police arrival. Of note, treatment, including hospitalization, at the time of the first police arrival significantly predicted an increased likelihood of a second police arrival. Treatment and medication use have also been associated with repeat ER use (9, 10). We surmise that police might be called, possibly on the recommendation of treatment providers, because families, schools, and residential programs lack other viable options and do not know what else to do.

Unlike in adult samples (3–7), psychosis, intoxication, and severe mood disorder were rare to absent in our sample of children. The diagnosis of ADHD, however, was made for 43% (N=146) of the children, and more often for Black children (N=42, 66%) than for White (N=80, 43%), Latinx (N=24, 29%), or Asian or other youths (N=0) (Table 4). ADHD is a common diagnosis among children with aggressive outbursts, and several recent studies have highlighted the importance of emotion dysregulation and impulsivity in this disorder (20–24). Moreover, higher temper outburst scores and levels of aggression among children with ADHD appear to be linked to their ADHD symptoms rather than to their mood symptoms (22). Detection of ADHD alone or in addition to other behavior disorders has important therapeutic implications, because adequate ADHD treatment significantly reduces aggression (23). Perhaps the child and adolescent psychiatrists in this CPEP, who were preferentially dispatched to see young referrals, were attentive to making a treatable diagnosis regardless of the patient’s race-ethnicity. By contrast, other studies report that ADHD is underdiagnosed in Black patients (24–26).

This study included a review of records of police arrivals in one suburban, university-based CPEP/psychiatric ER, and thus, generalizability of its findings is limited. However, no other comparable studies with samples of children are available. Although many studies have investigated pediatric ER referrals (17), they do not describe police involvement or do not ascertain presence of aggressive behavior (10, 17).

Socioeconomic information was limited in this study. Aggression and suicide severity were assessed after the fact on the basis of the extent of aggressive behavior (verbal and physical as well as destruction of property) or suicidality (verbal or behavioral) reported in the psychiatric intake history and police reports. On the other hand, as noted above, many studies have not acknowledged outbursts and aggressive behavior, focusing only on suicidality (10, 17). The lack of a consistent method of identifying outbursts and aggressive behavior limits gathering of data on this factor (12). Since this study was completed, the American Psychiatric Association’s DSM-5 committee has recently approved the use of an R code, R45.89, to be used for impairing emotional outbursts. We hope that this designation will improve data gathering in the future if clinicians use this code for children with outbursts.

Although study raters were blind to participants’ race-ethnicities, the clinicians in CPEP writing the notes were not. It is possible that implicit bias in the information was recorded in the context of police involvement. Similarly, recording of greater aggressiveness in the EMR may be used to justify police involvement. However, convergence of multiple sources of information, the greater frequency of CPEP revisits, and higher rates of hospitalization suggest that levels of behavioral severity were valid.We did not know the frequency of instances in which police were called but no ER referral was made, because local precincts did not have these data. Racial-ethnic and other biases may have influenced how police managed these situations.

This study describes the characteristics of children with outbursts of aggression and suicidal behavior that prompt families, school systems, and providers (12) to call the police, setting in motion a cascade of inpatient and outpatient treatments. In half of police arrivals to the CPEP, the treatment did not prevent a subsequent police arrival. Involving police adds an additional layer of risk for Black children, because previous research has shown that police interaction yields particularly poor health outcomes for this population (27).

Our data are consistent with reports of serious behavioral health crises among children and adolescents that are often not adequately addressed by ERs, inpatient units, and outpatient treatment. These crises thus lead to law enforcement referrals that are used disproportionately for individuals who are marginalized and publicly insured (9, 14, 15, 18, 19).

The National Suicide Hotline Designation Act of 2020, which established a dedicated crisis telephone number (988), could provide an immediate response to psychiatric emergencies, obviating the initial need for police involvement. Hoover and Bostic (28) further recommend school-based and community crisis response services, specific child and adolescent training for the 988 initiative, and development of programs for emergency psychiatric response technicians that include specialized training to help families and schools better manage mental health emergencies in the community. In addition, outbursts of aggression and suicidal behavior are often chronic problems, judging by treatment recidivism (14, 19–21, 29). These problems need better identification and sustained, effective, and long-term interventions with particular attention to underserved youths and families (30–33). We submit that these interventions are best designed by child mental health experts who have the skills to address the clinical and psychosocial factors leading to psychiatric emergency visits by children (34).

The authors thank Jessalyn Cruz, L.M.S.W., Romil Sareen, M.D., Satya Vatti, M.D., Caroline Wang, B.A., Laura Andreski, D.O., Ingrid Chen, M.D., Megan Desai, D.O., and Jessica Carbajal-Caceda, M.D., for skilled rating of medical records.