ObjectivesPediatric emergency department (ED) mental health visits are increasing in the United States. At the same time, child/adolescent psychiatric services are limited. This study examines the trajectory of pediatric patients presenting with mental health emergencies to better understand availability of specialty care resources in regional networks.MethodsThis retrospective cohort study used a California Office of Statewide Health Planning and Development linked ED and Inpatient Discharge Dataset (2005–2015) to study pediatric patients (5–17 years) who presented to an ED with a primary mental health diagnosis. Outcomes were disposition: discharge, admission, or transfer.Patients transferred were further analyzed for disposition. Regression models to identify characteristics associated with disposition were created.ResultsThere were 384,339 pediatric patients presented for a primary mental health emergency from 2005 to 2015; 287,997 were discharged, 17,564 were admitted, and 78,725 were transferred. Among those not discharged, patients with public (odds ratio [OR], 1.28; P < 0.01) or self-pay insurance (OR, 5.64; P < 0.01), Black (OR, 2.15; P < 0.01), or Native American race (OR, 2.32; P < 0.01), and who presented to rural EDs (OR, 3.10; P < 0.01), nonteaching hospitals (OR, 3.06; P < 0.01), or hospitals in counties without dedicated child/adolescent psychiatric beds (OR, 5.59; P < 0.01) had higher odds of transfer.Among those not discharged from the second hospital, Black patients (OR, 2.47; P < 0.03) and those who were transferred to a teaching hospital (OR, 1.9; P < 0.01) had higher odds of second transfer.ConclusionsPediatric patients with mental health emergencies experience different trajectories of care. Transfer protocols and regionalized networks may help streamline services and decrease inefficiencies in care.