Pediatric Disaster Behavioral Health (PDBH) Toolkit

The pediatric emergency department (ED) is the most disaster-exposed clinical environment in the children’s hospital. It is the de-facto front door for both physically injured and psychologically affected children, the principal site of pediatric care when capacity is exhausted, and the operational interface between bedside care and incident command. Because of this, ED readiness for pediatric disaster behavioral health is a core determinant of hospital-wide response capacity.

Many strategies in the Behavioral Health in Disasters section apply within the ED, including trauma-informed communication, Psychological First Aid, crisis de-escalation, and rapid behavioral health workflows. These should be implemented within the ED with the additional considerations below. For ED telepsychiatry implementation, see the Telehealth section and the Primer on Initiating a Hospital-Based Telepsychiatry Program.

Day-to-Day Readiness

The ED is often the first, and sometimes only, point of contact for youth in behavioral health crisis. Foundational day-to-day capabilities, trained staff, established workflows, validated screeners, and community partnerships are the platform on which disaster readiness is built. Hospitals without these in place have struggled to scale rapidly during an event. 

Common Pitfalls to Avoid

• Treating behavioral health surge as a downstream problem: In non-trauma disasters [Chemical, Biological, Radiological, Nuclear, and Explosive (CBRNE), infectious, mass violence, school-based incidents], behavioral health surges can lead physical surge [e.g., medically unexplained physical symptoms (MUPS)]. EDs that wait for a surge signal to activate surge protocols can be behind.
• Underestimating boarding load: Pediatric BH boarders consume disproportionate ED resources, including 1:1 sitters, prolonged length of stay, and complex disposition. Even a small absolute number of boarders can collapse throughput.
• Overreliance on social work/allied staff: Social work is essential but cannot substitute for embedded surge protocols, strong workflows, and physician-level decision support during surge.
• No surge trigger criteria: Without pre-defined activation thresholds, ED leadership ends up making ad hoc decisions under stress, often too late.
• Unclear interface with HICS: If ED leadership cannot quickly answer “who in incident command needs to know about boarding right now,” the response can suffer.

Disaster Readiness and Activation

During disaster events, EDs become the front line for both physical and psychological trauma. EDs should consider plans to:

• Embed pediatric behavioral health surge protocols into emergency operations plans with pre-defined activation criteria. These should reference both census measures (e.g., number of mental/behavioral health  boarders, MBH-related patients per shift relative to baseline) and qualitative triggers (e.g., mass violence event involving children, school-based incidents). 
• Integrate behavioral health considerations into HICS roles and ED-specific Job Action Sheets. See the Disaster Mental Health Primer for the HICS Mental/Behavioral Health Lead and HICS Behavioral Health Unit Leader Job Action Sheet for specific considerations.
• Establish family and caregiver support workflows, coping resources, and warm handoffs to reduce ED recidivism.
• Pre-designate physical space for behavioral health  surge: dedicated low-stimulation rooms, a defined family-support area, and a plan for converting shareable space (e.g., conference rooms) for caregiver psychological first aid when ED rooms cannot be released.
• Define an information flow from the ED to incident command for BH-relevant indicators (boarder census, restraint events, BH-related ED visits, agitation events).
• See the AAP Management of Children and Youth with Pediatric Behavioral Health Emergencies²⁰  for clinical guidance.
• Pediatric agitation and restraint use predictably increases under surge conditions and is a care quality and safety concern. Ensure pediatric-specific agitation pathways align with Joint Commission guidelines, covering verbal de-escalation, environmental modification, pharmacologic options in order sets with pre-set dosing recommendations, and debriefing after significant agitation or restraint events.

Pediatric Behavioral Health Boarding

Pediatric MBH boarding is both an operational challenge, consuming bed capacity, sitter staffing, and clinician attention, and a clinical challenge, as extended boarding correlates with worsened symptoms, increased restraint use, and reduced therapeutic engagement. EDs should consider:

• Alternative dispositions, including telepsychiatry-supported home discharge with urgent outpatient bridging, regional BH transfer agreements, mobile crisis response, and crisis stabilization unit referrals.
• Surge boarding protocols that pre-authorize converted space, define minimum staffing and safety standards, and address the therapeutic setting (e.g., lighting, noise, access to caregivers, age-appropriate activity, meals).
• Communication guidance for families when boarding is prolonged, including expected timelines, available supports, and how to escalate concerns.

Caregiver Behavioral Health in the ED

Parents and caregivers of acutely affected children are often acutely affected themselves, which influences both the child’s recovery and the family’s capacity to engage with discharge planning. ED workflows rarely accommodate caregiver needs explicitly. Considerations:

• Provide caregiver-facing materials at discharge addressing common reactions, when to seek help, and local resources, in plain language and multiple languages.
• Identify a clear pathway for caregivers requiring more than supportive intervention, including warm handoff to community supports or, when indicated, evaluation in the adult ED.
• Recognize that caregivers may also be patients themselves (injured or exposed) and plan for parallel care that maintains the caregiver-child relationship where possible.

Scalable Planning Based on Facility Size

Volume thresholds below refer to annual pediatric ED visits. They apply to both pediatric EDs and general EDs that see substantial pediatric volume.

• Small EDs (approximate volume <10,000 pediatric visits/year): Focus on foundational training, internal coordination protocols, and referral clarity. Establish transfer agreements with regional pediatric centers in advance. Consider Emergency Department Telepsychiatry (EDTP) partnerships to extend specialty access.
• Medium EDs (approximate volume 10,000–50,000 pediatric visits/year): Build BH surge triggers into ED planning, establish staff cross-training for flexibility, and maintain key partnerships with outpatient MH providers and regional pediatric resources. Develop pediatric-specific agitation pathways and surge boarding protocols.
• Large EDs (approximate volume >50,000 pediatric visits/year): Create dedicated pediatric BH boarding and surge protocols including warm handoff to outpatient providers; serve as a regional resource for smaller facilities; integrate ED telepsychiatry to extend reach; embed BH in HICS planning at the section-chief level.

ED Telepsychiatry