Jennifer Hoffmann, MD, MS, discusses overtriage and disparities in pediatric behavioral health

In a recent interview with Contemporary Pediatrics, Jennifer Hoffmann, MD, MS, a pediatric emergency medicine physician at Ann & Robert H. Lurie Children’s Hospital of Chicago, detailed the complexities of pediatric behavioral health triage within emergency departments, specifically focusing on the phenomena of overtriage and undertriage.

Overtriage occurs when a patient is assigned a higher priority level than their clinical needs actually require based on the resources used during their visit. Hoffmann noted that in her study, more than half of children presenting with behavioral health symptoms were overtriaged.

This is particularly prevalent among children aged 5 to 9 years, often involving those with autism spectrum disorder. Because these children may have limited communication abilities and express their needs physically or through aggressive behaviors, triage staff may assign higher acuity scores to ensure that they are seen quickly. However, these patients frequently do not require substantial emergency resources, leading to an operational flow that diverts care away from others.

Undertriage represents the opposite risk, occurring when a patient with a serious condition is assigned a low priority score, potentially leading to dangerous wait times, elopement, or behavioral escalation. The study highlighted significant disparities in this area, showing greater odds of undertriage for Hispanic patients, non-Hispanic Black patients, and families with a Spanish language preference.

Hoffmann explained that subjective judgment in high-pressure environments can allow implicit biases—unconscious beliefs or attitudes—to influence clinical decisions. To mitigate this, she recommends staff training on implicit bias to promote conscious thinking, alongside the consistent use of professional medical interpreters to ensure clear communication during the initial assessment.

Hoffmann noted that the Emergency Severity Index (ESI), the standard triage tool in the United States, was largely designed for acute medical and trauma cases and offers limited guidance for behavioral health. Currently, the ESI often defaults to a score of 2 for any patient at risk of self-harm or harming others.

Hoffmann suggests looking toward models such as those used in Australia, which provide concrete “anchors” based on observed behaviors, including acute agitation, suicidal thoughts, or symptoms of paranoia. By establishing more specific indicators, triage can become more objective and equitable. Finally, she noted that while artificial intelligence tools could help standardize this process, they must be carefully validated to ensure they do not reinforce existing health care disparities.

No relevant disclosures.

Reference

Hoffmann JA, Foster AA, Rojas CR, et al. Overtriage and undertriage of children presenting to the emergency department for behavioral health. JAMA Netw Open. 2026;9(3):e263042. doi:10.1001/jamanetworkopen.2026.3042