Race, Neighborhood Disadvantage, and Prehospital Law Enforcement Handcuffing in Children With Behavioral Health Emergencies

ImportanceMinoritized youth and children in resource-limited neighborhoods rely on emergency medical services (EMS) for accessing care, including during behavioral health emergencies (BHEs). Law enforcement (LE) officers sometimes use forceful tactics in such settings. Assessing LE actions is needed to ensure safe and equitable care for vulnerable populations. ObjectiveTo examine whether race and ethnicity, neighborhood disadvantage, sex, and age are associated with LE handcuffing during pediatric BHEs. Design, Setting, and ParticipantsThis cross-sectional study analyzed LE handcuffing, demographic factors, and neighborhood disadvantage in Alameda County, California. The study population included children younger than 18 years who were evaluated by EMS for BHEs between January 1, 2012, and June 30, 2019. Data analysis was completed between January 1, 2022, and August 30, 2023. ExposuresPrimary exposures included race and ethnicity and Area Deprivation Index (ADI) rank as ADI I (1-3 [lowest]), ADI II (4-6 [moderate]), and ADI III (7-10 [highest]). Main Outcome and MeasureThe primary outcome was LE handcuffing during BHEs. The study calculated handcuffing proportions stratified by race and ethnicity, ADI, and sex. ResultsThe final dataset consisted of 6759 pediatric BHE encounters with complete data. Among these, 3864 encounters (57.2%) were with females. The median age was 14.9 (IQR, 13.4-16.2) years. Overall, LE handcuffing occurred in 517 encounters (7.6%); Black children had higher odds than their White peers (adjusted odds ratio [AOR], 1.80; 95% CI, 1.39-2.33). Compared with low neighborhood disadvantage, moderate neighborhood disadvantage was independently associated with increased odds of handcuffing (ADI II: AOR, 1.51; 95% CI, 1.21-1.88), as was highest neighborhood disadvantage (ADI III: AOR, 1.54; 95% CI, 1.19-1.99). Male sex (AOR, 2.31; 95% CI, 1.91-2.79) and age (AOR per 1-year increase, 1.15; 95% CI, 1.10-1.21) were also associated with increased odds of handcuffing. In moderately disadvantaged neighborhoods, the odds were higher for Black children (AOR, 2.52; 95% CI, 1.65-3.86). When stratified by sex, the odds of handcuffing were significantly higher for Black females compared with White females (AOR, 2.59; 95% CI, 1.69-3.98). Conclusions and RelevanceThe findings of this cross-sectional study suggest that accessing EMS for BHEs may expose Black children and youth in disadvantaged neighborhoods to LE use of handcuffing. Emergency medical services should reconsider the role of LE officers in these settings.