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OBJECTIVES: Emergency department (ED) utilization by children with mental and behavioral health (MBH) conditions is increasing. During these visits, pharmacologic restraint may be used to manage acute agitation. Factors associated with pharmacologic restraint use are not well described. METHODS: This was a retrospective cohort study of ED visits from the Pediatric Health Information System database, 2010-2020. We included visits by children 3-21 years with a primary MBH diagnosis and identified visits with pharmacologic restraint. Regression models were used to analyze the association between patient- and hospital-level factors and restraint. RESULTS: Of 545 800 ED MBH visits over the study period, 22 194 visits (4.1%) involved pharmacologic restraint use. In multivariable analysis, restraint was associated with ages 18-21 years (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.59-2.22), male sex (OR, 1.25; 95% CI, 1.16-1.34), Black race (OR, 1.22; 95% CI, 1.09-1.35), visits starting overnight (OR, 1.68; 95% CI, 1.45-1.96), or the weekend (OR, 1.26; 95% CI, 1.22-1.30), and repeat ED visits (OR, 1.31; 95% CI, 1.17-1.47). Every 100-visit increase in average annual MBH volume was associated with a 0.09% decrease in restraint (95% CI, -0.15 to -0.04) with no significant association between average annual ED volume and restraint (95% CI, -0.25 to 0.25). CONCLUSIONS: For children in the ED with MBH conditions, ages 18-21 years, male sex, Black race, visits starting overnight or the weekend, and repeat ED visits were associated with pharmacologic restraint. These results can inform strategies to reduce restraint use and ensure safe and equitable ED care. [ABSTRACT FROM AUTHOR]