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Aim: Paediatric emergency departments (ED) nationwide experience a shared burden of boarding mental health patients. Whilst boarding, some patients have a change in disposition from hospitalization to discharge home. This phenomenon raises concern because EDs often have scarce resources for mental health patients. We sought to understand which patient and clinical factors are associated with a change in disposition outcome. Methods: A nested age‐sex‐race frequency‐matched case–control study was conducted including paediatric patients who presented to an urban PED for mental healthcare over a 36‐month period. Control patients included patients admitted to an inpatient psychiatric facility, whilst case patients were those discharged home. Descriptive statistics and multivariable logistic regression analyses were performed to compare groups. Results: Case patients were more likely to receive intramuscular Haloperidol (OR 2.2 [CI 1.1–4.4]) for agitation and a psychiatric consult (OR 2.3 [1.4–3.9]) whilst boarding. Case patients were also more likely to present with behavioural concerns (OR 1.8 [CI 1.1–3.1]) and have additional complexities such as medical comorbidities (OR 1.8 [CI 1.1–2.9]) or suicidal ideation/attempt (OR 2.6 [CI 1.1–6.1]). Amongst the most common themes for disposition change was improved patient status (58.8%). Conclusion: These findings suggest that boarding mental health patients have different disposition outcomes and thus may benefit from patient‐specific treatment interventions. Given that patients' statuses may change during the boarding period prompting discharge to home, more focus should be directed to developing brief evidence‐based practises that may be implemented in the ED and effectively bridge the gap to outpatient mental health services. [ABSTRACT FROM AUTHOR]