Introduction
Injuries are the leading cause of death and disability among children aged 1 year or older, accounting for more cases than all other diseases combined (1). According to the 2023 Korean Emergency Medical Statistics Annual Report, 27.2% of emergency department (ED) visits among patients aged 19 years or younger were injury-related (2). Pediatric patients are vulnerable to various injuries due to immature risk perception, limited situational judgment, or impulsive behavior (3). Among the injuries, intentional injuries such as self-harm and violence are important contributing factors to pediatric morbidity and mortality (4).
Between 2021 and 2023, approximately 2.8% of pediatric injury-related ED visits involved intentional self-harm, with the number of cases increasing each year (2,5,6). The prevalence of suicidal ideation, planning, or attempts has shown a continuous increase, with a particularly marked rise among girls (7), whereas school violence has been predominantly observed among boys (8-10). Suicide attempts are considered psychiatric emergencies with high lethality and recurrence risks (11). These injuries often extend beyond physical trauma to include serious psychological and social implications, with unpredictable prognoses and the potential for long-term disability, underscoring the need for early intervention and prevention (12).
We aimed to analyze the characteristics of self-harm- or violence-related pediatric injuries, among pediatric patients visiting EDs in Korea, to provide foundational data for the development of effective prevention strategies and policies.
Methods
1. Study population
This retrospective, cross-sectional study utilized data from the 2023 National Emergency Department Information System collected from January 1 through December 31, 2023. In 2023, a total of 8,532,294 visits to EDs of local emergency medical centers or higher-level were recorded nationwide, of which 301,852 were visits by pediatric patients (≤ 18 years) with injuries (Figure). The “injury” was classified based on the “non-disease-related” conditions per the National Emergency Department Information System criteria. Cases with missing or unentered data for any variable were excluded from the analysis. This study was exempt from institutional review board approval by the National Medical Center (IRB no. NMC 2025-07-020).
2. Variables of interest
The variables of interest include: intentionality (self-harm or violence), sex (boys or girls), age group (infants [0-1 years], children [2-11 years], or adolescents [12-18 years]) (13,14), time of visit (00:00-05:59, 06:00-11:59, 12:00-17:59, or 18:00-23:59), route of visit (direct, transfer from another hospital, or outpatient referral), mode of arrival (other vehicles [e.g., cars], firehouse ambulance, walk-in, other ambulances, medical facility ambulance, air ambulance, or public service vehicle), mechanism of injury (fall, slipping, collision, penetrating, machinery-related, burn, drowning, poisoning, asphyxia, traffic-related, or other and unspecified), ED outcomes (discharged home, hospitalization, inter-facility transfer, or death in the ED), the Korean Triage and Acuity Scale (KTAS) level (15), emergency department length of stay (EDLOS; difference between time of discharge and time of arrival), and primary care providers in the ED. The EDLOS was used as an indicator of the appropriateness of initial emergency care. To examine the distribution of patients by the time interval, the variable was categorized into 2-hour increments with reference to the Statistical Yearbook of National Emergency Medical Service (2). The primary care providers were defined as the top 10 most frequent departments responsible for providing the main treatment needed for the patients in the ED.
3. Statistical analysis
Injuries were categorized by intent, and differences between unintentional and intentional injuries were analyzed. Intentional injuries were further subdivided into the self-harm and violence categories. Frequencies and percentages were calculated for statistical comparisons. The chi-square tests or Fisher exact tests were used as appropriate. A P value less than 0.001 was considered significant. All analyses were conducted using R version 4.4.3 (R Foundation for Statistical Computing; https://www.r-project.org/).
Results
1. Characteristics of pediatric injury patients by injury intent
Table 1 shows the characteristics of 301,852 pediatric patients with injuries according to the injury intent. The intentional injuries showed higher proportions of girls, adolescents, visits during 00:00-05:59, visits via firehouse ambulances, injuries by collision, by penetration, or by poisoning, hospitalization, KTAS levels 1-3, an EDLOS of 2 hours or longer, and primary care by psychiatrists, compared to the unintentional injuries. The majority of visits were direct in both groups (95.0% in unintentional, 94.7% in intentional).
2. Characteristics of pediatric patients with intentional injuries
Table 2 lists the characteristics of pediatric patients with intentional injuries according to self-harm and violence. The self-harm injuries showed higher proportions of girls, adolescents, visits during 00:00-05:59 or 06:00-11:59, visits via firehouse ambulances, injuries by fall, penetrating injury, or poisoning, hospitalization or inter-facility transfer, KTAS levels 1-3, an EDLOS of 2 hours or longer, and primary care by psychiatrists as well as by orthopedic surgeons or pediatricians, compared to the violence injuries. In terms of primary care, the violence group was primarily managed by emergency physicians, plastic surgeons, or ophthalmologists. The majority of visits were direct in both groups (94.6% in the violence group, 94.7% in the self-harm group).
Discussion
The study classified pediatric injuries into intentional and unintentional categories, with a primary focus on elucidating the characteristics of intentional injuries. The analysis showed significant differences by age, sex, and injury severity. It is notable that overall intentional and self-harm injuries were more common in girls than in boys. Consistent with the findings from previous hospital-based studies by Bang et al. (11) and Ahn et al. (3).
In boys, higher levels of impulsivity and aggressiveness are often observed, which may increase the likelihood of physical conflicts or violent situations with peers. Moreover, boys frequently display physical strength or resort to direct violence in order to secure status or dominance within peer groups, thereby elevating the risk of injury (16). In contrast, girls demonstrate a greater propensity than boys to internalize psychological distress, and this tendency, characterized by heightened emotional sensitivity together with elevated levels of anxiety and depressive symptoms, may place them at particularly increased risk of engaging in self-harm or suicide (17-19). These findings underscore the importance of integrating sex-specific characteristics into the development of preventive strategies for self-harm among children and adolescents.
Age distribution also showed clear differences, with intentional injuries more frequent among adolescents. Infants and school-aged children were predominantly affected by domestic and accidental injuries. The increase in intentional injuries during adolescence is consistent with previous findings (20).
Notably, among intentional injuries, the severity of self-harm was higher than that of violence, with the majority of intentional injury-related fatalities resulting from self-harm. Prior studies have similarly indicated that both injury severity and mortality increase with age, often linked to heightened risk-taking behaviors during adolescence (20).
Suicide attempts in children and adolescents are alarmingly lethal, accounting for 6% of pediatric injuries with a 50% mortality (21). Suicide remains one of the leading causes of death among children and adolescents worldwide. In Korea, it is the leading cause of death among school-aged youths (4), while in the United States, it ranks as the second most common cause of death among adolescents and adults (21). In cases of self-harm, drug poisoning was the most common mechanism of injury, accounting for 49.8% (Table 2), consistent with the findings of Lee et al. (22). Similarly, Han’s study (23) on pediatric and adolescent poisoning showed a rising trend in adolescent cases, with intentional poisonings being more frequent and often requiring specialized treatment or hospitalization compared to those in children younger than 10 years.
Adolescents frequently visit EDs following suicidal behavior, making it an important point of contact for the early identification of high-risk individuals and for linking them to mental health services and developing preventive strategies (20). The EDs also provide a critical opportunity for screening depression and suicidal ideation (21).
Survivors of self-harm should also be linked to specialized psychiatric care through initial ED management. However, in this study, only 25.2% of these patients received psychiatric care at the EDs (Table 2), indicating the need to strengthen collaborative systems to ensure continuity of mental health care. Pediatric and adolescent patients presenting to EDs after a suicide attempt often remain in a state of severe emotional instability, even after initial medical management. Therefore, it is essential to provide a protected space where these patients can stabilize emotionally for at least 24 hours under the close observation and support of specialized healthcare personnel (19).
In addition, there were over 900 cases of violence among infants and young children, highlighting the need for the establishment of preventive child abuse education programs. Robust post-incident measures, such as mandatory reporting in EDs and the implementation of screening tools like the Finding Instrument for Non-accidental Deeds, must also be integrated into emergency care protocols. Child abuse requires a multidisciplinary approach as it leads to not only emotional disturbances but also adverse impacts on academics, social development, and behavior (24-27).
This study has several limitations that must be acknowledged. First, it was a retrospective study using the administrative data, and thus could not include in-depth clinical factors such as the patients’ psychological conditions, family environments, or school-related issues in relation to the intentional injuries. Second, given that the analysis was based on cross-sectional data, it was difficult to track whether the individuals returned to the EDs or suffered recurrent injuries. Third, since the dataset included only patients who presented to EDs, the study could not capture cases of those who either visited other medical facilities or did not seek medical care at all.
This study focused on pediatric injuries and identified that intentional injuries showed distinct differences according to sex, age, and other related variables. These findings emphasize that EDs serve not merely as places for the treatment of physical trauma but as crucial points of early recognition and intervention for intentional injuries such as self-harm, suicide, or abuse among children and adolescents. Therefore, it represents a key setting for the early identification of high-risk individuals and timely linkage to appropriate mental health services. For patients presenting with self-harm or suicide attempts, it is essential to obtain standardized mental health screening and prompt psychiatric referral during stay in the ED. In addition, for suspected cases of violence or abuse, it is imperative to strengthen mandatory reporting and screening systems. A multidisciplinary response system, which integrates emergency medicine, psychiatry, social work, and community protection services, should be established to ensure comprehensive and continuous management of pediatric and adolescent patients at risk of intentional injuries.
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