IMPORTANCE: Behavioral flags in the electronic health record (EHR) may introduce bias and perpetuate structural racism and discrimination. Descriptions of differences in the way that markers of behavioral risk are communicated will help clarify the inequities that pediatric patients and their families experience in the hospital. OBJECTIVE: To assess whether racially and socioeconomically marginalized pediatric patients and families are more likely than their counterparts to be assigned a behavioral flag in their EHR. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used EHR data for pediatric patients (aged <
18 years) hospitalized from June 2012 to July 2021 across care settings at the University of California, San Francisco health care facilities, an academic quaternary care hospital system that includes 2 pediatric inpatient facilities. The analysis was completed from December 29, 2022, to November 22, 2024. MAIN OUTCOME AND MEASURES: The primary outcome of interest was any of the following behavioral flags placed in a patient's EHR: witnessed substance abuse, history of inappropriate behavior, security, violent behavior, dismissal from practice, and child protective services (CPS) hold. The primary variables were patients' race, ethnicity, insurance status, and primary language. RESULTS: Of 55 865 pediatric encounters (52.2% among males
median patient age at the first encounter, 3 years [IQR, 0-12 years]), 236 (0.4%) had behavioral flags. Compared with encounters among patients who identified as White, encounters among patients who identified as Black or African American were more likely to have a behavioral flag (incidence rate ratio [IRR], 2.07
95% CI, 1.32-3.25). Behavioral flags were also more likely among encounters of individuals with government insurance compared with those with private insurance (IRR, 2.60
95% CI, 1.85-3.65). Black or African American patients younger than 1 year (IRR, 3.53
95% CI, 1.80-6.91) and aged 1 to 7 years (IRR, 2.87
95% CI, 1.34-6.15) had a higher likelihood of flag placement compared with their White counterparts. CONCLUSIONS AND RELEVANCE: This cohort study found significant inequities in incidence of behavioral flags in the EHR among racially and socioeconomically marginalized pediatric patients. This finding was most pronounced for Black or African American patients younger than 8 years, suggesting that this phenomenon may be a response to Black families rather than specific patient behavior.