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Background One in six young people have a probable mental health disorder, yet less than two-thirds access professional help. While planned mental health care treats serious, chronic conditions, acute crises requiring urgent care are also common. We previously demonstrated marked socio-demographic inequalities in access to planned mental health care in a single Scottish Health Board. However, we don’t know if the trends in routine care are replicated in the Emergency Department (ED), or whether there is variation in the characteristics of children accessing care in different settings. We aimed to better understand to scale and variety of ED attendance for mental health complaints among adolescents.Methods We analysed linked electronic health records for all children aged 12–17 living in NHS Grampian between 2015–2022. Data included records on mental health prescribing, inpatient/outpatient and ED attendances, and death certificates, linked via the Community Health Index Register, providing total population coverage. We calculated incidence counts and rates for ED attendances, stratified by age, sex, and deprivation level. We described incidence of first ED attendance for those who have and have not been previously treated in CAMHS.Results We identified 5,253 mental health related ED attendances, for 3,173 individuals. Between 2015 and 2022, the annual rate of emergency department attendances rose by 22% (131 to 161 per 10k). Females accounted for 61% of attendances (n = 1,933) and their annual rate increased by 27% (183 to 233 per 10k), whilst rates for males remained static (83.2 to 81.5 per 10k). Incidence rates in the most deprived quintile were four times higher than in the least deprived (2,364 vs. 570 per 10k). Results comparing ED attendances by prior CAMHS treatment status are awaiting final disclosure checks before they can be shared.Discussion Our analysis highlights rising incidence of ED attendance, particularly among teenage girls and people living in more deprived areas, highlighting theses as populations most in need of professional support. Strengths of our approach include population-level coverage and broad linkage across multiple NHS datasets related to mental health. However, identifying mental health attendances was challenging due to limitations in ED data, which rely heavily on clinicians’ free-text entries rather than standardised classifications. Our findings suggest that targeted interventions, improved crisis support, and better resource allocation to address rising ED attendances may be beneficial – particularly for teenage girls and those in deprived areas.