<p>Children and adolescents who make homicidal threats do not necessarily have homicidal ideation (HI), and children with HI generally do not go on to perpetrate violent crimes. However, homicidal threats in children and adolescents nevertheless generate considerable concern, particularly in schools. We conducted a retrospective chart review of all patients (<i>N</i> = 261) treated by an acute pediatric psychiatry service (ages ≤ 18) at a large, urban academic medical center between January 1, 2024 and June 30, 2024. Psychiatric notes were reviewed for the reason for referral (e.g. concern for homicidal or suicidal ideation), school referrals, and discharge recommendations. Children who were evaluated for HI (<i>n</i> = 29, 11.07%) had decreased odds of inpatient psychiatric hospitalization, compared to children evaluated for any other reason (OR = 0.26, 95% CI [0.08–0.89], <i>p</i> = 0.02). Most HI cases (<i>n</i> = 19, 65.52%) included generalized statements or behaviors, rather than a specific intent to harm an individual or group. Conversely, children who were evaluated for SI (<i>n</i> = 124, 47.3%) had increased odds of inpatient psychiatric hospitalization, compared to children who were evaluated for any other reason (OR = 3.18, 95% CI [1.80–5.62], <i>p</i> &lt; 0.001). Patients evaluated for possible SI were more likely to have been referred for evaluation by their school, compared to children with no SI (OR = 1.89, 95% CI [1.06–3.35], <i>p</i> = 0.03). However, patients evaluated for HI were substantially more likely to have been referred by their school, compared to patients with no HI (OR = 5.58, 95% CI 2.49–12.48, <i>p</i> &lt; 0.001). Schools have over five times the odds of referring children for psychiatric evaluation if there is concern for HI, but these same patients ultimately have decreased odds of inpatient psychiatric hospitalization. This suggests a mismatch between school responses to HI and clinical urgency, and the need for improved guidelines for evaluating HI in youth.</p>