The interplay of outpatient services and psychiatric hospitalization among Medicaid-enrolled children with autism spectrum disorders

Characterizing the clinical and sociodemographic profiles of hospitalized adolescents with autism spectrum disorder

The prevalence of autism spectrum disorder (ASD) is increasing worldwide. Youngsters with ASD demonstrate higher rates of intellectual disabilities (IDs), comorbid psychopathology and psychiatric hospitalizations, compared to children in the general population. This study characterizes the demographics and clinical parameters of adolescent psychiatric inpatients with ASD compared to inpatients without ASD, all hospitalized during the study period. Additionally, within the ASD group, those with ID were compared to those without. The rate of males among participants with ASD was significantly higher than among those without ASD, and the duration of hospitalization was longer. In contrast, the rate of cigarette smoking, major depressive disorder and suicidal thoughts among those with ASD was lower. One-third of those with ASD had moderate to severe ID, about 10% had comorbid epilepsy, and about half of them demonstrated aggressive behavior. Most ASD patients showed significant improvement upon discharge, although the extent of improvement was more prominent among ASD patients with no ID. Our findings, consistent with previous research, indicate that hospitalization is beneficial to youths with ASD, both those with and those without ID. Further studies that include long-term follow-up are needed.

1915(c) Medicaid Waivers for Children With Severe Emotional Disturbance: Participant Characteristics, Enrollment, and Out-of-Home Service Use

Several states have invested in 1915(c) Home and Community Based Service (HCBS) Medicaid policies to improve outcomes and reduce costs for children and youth with significant behavioral health needs, or Severe Emotional Disturbance (SED). However, little is known about these programs and the children they serve. Through a retrospective cross-sectional analysis, this study aimed to understand if the program was successfully reaching its target population: children and youth with the highest clinical need, at the greatest risk for out-of-home care, and who may not otherwise be eligible for Medicaid through other avenues. Results describe the demographic, clinical, and service use characteristics of children and youth enrolled in one SED Waiver program, comparing them with those of similar, non-waiver enrolled children with behavioral health needs. Findings report that the waiver program examined rarely served children and families not otherwise eligible for Medicaid, but that waiver-enrolled children and youth had substantially more severe clinical need, were at higher risk for out-of-home placement and incurred greater public expenditures for service use. Findings suggest the program studied is serving children with more significant psychiatric needs, as the program intends, but points to the need for further research to understand the impacts of such programs on system and clinical outcomes.

Health conditions and service use of autistic women and men: A retrospective population-based case-control study

LAY ABSTRACT

This study used administrative data from Ontario, Canada to compare the health conditions and service use of autistic women and men with adults with other developmental disabilities and with adults without developmental disabilities. Autistic women and men were more likely to have physical and mental health conditions compared to adults without developmental disabilities. Rates of health conditions were similar or lower among autistic adults compared to adults with other developmental disabilities, except more autistic adults had psychiatric conditions. Autistic women and men used higher rates of psychiatric services compared to all other groups. When comparing autistic women with same aged autistic men, sex differences were found for specific physical (Crohn's disease/colitis, rheumatoid arthritis) and psychiatric conditions (psychotic disorders, non-psychotic disorders), as well differences in service use (emergency department visits, hospitalizations, family doctor and neurologist visits). These results further highlight the high health needs and service use of autistic women and men, as well as adults with other developmental disabilities. It is critical for future research to focus on mental health support for autistic adults and to better understand how to tailor supports to best serve autistic women.

Behavioral Management of Children With Autism in the Emergency Department

ABSTRACT

Autism spectrum disorder (ASD) is characterized by impaired social communication in conjunction with patterned behaviors. Often associated with emotional dysregulation, irritability, aggression, depression, and suicidality, ASD youth frequently present to the emergency department for behavioral and mental health evaluation. Psychiatric comorbidities, agitation, and depression are commonly encountered. During these visits, practitioners must thoughtfully consider organic etiologies for presenting symptoms, formulate plans to address risk of agitation, and understand how to effectively formulate disposition options in this patient population.

Hospitalizations Among Children and Youth With Autism in the United States: Frequency, Characteristics, and Costs

National estimates of hospitalization diagnoses and costs were determined using the 2016 HCUP Kids' Inpatient Database. Children and youth with autism were hospitalized over 45,000 times at over $560 million in costs and 260,000 inpatient days. The most frequent principal diagnoses for hospitalizations of children and youth with autism were epilepsy, mental health conditions, pneumonia, asthma, and gastrointestinal disorders, which resulted in almost $200 million in costs and 150,000 inpatient days. Mental health diagnoses accounted for 24.8% of hospitalizations, an estimated $82 million in costs, and approximately 94,000 inpatient days. Children and youth with autism were more likely hospitalized for epilepsy, mental health diagnoses, and gastrointestinal disorders, and less likely for pneumonia and asthma compared to other children and youth.

Clinical Characteristics of Youth with Autism or Developmental Disability during Inpatient Psychiatric Admission

Children with autism spectrum disorder and developmental disabilities (ASD/DD) often experience severe co-occurring psychological and behavioral challenges, which can warrant inpatient psychiatric care. However, very little is known about the characteristics and clinical care of children with ASD/DD within the context of inpatient psychiatric settings. In this paper, we describe factors unique to inpatients with ASD or DD, by drawing on electronic health records from over 2300 children and adolescents ages 4–17 years admitted to a pediatric psychiatric inpatient unit over a 3-year period. Patients with ASD/DD accounted for approximately 16% of inpatients and 21% of admissions, were younger, more likely to be readmitted, more likely to be male, and more likely to have Medicaid insurance, as compared to patients without ASD/DD. Clinically, those with ASD/DD more frequently had externalizing concerns documented in their records, in contrast to more frequent internalizing concerns among other patients. Within the ASD/DD group, we identified effects of patient age, sex, and race/ethnicity on multiple dimensions of clinical care, including length of stay, use of physical restraint, and patterns of medication use. Results suggest the need for psychiatric screening tools that are appropriate for ASD/DD populations, and intentional integration of anti-racist practices into inpatient care, particularly with regard to use of physical restraint among youth.

Heterogeneity in Autism Spectrum Disorder Case-Finding Algorithms in United States Health Administrative Database Analyses

Strengthening systems of care to meet the needs of individuals with autism spectrum disorder (ASD) is of growing importance. Administrative data provide advantages for research and planning purposes, including large sample sizes and the ability to identify enrollment in insurance coverage and service utilization of individuals with ASD. Researchers have employed varying strategies to identify individuals with ASD in administrative data. Differences in these strategies can limit the comparability of results across studies. This review describes implications of the varying strategies that have been employed to identify individuals with ASD in US claims databases, with consideration of the strengths and limitations of each approach.

Parents matter: Parent acceptance of school-based executive functions interventions relates to improved child outcomes

OBJECTIVES

School-based interventions with parent-training components might improve access among lower-income families to effective help for children with neurodevelopmental disorders. This potential might be realized, however, only if parents perceive the interventions as acceptable and therefore engage with treatment.

METHODS

Parents (N = 124) of 3rd-5th grade students diagnosed with Autism Spectrum Disorder or Attention-Deficit/Hyperactivity Disorder rated the acceptability of their child's treatment (one of two culturally responsive behavioral interventions). Parent engagement was measured through attendance at parent training sessions and the extent to which they read a corresponding workbook.

RESULTS

Education and income correlated inversely with parent perceptions of treatment acceptability. Acceptability correlated positively with engagement, more strongly among lower-income families. Acceptability had an indirect effect on treatment outcome, mediated by parent engagement.

CONCLUSIONS

Treatment providers should focus on strategies to increase parent acceptability, with particular attention to improving access for lower-income families.

The Association of the Medicaid 1915(c) Home and Community-Based Services Waivers with Emergency Department Utilization among Youth with Autism Spectrum Disorder

Using the 2008-2013 Medicaid Analytic eXtract files, this retrospective cohort study was to evaluate the effect of Medicaid home and community-based services (HCBS) waiver programs on emergency department (ED) utilizations among youth with autism spectrum disorder (ASD). Our study showed that the annual ED utilization rates were 13.5% and 18.8% for individuals on autism specific and intellectual and developmental disabilities (IDD) waivers respectively, vs. 28.5% for those without a waiver. Multivariable logistic regression showed that, compared to no waiver, autism specific waivers (adjusted odds ratio: 0.62; 95% Confidence Interval: [0.58-0.66]) and IDD waivers (0.65; [0.64-0.66]) were strongly associated with reduced ED. These findings suggest that HCBS waivers are effective in reducing the incidence of ED visits among youth with ASD.

United States Medicaid home and community-based services for people with intellectual and developmental disabilities: A scoping review

Emerging research tests the impact of United States Medicaid home and community-based (HCBS) waiver policy on outcomes for people with intellectual and developmental disabilities; however, this body of work has yet to be synthesized. We conducted a scoping review to establish what is known about the impact of Medicaid HCBS policy on the lives of people with intellectual and developmental disabilities. Seven studies met final inclusion criteria. Their findings contribute to preliminary evidence that Medicaid HCBS waivers provide economic benefit at the state and federal level, reduce unmet healthcare needs, increase the likelihood that parents will be able to continue working, and reduce racial disparities in access to care. Additional work should compare HCBS waiver programmes, and their causal pathways, as well as draw international comparisons to similar programming, to determine essential infrastructure needed for a successful HCBS programme.

Understanding Racial and Ethnic Disparities in Autism-Related Service Use Among Medicaid-Enrolled Children

Racial and ethnic disparities in the use of nine common autism-related services among Medicaid-enrolled children with autism spectrum disorder (ASD) were examined, distinguishing between school and other community-based outpatient settings. Using 2012 Medicaid Analytic Extract data, we identified 117,848 continuously enrolled children with ASD. Several racial and ethnic disparities were found, varying by geography. Black, Asian, and Native American/Pacific Islanders received fewer outpatient services compared with white children, but there was no disparity for Latinx children. Black and Asian children received more school-based services than white children. Disparities in case management/care coordination services were largest and present in each minority group. Geographic variation in receipt of services suggests targets for policy intervention to improve access for minorities with ASD.

A Comparison of Health Care Expenditures for Medicaid-Insured Children with Autism Spectrum Disorder and Asthma in an Expanding Accountable Care Organization

As value-based care continues to expand, more children with autism spectrum disorder (ASD) will be treated by accountable care organizations (ACOs), provider organizations seeking to improve population health while reducing costs. To inform ACO strategies for children with ASD, this study compared health care expenditures of children insured by a Medicaid managed care organization, empaneled to a safety net ACO, with ASD, asthma, and neither diagnosis. Compared to other study groups, children with ASD were more costly, had lower rates of acute care, and had higher rates of "leaked" care provided by home- and community-based mental health agencies outside of the ACO. These findings highlight the need for unique value-based strategies for children with ASD in a public sector ACO.

Parents' experiences of accessing respite care for children with Autism Spectrum Disorder (ASD) at the acute and primary care interface: a systematic review

BACKGROUND

Population prevalence estimates by the World Health Organisation suggest that 1 in 160 children worldwide has an Autism Spectrum Disorder (ASD). Accessing respite care services for children with an ASD can often be a daunting and exhaustive process, with parents sometimes forced to access acute hospital services as an initial point of contact for respite care or in a crisis situation. To gain an in-depth understanding of accessing respite care for children with an ASD, from the perspectives of parents, a systematic review of the evidence on parent's experiences and views of respite care for children with an ASD at the acute and primary interface was undertaken.

METHODS

Pubmed, Embase, CINAHL and PsycINFO were systematically searched. Studies identified as relevant based on predetermined eligibility criteria were selected for inclusion. The search strategy also targeted unpublished studies and grey literature. Qualitative data and qualitative components of mixed method studies that represented the experiences of parents accessing respite care for children with an ASD were eligible for inclusion. A meta-aggregative approach was used during data synthesis.

RESULTS

Database searching elicited 430 records of which 291 studies remained after removal of duplicates. These 291 studies were screened for title and abstract by two reviewers resulting in 31 studies to be screened at full text and assessed for eligibility. Six studies met the inclusion criteria and a further additional study also met the inclusion criteria during a manual search. As a result, 7 studies were selected for the review as set out in Fig. 1.

CONCLUSION

In the absence of appropriate services and defined pathways to support services such as respite care, overwhelmed parents and community providers of mental health resources may not be in a position to meet the specific needs of children with an ASD and their families which may be contributing to a direct increase in hospitalizations. This systematic review identified a number of barriers to respite care, of which the findings can be used to inform future service development and further research. Knowledge of parental experiences in caring for a child with an ASD is vital in addressing the need and type of respite care required for children with an ASD.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018106629.

Psychiatric Readmission of Children and Adolescents: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate predictors of psychiatric hospital readmission of children and adolescents, a systematic review and meta-analysis was conducted.

METHODS

Following PRISMA statement guidelines, a systematic literature search of articles published between 1997 and 2018 was conducted in PubMed/MEDLINE, Google Scholar, and PsycINFO for original peer-reviewed articles investigating predictors of psychiatric hospital readmission among youths (<18 years old). Effect sizes were extracted and combined by using random-effects meta-analysis. Covariates were investigated with meta-regression and subgroup analyses.

RESULTS

Thirty-three studies met inclusion criteria, containing information on 83,361 children and adolescents, of which raw counts of readmitted vs. non-readmitted youths were available for 76,219. Of these youths, 13.2% (N=10,076) were readmitted. The mean±SD study follow-up was 15.9±15.0 months, and time to readmission was 13.1±12.8 months. Readmission was associated with, but not limited to, suicidal ideation at index hospitalization (pooled odds ratio [OR_pooled]=2.35, 95% confidence interval [CI]=1.64-3.37), psychotic disorders (OR_pooled=1.87, 95% CI=1.53-2.28), prior hospitalization (OR_pooled=2.51, 95% CI=1.76-3.57), and discharge to residential treatment (OR_pooled=1.84, 95% CI=1.07-3.16). There was evidence of moderate study bias. Prior investigations were methodologically and substantively heterogeneous, particularly for measurement of family-level factors.

CONCLUSIONS

Interventions to reduce child psychiatric readmissions should place priority on youths with indicators of high clinical severity, particularly with a history of suicidality, psychiatric comorbidity, prior hospitalization, and discharge to residential treatment. Standardization of methods to determine prevalence rates of readmissions and their predictors is needed to mitigate potential biases and inform a national strategy to reduce repeated child psychiatric hospital readmissions.

Effectiveness of Parent Education in Pivotal Response Treatment on Pivotal and Collateral Responses

In two studies, we investigated the effectiveness of parent education in Pivotal Response Treatment (PRT) on parent-created opportunities and spontaneous child initiations in two community-based treatment facilities for children with autism spectrum disorder (ASD). Changes in parental stress and self-efficacy were explored. Participants were 26 parents and their children who participated in group (Study 1) or individual (Study 2) parent education in PRT. Results indicated that group-based parent education resulted in moderate increases in opportunities, functional initiations, and empathic social initiations. Furthermore, parental stress reduced and self-efficacy increased. Individual parent education resulted in large increases in opportunities and functional initiations, but parental stress and self-efficacy did not change. Implications for clinical practice and directions for future research are discussed.

Effect of Outpatient Service Utilization on Hospitalizations and Emergency Visits Among Youths With Autism Spectrum Disorder

OBJECTIVE

Psychiatric hospitalizations and emergency department (ED) visits occur more frequently for youths with autism spectrum disorder (ASD). One mechanism that may reduce the likelihood of these events is utilization of home and community-based care. Using commercial claims data and a rigorous analytical framework, this retrospective study examined whether spending on outpatient services for ASD, including occupational, physical, and speech therapies and other behavioral interventions, reduced the likelihood of psychiatric hospitalizations and ED visits.

METHODS

The study sample was composed of >100,000 children and young adults with ASD and commercial insurance from every state between 2008 and 2012. The authors estimated maximum-likelihood complementary log-log link survival models with robust standard errors. The outcomes of interest were a hospitalization or an ED visit with an associated psychiatric diagnosis code (ICD-9-CM 290 through 319) in a given week.

RESULTS

An increase of $125 in weekly spending on ASD-specific outpatient services in the 7 to 14 weeks prior to a given week reduced the likelihood of a psychiatric hospitalization in that week by 2%. ASD-specific outpatient spending during the 6 weeks prior to a psychiatric hospitalization did not decrease risk of hospitalization. Spending on ASD-specific outpatient services did not reduce the likelihood of a psychiatric ED visit.

CONCLUSIONS

The financial burden associated with ASD is extensive, and psychiatric hospitalizations remain the most expensive type of care, costing more than $4,000 per week on average. Identifying the mechanisms by which psychiatric hospitalizations occur may reduce the likelihood of these events.

State Mandate Laws for Autism Coverage and High-Deductible Health Plans

OBJECTIVES

Most states have passed insurance mandates requiring health plans to cover services for children with autism spectrum disorder (ASD). Research reveals that these mandates increased treated prevalence, service use, and spending on ASD-related care. As employer-sponsored insurance shifts toward high-deductible health plans (HDHPs), it is important to understand how mandates affect children with ASD in HDHPs relative to traditional, low-deductible plans.

METHODS

Insurance claims for 2008-2012 for children covered by 3 large US insurers (United Healthcare, Aetna, and Humana) available through the Health Care Cost Institute were used to compare the effects of mandates on ASD-related spending for children in HDHPs and traditional health plans.

RESULTS

Relative to children in traditional plans, mandates were associated with higher average monthly spending increases for children in HDHPs. Mandate-attributable spending differences between children enrolled in HDHPs relative to traditional plans were $77 for ASD-specific services (95% confidence interval [CI]: $10 to $144), $125 for outpatient health services (95% CI: $26 to $223), and $144 for all health services (95% CI: $36 to $253). These spending differentials were driven by differences in plan spending and not out-of-pocket (OOP) spending.

CONCLUSIONS

Spending on ASD-related services attributable to autism mandates was higher among children in HDHPs, but higher spending did not translate into a greater OOP burden. For families with consistently high health care expenditures on ASD-related services, high-deductible products may be worth considering in the context of mandate laws. Families in mandate states with children with ASD enrolled in HDHPs were able to increase service use without paying more OOP.

Use, costs, and predictors of psychiatric healthcare services following an autism spectrum diagnosis: Population-based cohort study

A number of cross-sectional studies report extensive use of psychiatric services and high healthcare costs in autistic youths. However, little is known about how the use of these services evolves from the time of diagnosis, as children grow up. Our objectives were to investigate the use, costs, and predictors of psychiatric services following autism spectrum diagnosis. We built a cohort of 1227 newly diagnosed autism spectrum individuals identified in the Quebec (Canada) Régie de l'assurance maladie du Québec administrative database (January 1998 to December 2010). Mean number and cost per individual of psychiatric healthcare use (hospitalizations, medical visits, psychoactive drug use) were calculated yearly for 5 years following autism spectrum diagnosis. Mean number of psychiatric visits decreased over time by more than threefold (7.5 vs 2.1 visits) from year 1 to year 5, whereas psychoactive drug use increased from 16.0 to 25.2 claims. Psychiatric hospitalizations decreased during follow-up, but still represented the greatest costs per individual (CAD9820 for year 1; CAD4628 for year 5). Antipsychotics represented over 50% of drug costs. Mixed-effect model with repeated measures showed that previous psychoactive drug use was the strongest predictor of greater psychiatric healthcare cost during follow-up (odds ratio: 9.96; 95% confidence interval: 7.58-13.10). These trends contrast with guidelines advocating cautious prescribing of antipsychotics with periodical re-assessment of their benefit.

Foster Care Involvement Among Medicaid-Enrolled Children with Autism

The prevalence and risk of foster care involvement among children with autism spectrum disorder (ASD) relative to children with intellectual disability (ID), children with ASD and ID, and typically developing children were examined using 2001-2007 Medicaid data. Children were followed up to the first foster care placement or until the end of 2007; a discrete time logistic regression analysis was conducted. Both the prevalence and risk of foster care involvement were greatest for children with ASD, and the prevalence increased substantially over the study period among children with ASD. Continued examination of the factors contributing to the higher risk of foster placement is warranted to unravel the complex circumstances facing these vulnerable children and their families.

Predictors of Inpatient Psychiatric Hospitalization for Children and Adolescents with Autism Spectrum Disorder

Autism Spectrum Disorder (ASD) is associated with significant healthcare expenditures and a greater utilization of psychiatric health services. High utilization may not be evenly distributed across individuals with ASD. The objective of this study was to identify individual and family characteristics that increase the risk of psychiatric hospitalization. Naturalistic study of two age- and gender-matched ASD cohorts, inpatients enrolled in the Autism Inpatient Collection (AIC) and outpatients enrolled in the Rhode Island Consortium of Autism Research and Treatment (RI-CART), revealed a number of factors associated with hospitalization. Multiple logistic regression analyses revealed that adaptive functioning, ASD symptom severity, primary caregiver's marital status, the presence of mood disorders, and the presence of sleep problems independently increased the risk of psychiatric hospitalization.

Autism spectrum disorder

Autism spectrum disorder is a term used to describe a constellation of early-appearing social communication deficits and repetitive sensory-motor behaviours associated with a strong genetic component as well as other causes. The outlook for many individuals with autism spectrum disorder today is brighter than it was 50 years ago; more people with the condition are able to speak, read, and live in the community rather than in institutions, and some will be largely free from symptoms of the disorder by adulthood. Nevertheless, most individuals will not work full-time or live independently. Genetics and neuroscience have identified intriguing patterns of risk, but without much practical benefit yet. Considerable work is still needed to understand how and when behavioural and medical treatments can be effective, and for which children, including those with substantial comorbidities. It is also important to implement what we already know and develop services for adults with autism spectrum disorder. Clinicians can make a difference by providing timely and individualised help to families navigating referrals and access to community support systems, by providing accurate information despite often unfiltered media input, and by anticipating transitions such as family changes and school entry and leaving.

Effects Of State Insurance Mandates On Health Care Use And Spending For Autism Spectrum Disorder

Forty-six states and the District of Columbia have enacted insurance mandates that require commercial insurers to cover treatment for children with autism spectrum disorder (ASD). This study examined whether implementing autism mandates altered service use or spending among commercially insured children with ASD. We compared children age twenty-one or younger who were eligible for mandates to children not subject to mandates using 2008-12 claims data from three national insurers. Increases in service use and spending attributable to state mandates were detected for all outcomes. Mandates were associated with a 3.4-percentage-point increase in monthly use and a $77 increase in monthly spending on ASD-specific services. Effects were larger for younger children and increased with the number of years since mandate implementation. These increases suggest that state mandates are an effective tool for broadening access to autism treatment under commercial insurance.

Psychiatric hospital treatment of youth with autism spectrum disorder in the United States: needs, outcomes, and policy

Children with Autism Spectrum Disorder (ASD) are admitted to inpatient psychiatric units at markedly high rates. As health insurance companies and government healthcare systems and regulators seek more evidence for healthcare outcomes, it is important to learn more about the effectiveness of psychiatric inpatient admissions for children with ASD to best inform decisions on provision and access to this level of care. Evidence for models of inpatient treatment for youth with ASD is presented, and key characteristics and consensus recommendations for care are discussed.

Effects of State Autism Mandate Age Caps on Health Service Use and Spending Among Adolescents

OBJECTIVE

Many states with mandates requiring commercial insurers to cover autism spectrum disorder (ASD) health services specify upper age limits above which coverage is no longer mandated. It is unknown what effects these age caps have on health service use and spending among adolescents who have exceeded the age cap.

METHOD

Using administrative claims data from 3 national commercial insurers, a difference-in-differences approach was used to estimate effects of age caps on health service use and spending among adolescents with ASD. Statistical models compared changes in use and spending between those above versus below the age cap among individuals eligible versus ineligible for mandated coverage. The analytic sample included data from 2008 through 2012 on 7,845 individuals (151,976 person-months) ages 10 to 21 years in 11 states imposing mandate age caps going into effect during adolescence.

RESULTS

Age caps were associated with 4.2 percentage point (95% CI = -7.0, -1.5) lower probability of any ASD-specific service use in a month and $69 less (95% CI = -112, -$26) in average monthly spending on ASD-specific services than would have been expected given concomitant pre-post age cap differences among individuals in the same states who were never eligible for mandate-covered services. In addition, age caps were associated with $99 (95% CI = -$168, -$30) lower average monthly spending on all health care services.

CONCLUSION

Insurance mandates that include age caps going into effect during adolescence reduce health service use and spending among individuals with ASD during a critical phase of the life course.

Characteristics of psychiatric emergency department use among privately insured adolescents with autism spectrum disorder

This study examined differences in the rates of psychiatric-related emergency department visits among adolescents with autism spectrum disorder, adolescents with attention deficit hyperactivity disorder, and adolescents without autism spectrum disorder or attention deficit hyperactivity disorder. Additional outcomes included emergency department recidivism, probability of psychiatric hospitalization after the emergency department visit, and receipt of outpatient mental health services before and after the emergency department visit. Data came from privately insured adolescents, aged 12-17 years, with autism spectrum disorder (N = 46,323), attention deficit hyperactivity disorder (N = 408,066), and neither diagnosis (N = 2,330,332), enrolled in the 2010-2013 MarketScan Commercial Claims Database. Adolescents with autism spectrum disorder had an increased rate of psychiatric emergency department visits compared to adolescents with attention deficit hyperactivity disorder (IRR = 2.0, 95% confidence interval: 1.9, 2.1) and adolescents with neither diagnosis (IRR = 9.9, 95% confidence interval: 9.4, 10.4). Compared to the other groups, adolescents with autism spectrum disorder also had an increased probability of emergency department recidivism, psychiatric hospitalization after the emergency department visit, and receipt of outpatient care before and after the visit (all p < 0.001). Further research is required to understand whether these findings extend to youth with other neurodevelopmental disorders, particularly those who are publicly insured.

Support Needs and Coping Strategies as Predictors of Stress Level among Mothers of Children with Autism Spectrum Disorder

This study examined maternal stress, coping strategies, and support needs among mothers of children with Autism Spectrum Disorder (ASD). A convenience sample of 70 mothers completed the Parent Stress Index Short Form (PSI-SF), Coping Health Inventory for Parents (CHIP), and Modified Family Needs Questionnaire (FNQ). PSI-SF scores reflected clinically significant levels of stress for 77% of mothers, and mothers identified 62.4% of important needs as unmet. The five most frequently reported important unmet needs were (1) financial support; (2) break from responsibilities; (3) understanding of other after-school program children; (4) rest/sleep; (5) help remaining hopeful about the future. Most coping strategies (81%) were identified as helpful. Additionally, both coping strategies and support needs served as predictors for maternal stress. Maternal stress scores decreased by .402 points for each percent increase in helpful coping strategy, and stress scores increased by .529 points with each percent increase in unmet needs. Given large variation in questionnaire responses across participants and studies, utilization of user-friendly questionnaires, such as the PSI-SF, CHIP, and FNQ, is advocated to determine the evolving important needs unique to each family over the child's lifetime as well as guide prioritization of care, compilation of resources, and referrals for additional services.

Predictors of emergency department use by adolescents and adults with autism spectrum disorder: a prospective cohort study

OBJECTIVES

To determine predictors of emergency department (ED) visits in a cohort of adolescents and adults with autism spectrum disorder (ASD).

DESIGN

Prospective cohort study.

SETTING

Community-based study from Ontario, Canada.

PARTICIPANTS

Parents reported on their adult sons and daughters with ASD living in the community (n=284).

MAIN OUTCOME MEASURES

ED visits for any reason, ED visits for medical reasons and ED visits for psychiatric reasons over 1 year.

RESULTS

Among individuals with ASD, those with ED visits for any reason were reported to have greater family distress at baseline (p<0.01), a history of visiting the ED during the year prior (p<0.01) and experienced two or more negative life events at baseline (p<0.05) as compared with those who did not visit the ED. Unique predictors of medical versus psychiatric ED visits emerged. Low neighbourhood income (p<0.01) and living in a rural neighbourhood (p<0.05) were associated with medical but not psychiatric ED visits, whereas a history of aggression (p<0.05) as well as being from an immigrant family (p<0.05) predicted psychiatric but not medical emergencies.

CONCLUSIONS

A combination of individual and contextual variables may be important for targeting preventative community-based supports for individuals with ASD and their families. In particular, attention should be paid to how caregiver supports, integrative crisis planning and community-based services may assist in preventing or minimising ED use for this vulnerable population.

The Transition to the Adult Health Care System Among Youths With Autism Spectrum Disorder

OBJECTIVE

The study examined how health care utilization patterns among youths with autism spectrum disorder (ASD) change as they transition into the adult health care system.

METHODS

Data came from the Clinformatics Data Mart Database, a nationally diverse, clinically rich, private insurance claims database. The analytic sample consisted of youths ages 16 to 23 who were diagnosed as having ASD (N=16,338). Cross-sectional multivariate linear regressions determined whether service usage in home, office or outpatient, inpatient, and emergency department (ED) settings differed by age.

RESULTS

The proportion of youths with ASD who received services declined with age in each setting except the ED. A similar reduction existed in number of visits to office or outpatient settings and inpatient settings, while home and ED visits remained stable. Service utilization declined faster among youths with co-occurring intellectual disability.

CONCLUSIONS

There is a notable decline in service utilization across multiple settings as youths with ASD transition from pediatric to adult health care.

Psychiatric hospitalisation among individuals with intellectual disability referred to the START crisis intervention and prevention program

BACKGROUND

Little is known about inpatient psychiatric hospitalisation among adults with intellectual disability (ID) in the United States. Greater research is, therefore, required to inform efforts aimed at preventing this costly and restrictive form of care.

METHODS

Data were from 3299 individuals with ID (mean age = 31 years; SD = 14 years) who were referred to START (Systemic, Therapeutic, Assessment, Resources, and Treatment), a community-based crisis intervention and prevention programme. A random effects logistic regression model was used to examine the association between 11 factors and caregiver report of psychiatric hospitalisation in the past 12 months.

RESULTS

Twenty eight percent of the sample had at least one psychiatric inpatient stay in the prior year. Factors associated with an increased likelihood of prior hospitalisation included: younger age, diagnosis of a psychotic disorder, a score of >30 on the irritability subscale of the Aberrant Behavior Checklist, increasing number of psychiatric diagnoses, less severe ID, Black/AA race and not having a home and community waiver.

CONCLUSIONS

Among this high-risk referred group, more than 1 in 4 individuals were hospitalised in the year prior to referral. While results from the analyses will help profile those at risk for hospitalisation, the findings suggest that interventions at the policy level may play an important role in reducing psychiatric hospitalisation.

Medicaid 1915(c) Home- and Community-Based Services waivers for children with autism spectrum disorder

This research aims to describe the characteristics of 1915(c) Home- and Community-Based Services waivers for children with autism spectrum disorder across states and over time. While increasingly popular, little is known about these Medicaid waivers. Understanding the characteristics of these programs is important to clinicians and policymakers in designing programs to meet the needs of this vulnerable population and to set the stage for evaluating changes that occur with the implementation of health-care reform. Home- and Community-Based Services waiver applications that included children with autism spectrum disorder as a target population were collected from the Centers for Medicare and Medicaid Services website, state websites, and state administrators. A data extraction tool was used to document waiver inclusions and restrictions, estimated service provision and institutional costs, and the inclusion of four core autism spectrum disorder services: respite, caregiver support and training, personal care, and evidence-based treatments. Investigators identified 50 current or former waivers across 29 states that explicitly included children with autism spectrum disorder in their target populations. Waivers differed substantially across states in the type and breadth of autism spectrum disorder coverage provided. Specifically, waivers varied in the populations they targeted, estimated cost of services, cost control methods employed, and services offered to children with autism spectrum disorder. Home- and Community-Based Services waivers for children with autism spectrum disorder are very complex and are not consistent across states or over time. Further efforts are needed to examine the characteristics of programs that are associated with improved access to care and clinical outcomes to maximize the benefits to individuals with autism spectrum disorder and their families.

The difference in medical utilization and associated factors between children and adolescents with and without autism spectrum disorders

This study determined differences in health care utilization and health care expenditures between children with and without autism spectrum disorder (ASD) and examined possible reasons for these differences. A retrospective longitudinal study of children aged younger than 18 years both with and without ASD was conducted using the 2008 database of the Ministry of the Interior registry of the disabled persons in tandem with the National Health Insurance Research Database. Propensity score matching for the covariates of age, sex, and parental monthly salary was used to match children at a ratio of 1:3 for observing health care utilization among children with and without ASD from 2008 to 2011. Generalized estimating equation analysis was performed to determine factors that affect health care utilization, such as physician visits, emergency room (ER) visits, hospitalizations, and health care expenditures. After matching was completed, the sample size comprised 3280 children with ASD and 9840 children without ASD. Among the children in the sample, most were boys (86.68%) between the ages of 6-11 years, and the average age of both samples was 9.8 years. After relevant factors were controlled for, the children with ASD yielded an average of 14.2 more annual physician visits and were more likely to visit the ER (OR=1.12, P<.05) or be hospitalized (OR=1.48; P<.05) compared with the children without ASD. Compared with the children without ASD, the children with ASD exhibited higher annual physician visit expenditures (NT$26,580 more), higher ER visit expenditures (NT$50 more), higher hospitalization expenditures (NT$5830 more), and NT$32,460 more total health care expenditures (all P<.05). Significant predictors of health care expenditures among the children with ASD were age, parental monthly salary, and severity of comorbidity. The most common reasons for physician visits or hospitalizations among the children with ASD were psychiatric illnesses, respiratory illnesses, and digestive illnesses. The children without ASD most commonly experienced respiratory, digestive, and nervous system or sense organ illnesses. Health care utilization among children with ASD is higher than that among children without ASD. The results of this study can serve as a reference for governmental agencies enacting relevant health care policies.

Predictors of emergency service use in adolescents and adults with autism spectrum disorder living with family

INTRODUCTION

The use of emergency services among adolescents and adults with autism spectrum disorder (ASD) transitioning into adult health services has not been well described.

OBJECTIVES

To describe emergency service use including emergency departments (EDs), paramedics, and police involvement among adolescents and adults with ASD and to examine predictors of using emergency services.

METHODS

Caregivers of 396 adolescents and adults with ASD were recruited through autism advocacy agencies and support programmes in Ontario to complete a survey about their child's health service use. Surveys were completed online, by mail and over the phone between December 2010 and October 2012. Parents were asked to describe their child's emergency service use and provide information about potential predictive factors including predisposing, enabling and clinical need variables.

RESULTS

According to parents, 13% of their children with ASD used at least one emergency service in a 2-month period. Sedation or restraints were used 23% of the time. A combination of need and enabling variables predicted emergency service use with previous ED use in the last year (OR 3.4, 95% CI 1.7 to 6.8), a history of hurting others (OR 2.3, 95% 1.2 CI to 4.7) and having no structured daytime activities (OR 3.2, 95% CI 1.4 to 7.0) being the strongest multivariate predictors in the model.

CONCLUSIONS

Patients with ASD and their families are likely to engage with paramedics or police or visit the ED. Further education and support to families and emergency clinicians are needed to improve and, when possible, prevent such occurrences.

Predictors of admission to acute inpatient psychiatric care among children enrolled in Medicaid

This study examined acute inpatient psychiatric admissions among child Medicaid recipients with a mental health diagnosis in one Midwestern state. The authors used multivariable logistic regression to determine the demographic, clinical, and service factors associated with admissions among 51,233 Medicaid enrolled children 3-17 years old who were identified as having a mental health diagnosis. Compared to available data from other states, the overall acute admission rate was low (2.5 %). Clinical factors were the strongest predictors of hospitalization. Youths with mood, disruptive and psychotic disorder diagnoses were 14.1, 6.2, and 5.8 times more likely than other mental health beneficiaries to experience one or more acute inpatient psychiatric admissions. Other predictors of acute admission included prior hospitalization, receipt of two or more concurrent psychotropic medications, older age, and urban residence. A low rate of acute inpatient admissions may indicate successful delivery of community-based mental health services; conversely, it may suggest underservice to youths with mental health need, particularly those in rural areas. Implications for publicly funded children's mental health care are discussed.

Psychiatric hospital treatment of children with autism and serious behavioral disturbance

Children with autism spectrum disorder are psychiatrically hospitalized much more frequently than children in the general population. Hospitalization occurs primarily because of externalizing behaviors and is associated with behavioral disturbance, impaired emotion regulation, and psychiatric comorbidity. Additionally, a lack of practitioner and/or administrator training and experience with this population poses risks for denial of care by third-party payers or treatment facilities, inadequate treatment, extended lengths of stay, and poor outcomes. Evidence and best practices for the inpatient psychiatric care of this population are presented. Specialized treatment programs universally rely on multidisciplinary approaches, including behaviorally informed interventions.

Healthcare service use and costs for autism spectrum disorder: a comparison between medicaid and private insurance

Healthcare costs and service use for autism spectrum disorder (ASD) were compared between Medicaid and private insurance, using 2003 insurance claims data in 24 states. In terms of costs and service use per child with ASD, Medicaid had higher total healthcare costs ($22,653 vs. $5,254), higher ASD-specific costs ($7,438 vs. $928), higher psychotropic medication costs($1,468 vs. $875), more speech therapy visits (13.0 vs. 3.6 visits), more occupational/physical therapy visits (6.4 vs. 0.9 visits), and more behavior modification/social skills visits (3.8 vs. 1.1 visits) than private insurance (all p < 0.0001). In multivariate analysis, being enrolled in Medicaid had the largest effect on costs, after controlling for other variables. The findings emphasize the need for continued efforts to improve private insurance coverage of autism.

Age-related variation in health service use and associated expenditures among children with autism

This study examined differences by age in service use and associated expenditures during 2005 for Medicaid-enrolled children with autism spectrum disorders. Aging was associated with significantly higher use and costs for restrictive, institution-based care and lower use and costs for community-based therapeutic services. Total expenditures increased by 5 % with each year of age; by 23 % between 3-5 and 6-11 year olds, 23 % between 6-11 and 12-16, and 14 % between 12-16 and 17-20 year olds. Use of and expenditures for long-term care, psychiatric medications, case management, medication management, day treatment/partial hospitalization, and respite services increased with age; use of and expenditures for occupational/physical therapy, speech therapy, mental health services, diagnostic/assessment services, and family therapy declined.

Parent and family impact of autism spectrum disorders: a review and proposed model for intervention evaluation

Raising a child with an autism spectrum disorder (ASD) can be an overwhelming experience for parents and families. The pervasive and severe deficits often present in children with ASD are associated with a plethora of difficulties in caregivers, including decreased parenting efficacy, increased parenting stress, and an increase in mental and physical health problems compared with parents of both typically developing children and children with other developmental disorders. In addition to significant financial strain and time pressures, high rates of divorce and lower overall family well-being highlight the burden that having a child with an ASD can place on families. These parent and family effects reciprocally and negatively impact the diagnosed child and can even serve to diminish the positive effects of intervention. However, most interventions for ASD are evaluated only in terms of child outcomes, ignoring parent and family factors that may have an influence on both the immediate and long-term effects of therapy. It cannot be assumed that even significant improvements in the diagnosed child will ameliorate the parent and family distress already present, especially as the time and expense of intervention can add further family disruption. Thus, a new model of intervention evaluation is proposed, which incorporates these factors and better captures the transactional nature of these relationships.

Psychiatric-related emergency department visits among children with an autism spectrum disorder

OBJECTIVE

This study aimed to examine the prevalence and characteristics of psychiatry-related emergency department (ED) visits among children with an autism spectrum disorder (ASD), including the specific reason for visit, as well as the influence of insurance type.

METHODS

Data used for this cross-sectional, observational study were obtained from the 2008 National Emergency Department Sample, the largest all-payer ED database in the United States. Psychiatry-related visits to the ED among children with ASD were identified using International Classification of Diseases, Ninth Revision, billing codes. A total of 3,974,332 visits (unweighted) were present for youth 3-17 years, of which 13,191 involved a child with ASD.

RESULTS

Thirteen percent of visits among children with ASD were due to a psychiatric problem, as compared with 2% of all visits by youths without ASD. Results from the multivariate analyses revealed that the likelihood for a psychiatric ED visit was increased 9-fold (odds ratio [OR], 9.13; 95% confidence interval [CI], 8.61-9.70) among pediatric ASD visits, compared with non-ASD visits. Children with ASD who were covered by private insurance, compared with those with medical assistance, were at even greater risk for a psychiatric ED visit (OR, 1.58; 95% CI, 1.53-1.63). Visits among children with ASD were more likely to be due to externalizing (OR, 1.62; 95% CI, 1.44-1.83) and psychotic (OR, 1.93; 95% CI, 1.58-2.35) disorders compared with visits among non-ASD children.

CONCLUSIONS

This study highlights the need for improving community-based psychiatric systems of care for youths with ASD to divert psychiatry-related ED visits, particularly for those children with private insurance.