The role of race in diagnostic and disposition decision making in a pediatric psychiatric emergency service

Patient clinical and demographic factors associated with involuntary psychiatric admission in the northern territory top end

OBJECTIVE

Australia has inadequate publicly available data regarding the use of involuntary psychiatric care. This study examined the association between patient clinical/demographic factors and involuntary psychiatric admission following initial psychiatric assessment in Royal Darwin Hospital.

METHOD

Retrospective review of 638 psychiatric assessments followed by covariate analysis of patient variables associated with involuntary psychiatric admission.

RESULTS

Most of the 225 psychiatric admissions were involuntary (92%). Male patients and those with a preferred language other than English had the highest risk of being admitted involuntarily (RR 1.09, χ2 [1] = 3.9, p = .048, and RR 1.11, p = .036, respectively).

CONCLUSIONS

Further research regarding the influence of patient demographics and clinical factors on rates of involuntary admissions, particularly for Aboriginal patients, is recommended. The findings prompt discussion on strategies to improve monitoring of involuntary care and barriers to voluntary treatment.

Inequalities in the Incidence of Psychotic Disorders Among Racial and Ethnic Groups

OBJECTIVE

The authors examined recent trends in incidence of psychotic disorders, demographic characteristics, and comorbid psychiatric and medical conditions among six racial/ethnic groups.

METHOD

A retrospective cohort study design was used to examine the incidence of psychotic disorders across race/ethnicity groups and comorbid psychiatric and medical conditions among members of Kaiser Permanente Northern California from 2009 to 2019 (N=5,994,758). Poisson regression was used to assess changes in annual incidence, and Cox proportional hazards and logistic regression models adjusted for age and sex were used to test correlates and consequences.

RESULTS

Overall, the incidence of nonaffective psychotic disorders decreased slightly over the study period. Compared with White members, the risk of nonaffective psychosis diagnosis was higher among Black (hazard ratio=2.13, 95% CI=2.02-2.24) and American Indian or Alaskan Native (AIAN) (hazard ratio=1.85, 95% CI=1.53-2.23) members and lower among Asian (hazard ratio=0.72, 95% CI=0.68-0.76) and Hispanic (hazard ratio=0.91, 95% CI=0.87-0.96) members, as well as those whose race/ethnicity was categorized as "other" (hazard ratio=0.92, 95% CI=0.86-0.99). Compared with White members, the risk of affective psychosis diagnosis adjusted for age and sex was higher among Black (hazard ratio=1.76, 95% CI=1.62-1.91), Hispanic (hazard ratio=1.09, 95% CI=1.02-1.16), and AIAN (hazard ratio=1.38, 95% CI=1.00-1.90) members and lower among Asian (hazard ratio=0.77, 95% CI=0.71-0.83), Native Hawaiian or other Pacific Islander (hazard ratio=0.69, 95% CI=0.48-0.99), and "other" (hazard ratio=0.86, 95% CI=0.77-0.96) members. Psychotic disorders were associated with significantly higher odds of suicide (odds ratio=2.65, 95% CI=2.15-3.28), premature death (odds ratio=1.30, 95% CI=1.22-1.39), and stroke (odds ratio=1.64, 95% CI=1.55-1.72) and lower odds of health care utilization (odds ratio=0.44, 95% CI=0.42-0.47).

CONCLUSIONS

This study demonstrates racial and ethnic variation in incident psychotic disorder diagnoses in the United States, compared with non-Hispanic Whites. Individuals diagnosed with psychosis face a greater burden of other negative health outcomes and lower odds of health care utilization, reflecting personal and economic impacts. Identifying risk factors for elevated rates and protective influences in subgroups can inform strategies for prevention and interventions to ameliorate severe consequences of psychotic syndromes.

Systemic Racism's Impact on Minority Children and Youth With Psychosis: Enacting Antiracist Strategies in Psychosis Care

Psychotic disorders represent a treatable but debilitating subset of mental illnesses. Children and adolescents who are given a diagnosis of psychosis are at risk for serious sequelae that may affect cognitive and social function. Alarmingly, evidence has shown that racial differences exist in the diagnosis and progression of pathology. This article presents a conceptualization of the challenges that minority pediatric patients diagnosed with a psychotic disorder often confront, and explores practical means to antiracist care.

Race, racism, and antiracism in emergency medicine: A scoping review of the literature and research agenda for the future

OBJECTIVES

The objective was to conduct a scoping review of the literature and develop consensus-derived research priorities for future research inquiry in an effort to (1) identify and summarize existing research related to race, racism, and antiracism in emergency medicine (EM) and adjacent fields and (2) set the agenda for EM research in these topic areas.

METHODS

A scoping review of the literature using PubMed and EMBASE databases, as well as review of citations from included articles, formed the basis for discussions with community stakeholders, who in turn helped to inform and shape the discussion and recommendations of participants in the Society for Academic Emergency Medicine (SAEM) consensus conference. Through electronic surveys and two virtual meetings held in April 2021, consensus was reached on terminology, language, and priority research questions, which were rated on importance or impact (highest, medium, lower) and feasibility or ease of answering (easiest, moderate, difficult).

RESULTS

A total of 344 articles were identified through the literature search, of which 187 met inclusion criteria; an additional 34 were identified through citation review. Findings of racial inequities in EM and related fields were grouped in 28 topic areas, from which emerged 44 key research questions. A dearth of evidence for interventions to address manifestations of racism in EM was noted throughout.

CONCLUSIONS

Evidence of racism in EM emerged in nearly every facet of our literature. Key research priorities identified through consensus processes provide a roadmap for addressing and eliminating racism and other systems of oppression in EM.

Folk Classification and Factor Rotations: Whales, Sharks, and the Problems With the Hierarchical Taxonomy of Psychopathology (HiTOP)

The Hierarchical Taxonomy of Psychopathology (HiTOP) uses factor analysis to group people with similar self-reported symptoms (i.e., like-goes-with-like). It is hailed as a significant improvement over other diagnostic taxonomies. However, the purported advantages and fundamental assumptions of HiTOP have received little, if any scientific scrutiny. We critically evaluated five fundamental claims about HiTOP. We conclude that HiTOP does not demonstrate a high degree of verisimilitude and has the potential to hinder progress on understanding the etiology of psychopathology. It does not lend itself to theory-building or taxonomic evolution, and it cannot account for multifinality, equifinality, or developmental and etiological processes. In its current form, HiTOP is not ready to use in clinical settings and may result in algorithmic bias against underrepresented groups. We recommend a bifurcation strategy moving forward in which the DSM is used in clinical settings while researchers focus on developing a falsifiable theory-based classification system.

Depression in African American and Black Caribbean Youth and the Intersection of Spirituality and Religion: Clinical Opportunities and Considerations

This article reviews the risk and protective factors, symptom presentation, and the significant interface of spirituality and religion of depression in African American and black Caribbean children and adolescents and their families. The article provides practical implications for diagnosis and treatment of depression in this special population of youth.

We all make choices: A decision analysis framework for disposition decision in the ED

BACKGROUND

Emergency Department (ED) providers' disposition decision impacts patient care and safety. The objective of this brief report is to gain a better understanding of ED providers' disposition decision and risk tolerance of associated outcomes.

METHODS

We synthesized qualitative and quantitative methods including decision mapping, survey research, statistical analysis, and word clouds. Between July 2017 and August 2017, a 10-item survey was developed and conducted at the study hospital. Descriptive and statistical analyses were used to assess the relationship between the participant characteristics (age, gender, years of experience in the ED, and level of expertise) and risk tolerance of outcomes (72-h return and negative outcome) associated with disposition decision. Word clouds facilitated prioritization of qualitative responses regarding information impacting and supporting the disposition decision.

RESULTS

Total of 46 participants completed the survey. The mean age was 39.5 (standard deviation (SD) 10years), and mean years of experience was 9.6years (SD 8.7years). Decision map highlighted the connections between patient-, provider-, and system-related factors. Survey results showed that negative outcome resulted in less risk tolerance compared to 72-h return. Chi-square tests did not provide sufficient evidence to indicate that the responses are independent of participants characteristics - except age and the risk of 72-h return (p=0.046).

CONCLUSION

Discharge decision making in the ED is complex as it involves interconnected patient, provider, and system factors. Synthesizing qualitative and quantitative methods promise enhanced understanding of how providers arrive to disposition decision, as well as safety and quality of care in the ED.

Predictors and Outcomes of Psychiatric Hospitalization in Youth Presenting to the Emergency Department with Suicidality

Youth suicide attempters presenting to the emergency department (ED) are frequently admitted to psychiatric inpatient hospitals, yet little is known about how clinicians decide which youths to admit versus discharge to outpatient care. We examine predictors of inpatient hospitalization and describe service use outcomes associated with hospitalization in 181 youths drawn from consecutive ED admissions for suicidality. Predictors of hospitalization include ED site, suicide plan, and parent report of problems. Hospitalization was associated with improved linkage to outpatient treatment and more intensive service use. Future research is needed to understand the best service delivery and treatments for these high-risk youth.

Mental Health Diagnostic Considerations in Racial/Ethnic Minority Youth

Misdiagnoses of racial/ethnic minority youth's mental health problems can potentially contribute to inappropriate mental health care. Therefore, we conducted a systematic review that focuses on current theory and empirical research in an attempt to answer the following two questions: 1) What evidence exists that supports or contradicts the idea that racial/ethnic minority youth's mental health problems are misdiagnosed? 2) What are the sources of misdiagnoses? Articles were reviewed from 1967 to 2014 using PsychINFO, PubMed, and GoogleScholar. Search terms included "race", "ethnicity", "minority", "culture", "children", "youth", "adolescents", "mental health", "psychopathology", "diagnosis", "misdiagnosis", "miscategorization", "underdiagnosis", and "overdiagnosis". Seventy-two articles and book chapters met criteria and were included in this review. Overall, evidence was found that supports the possibility of misdiagnosis of ethnic minority youth's emotional and behavioral problems. However, the evidence is limited such that it cannot be determined whether racial/ethnic differences are due to differences in psychopathology, mental health biases, and/or inaccurate diagnoses. Cultural and contextual factors that may influence misdiagnosis as well as recommendations for research and practice are discussed.

Delayed Access to Involuntary Mental Health Examinations

Delayed access to involuntary mental health examination for people who receive care in emergency departments (EDs) was examined, and factors that influenced delayed access were explored. A retrospective review of records for the 12 months prior to data collection was conducted to address the study questions. The health services utilization model served as the conceptual framework for this study. Societal, system, and individual factors were considered in examining access to involuntary emergency mental health examination by adult ED patients. Records of 170 people who sought care in EDs and who required involuntary mental health examinations at two hospitals in Florida served as the sources for study data. The mean duration of delay was 14.9 h. The determinants that were significantly associated with longer delays were being male, increased age, and intoxication. The findings can inform the allocation of resources to increase opportunities for positive long-term outcomes following involuntary care.

Characteristics and disposition of youth referred from schools for emergency psychiatric evaluation

We aimed to describe the characteristics and disposition of youth referred from schools to the emergency department (ED) for psychiatric evaluations. Consecutive 12-month records of ED psychiatric consultations at a large urban hospital from 07.01.2009 to 06.30.2010 were retrospectively analyzed. School-initiated referrals were deemed inappropriate if youth were discharged from the ED without any recommended mental health follow-up. Of the 551 psychiatric ED evaluations, 243 (44.1%) were initiated by schools. Of all school referrals, only 19 (7.8%) children were psychiatrically hospitalized, 108 (44.4%) were discharged from the ED with a follow-up appointment; and 116 (47.7%) were discharged without arranged follow-up. Those with a chief complaint of "suicidality" (n = 109, 44.9%) were more likely to be discharged without arranged follow-up than youth with other presenting complaints (56.0 vs. 41.0%, p = 0.021). Altogether, only 37 (18.5%) of 200 school-referred youth with information were evaluated by a school nurse, social worker, or other professional before being sent to the ED. Students without in-school screening were significantly more frequently discharged without follow-up than students with in-school evaluations prior to the ED referral (51.5 vs. 27.0%, p = 0.0070; odds ratio = 2.87 (95% CI 1.30-6.31). Multivariate predictors of inappropriate school referrals of youth discharged without any outpatient follow-up were higher Children's Global Assessment Scale score (p < 0.0001), absent in-school evaluation (p = 0.0069), absent prior psychiatric history (p = 0.011) and absent current psychotropic medication treatment (p = 0.012) (r(2) = 0.264%, p < 0.0001). Altogether 44.1% of ED consultations were school referred, of which 47.7% were potentially inappropriate for the emergency setting. In-school screening, which occurred infrequently, reduced unnecessary evaluations by 52%.

Bruising in Children: Practice Patterns of Pediatric Hematologists and Child Abuse Pediatricians

The evaluation for children with bruising may be affected by the specialty to which they are referred. We conducted a 3-year retrospective review of subjects referred for bruising to Child Abuse Pediatrics (CAP) or Pediatric Hematology to identify characteristics associated with referral to each specialty and to compare the diagnostic evaluations and diagnoses based on specialty. Of 369 subjects, 275 were referred to CAP and 94 to Hematology. Clinical exam findings were similar in both groups. Hematology referrals were significantly more likely to have laboratory evaluations. Among those referred to CAP, 9.5% had head computed tomography scans and 27.3% had skeletal surveys. No children referred to Hematology had these imaging studies performed. Hematology never diagnosed child physical abuse, and CAP never diagnosed bleeding disorders. Pediatric hematologists and CAPs perform different evaluations and reach different diagnostic conclusions for similar patients with bruising. Further investigation of these practice patterns is warranted.

Clinician reasoning in the use of cultural formulation to resolve uncertainty in the diagnosis of psychosis

We examined how the process of cultural formulation contributes to diagnostic assessment of patients with psychotic disorders at a specialized Cultural Consultation Service (CCS). Specifically, we investigated the reasoning process used to resolve uncertainty of psychotic disorder diagnosis in African immigrant patients referred to the CCS for assessment of possible psychotic disorder. Qualitative thematic analysis of 23 clinical case conference transcripts was used to identify clinicians' reasoning styles. Use of the CF appears to facilitate the emergence of a rule-governed reasoning process that involved three steps: (i) problematize the diagnosis of the intake 'psychosis' symptoms or behavior; (ii) elaborate explanations as to why the symptoms or behavior may or may not be psychosis; and (iii) confirm the diagnosis of psychosis or re-interpret as non-psychosis. Prototypes and exemplars drawn from previous experience in intercultural work featured prominently in clinicians' reasoning. Prototypes were crucial in diagnostic decision-making and appear to be important sources of both clinician expertise and bias, and may need to be targeted specifically in cultural competence training.

Racial disparities in psychotic disorder diagnosis: A review of empirical literature

Psychotic disorder diagnoses are common in the United States and internationally. However, racial disparities in rates of psychotic disorder diagnoses have been reported across time and mental health professions. This literature review provides an updated and comprehensive summary of empirical research on race and diagnosis of psychotic disorders spanning a 24-year period. Findings reveal a clear and pervasive pattern wherein African American/Black consumers show a rate of on average three to four higher than Euro-American/White consumers. Latino American/Hispanic consumers were also disproportionately diagnosed with psychotic disorders on average approximately three times higher compared to Euro-American/White consumers. In addition, a trend among international studies suggests that immigrant racial minority consumers receiving mental health services may be assigned a psychotic disorder diagnosis more frequently than native consumers sharing a majority racial background. Potential explanations for this phenomenon are discussed, including possible clinical bias and sociological causes such as differential access to healthcare and willingness to participate in mental health services. Directions for future research should include the exploration of disproportionate diagnoses according to race through qualitative interviewing as well as empirical investigation.

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.

Racial/ethnic disparities in chronic diseases of youths and access to health care in the United States

Racial/ethnic minorities are 1.5 to 2.0 times more likely than whites to have most of the major chronic diseases. Chronic diseases are also more common in the poor than the nonpoor and this association is frequently mediated by race/ethnicity. Specifically, children are disproportionately affected by racial/ethnic health disparities. Between 1960 and 2005 the percentage of children with a chronic disease in the United States almost quadrupled with racial/ethnic minority youth having higher likelihood for these diseases. The most common major chronic diseases of youth in the United States are asthma, diabetes mellitus, obesity, hypertension, dental disease, attention-deficit/hyperactivity disorder, mental illness, cancers, sickle-cell anemia, cystic fibrosis, and a variety of genetic and other birth defects. This review will focus on the psychosocial rather than biological factors that play important roles in the etiology and subsequent solutions to these health disparities because they should be avoidable and they are inherently unjust. Finally, this review examines access to health services by focusing on health insurance and dental insurance coverage and access to school health services.

Emergency psychiatric care for children and adolescents: a literature review

OBJECTIVES

Over the years, increasing numbers of children and adolescents have sought help for acute psychiatric problems. The responses to this treatment-seeking behavior are heterogeneous in different settings and nations. This review aimed to provide an answer to the questions "which care should be offered to children and adolescents presenting with a psychiatric emergency or crisis and how should it be organized."

METHODS

We committed a literature review to find out if any recommendations can be made regarding the organization of emergency care for children and adolescents with acute mental health problems.

RESULTS

The lack of a clear definition of emergencies or urgencies hampered this review; we note the differences between adult and child or adolescent psychiatry. The theoretical models of care found in the literature are built up from several process and structural components, which we describe in greater detail. Furthermore, we review the main service delivery models that exist for children and adolescents.

CONCLUSIONS

Currently, emergency psychiatric care for children and adolescents is practiced within a wide range of care models. There is no consensus on recommended care or recommended setting for this population. More research is needed to make exact recommendations on the standardization of psychiatric care for young people in emergency settings.

Using electronic health records data to assess comorbidities of substance use and psychiatric diagnoses and treatment settings among adults

OBJECTIVE

To examine prevalences of substance use disorders (SUD) and comprehensive patterns of comorbidities among psychiatric patients ages 18-64 years (N = 40,099) in an electronic health records (EHR) database.

METHOD

DSM-IV diagnoses among psychiatric patients in a large university system were systematically captured: SUD, anxiety (AD), mood (MD), personality (PD), adjustment, childhood-onset, cognitive/dementia, dissociative, eating, factitious, impulse-control, psychotic (schizophrenic), sexual/gender identity, sleep, and somatoform diagnoses. Comorbidities and treatment types among patients with a SUD were examined.

RESULTS

Among all patients, 24.9% (n = 9984) had a SUD, with blacks (35.2%) and Hispanics (32.9%) showing the highest prevalence. Among patients with a SUD, MD was prevalent across all age groups (50.2-56.6%). Patients aged 18-24 years had elevated odds of comorbid PD, adjustment, childhood-onset, impulse-control, psychotic, and eating diagnoses. Females had more PD, AD, MD, eating, and somatoform diagnoses, while males had more childhood-onset, impulse-control, and psychotic diagnoses. Blacks had greater odds than whites of psychotic and cognitive/dementia diagnoses, while whites exhibited elevated odds of PA, AD, MD, childhood-onset, eating, somatoform, and sleep diagnoses. Women, blacks, and Native American/multiple-race adults had elevated odds of using inpatient treatment; men, blacks, and Hispanics had increased odds of using psychiatric emergency care. Comorbid MD, PD, adjustment, somatoform, psychotic, or cognitive/dementia diagnoses increased inpatient treatment.

CONCLUSION

Patients with a SUD, especially minority members, use more inpatient or psychiatric emergency care than those without. Findings provide evidence for research on understudied diagnoses and underserved populations in the real-world clinical settings.

Disparities in psychiatric emergency department visits among youth in Hawai'i, 2000-2010

OBJECTIVE

To describe the frequency and patient characteristics of emergency department encounters for mental health among youth, and to examine differences in utilization and treatment patterns.

STUDY DESIGN

Data were obtained from the Hawai'i Health Information Corporation database of emergency department records between January 1, 2000, and December 31, 2010. Analyses were limited to records of visits by patients aged <18 years with a diagnosis of mental disorder or a suicide attempt.

RESULTS

The annual average rate was 49.7 emergency department visits related to mental health issues per 10 000 youth, accounting for 2.1% of all emergency department visits among youth. Rates of mental health-related visits significantly and steadily increased, from a low of 25.8 in 2000 to a high of 67.4 in 2010. Rural areas consistently exhibited higher rates and acceleration at a steeper incline across time. Rural youth were more likely to be discharged or transferred for inpatient care or outpatient services compared with urban youth (6.3% vs 12.4%; χ(2) = 61.42; df = 3; P < .001).

CONCLUSION

The trend in emergency department utilization for mental health-related issues in adolescents is apparently increasing, with significantly higher rate and morbidity for youth in rural areas. Several recommendations are described for creating a responsive and integrated system of mental health care for youth, covering training, consultation, screening, and brief interventions.

Physician styles of patient management as a potential source of disparities: cluster analysis from a factorial experiment

OBJECTIVE

To identify styles of physician decision making (as opposed to singular clinical actions) and to analyze their association with variations in the management of a vignette presentation of coronary heart disease (CHD).

DATA SOURCE

Primary data were collected from primary care physicians in North and South Carolina.

STUDY DESIGN

In a balanced factorial experimental design, primary care physicians viewed one of 16 (2(4)) video vignette presentations of CHD and provided detailed information about how they would manage the case.

DATA COLLECTION METHOD

256 MD primary care physicians were interviewed face-to-face in North and South Carolina.

PRINCIPAL FINDINGS

We identify three clusters depicting unique styles of CHD management that are robust to controls for physician (gender and level of experience) and patient characteristics (age, gender, socioeconomic status, and race) as well as key organizational features of physicians' work settings. Physicians in Cluster 1 "Cardiac" (N = 92) were more likely to focus on cardiac issues compared with their counterparts; physicians in Cluster 2 "Talkers" (N = 93) were more likely to give advice and take additional medical history; whereas physicians in Cluster 3 "Minimalists" (N = 71) were less likely than their counterparts to take action on any of the types of management behavior.

CONCLUSIONS

Variations in styles of decision making, which encompass multiple outcome variables and extend beyond individual-level demographic predictors, may add to our understanding of disparities in health quality and outcomes.

Substance use disorders and comorbid Axis I and II psychiatric disorders among young psychiatric patients: findings from a large electronic health records database

This study examined the prevalence of substance use disorders (SUDs) among psychiatric patients aged 2-17 years in an electronic health records database (N=11,457) and determined patterns of comorbid diagnoses among patients with a SUD to inform emerging comparative effectiveness research (CER) efforts. DSM-IV diagnoses of all inpatients and outpatients at a large university-based hospital and its associated psychiatric clinics were systematically captured between 2000 and 2010: SUD, anxiety (AD), mood (MD), conduct (CD), attention deficit/hyperactivity (ADHD), personality (PD), adjustment, eating, impulse-control, psychotic, learning, mental retardation, and relational disorders. The prevalence of SUD in the 2-12-year age group (n=6210) was 1.6% and increased to 25% in the 13-17-year age group (n=5247). Cannabis diagnosis was the most prevalent SUD, accounting for more than 80% of all SUD cases. Among patients with a SUD (n=1423), children aged 2-12 years (95%) and females (75-100%) showed high rates of comorbidities; blacks were more likely than whites to be diagnosed with CD, impulse-control, and psychotic diagnoses, while whites had elevated odds of having AD, ADHD, MD, PD, relational, and eating diagnoses. Patients with a SUD used more inpatient treatment than patients without a SUD (43% vs. 21%); children, females, and blacks had elevated odds of inpatient psychiatric treatment. Collectively, results add clinical evidence on treatment needs and diagnostic patterns for understudied diagnoses.

A comparison of autism spectrum disorder DSM-IV criteria and associated features among African American and white children in Philadelphia County

BACKGROUND

Racial differences are documented in the timing and type of autism spectrum disorder (ASD) diagnosis among white and African American children. Differences in clinical presentation by race may contribute to these disparities. This study explores documented differences in core ASD symptoms and associated behavioral features among African American and white children.

METHODS

This project is a secondary data analysis from the Pennsylvania Autism and Developmental Disabilities Surveillance Program and utilized methodology that evaluates existing records, reviews, and codes for DSM-IV criteria for ASD and 12 associated behavioral features. The sample comprised 343 children meeting surveillance case definition for ASD, from 3 population-based cohorts of children in Philadelphia County.

RESULTS

A higher frequency of white children compared to African American children with ASD have documented DSM-IV criteria of inflexible adherence to nonfunctional routines/rituals (92% vs 81%; p = .005) and persistent preoccupation with parts of objects (67% vs 50%; p = .002). A higher frequency of white children with ASD compared to African American children with ASD have documented abnormal motor development (74% vs 60%; p = .008) and odd responses to sensory stimuli (76% vs 51%; p < .001). There were no significant differences in externalizing behaviors or reciprocal social interaction.

CONCLUSIONS

This study suggests differences in the types of ASD symptoms and associated behavioral features exhibited by African American as compared to white children with ASD. Further research is needed to determine if these differences contribute to disparities in the timing or type of ASD diagnosis.

Discordance in Diagnoses and Treatment of Psychiatric Disorders in Children and Adolescents with 22q11.2 Deletion Syndrome

This study examines the rate of utilization of mental health services in children and adolescents with 22q11DS relative to their remarkably high rate of psychiatric disorders and behavior problems. Seventy-two children and adolescents with 22q11DS were participants; their parents completed the Diagnostic Interview Schedule for Children (DISC) and the Child Behavior Checklist (CBCL). The results indicated that 22q11DS children and adolescents have higher rates of psychopathology than the general pediatric population, with ADHD and anxiety disorders being the most common. However, among youth with 22q11DS, those with psychopathology are often no more likely to receive either pharmacological or non-pharmacological mental health care than those without a given psychiatric diagnosis. Thus, although psychopathology is fairly common in this sample, many children with 22q11DS may not be receiving needed psychiatric care. These results have significant implications for these children and their families, as well as for the health care providers who treat them. In particular, the results may suggest a need for careful screening of psychiatric disorders that are likely to affect this population as well, as making appropriate treatment recommendations to remedy childhood mental health problems. Since these children face an extraordinarily high risk of psychoses in late adolescence/adulthood, treatment of childhood psychopathology could be crucial in mitigating the risk/consequences of major psychiatric illnesses in later life.

The impact of race and ethnicity on care in the pediatric emergency department

PURPOSE OF REVIEW

To review healthcare disparities encountered by pediatric patients in the emergency department. The discussion focuses on recent research that is relevant to the field of pediatric emergency medicine.

RECENT FINDINGS

The majority of recent research focuses on healthcare disparities affecting black and Hispanic children and adolescents. Disparities are identified in the areas of emergency department utilization, the provision of effective interpreter services, and the epidemiology and management of specific illnesses, including asthma, adolescent sexual health, and mental health. The findings suggest that disparities persist after controlling for socioeconomic factors and that the effect on healthcare outcomes is measurable. Interventions to mitigate healthcare disparities have shown mixed results. There is some evidence that disparity reduction is possible.

SUMMARY

Recent research demonstrates that healthcare disparities exist in several areas affecting the delivery of quality pediatric emergency care. These disparities are shaped by a complex interaction of social, cultural, behavioral, educational, and financial factors. More research is needed to increase the body of knowledge as to why disparities exist. The success of this future research may require an interdisciplinary approach incorporating experts from multiple scientific fields.

Social and clinical factors associated with psychiatric emergency service use and civil commitment among African-American youth

PURPOSE

We examined the social and clinical factors associated with arrival status (e.g., involuntary versus voluntary) and civil commitment decisions in psychiatric emergency services (PES) to assess African-American youths' help-seeking patterns and entrée into care.

METHODS

Patient records were reviewed for 1621 African-American youth from an inner-city PES between October 2001 and September 2002. Multivariate logistic regression was used to examine the social and clinical factors associated with arrival status (e.g., involuntary vs. voluntary admission) and case disposition among youth who were involuntarily and voluntarily admitted (e.g., disposition upheld vs. dismissed).

RESULTS

Low-income youth with behavior disorders were less likely to arrive voluntarily to PES. Medical insurance, suicidality, DSM diagnosis, substance involvement, Global Assessment of Function (GAF) scores and time of day the youth arrived to PES were predictors of voluntary arrival. Older age and GAF scores significantly predicted the decision to uphold an involuntary commitment. Age (younger age less likely), higher GAF scores, insurance status, substance abuse involvement and arrival time (evening shift) significantly predicted the decision to uphold a voluntary decision.

IMPLICATIONS

Our findings suggest that psychiatric and nonpsychiatric factors influence both how African-American youth arrive to PES and the decisions made regarding their voluntary/involuntary commitment.