School-Based Behavioral Health Service Use and Expenditures for Children With Autism and Children With Other Disorders

Autistic-Delivered Peer Support: A Feasibility Study

Peer support has been an undeveloped pathway for filling the service gap and to generate employment opportunities for autistic individuals. Peer supports have been deployed widely in mental health and among veterans and understanding the utility of this service modality among autistic individuals illuminates opportunities for research, policy, and practice. This study examined characteristics of participants in an autistic-delivered peer support program and reports on use of and satisfaction with the program. Half of autistic participants had a co-occurring mental health diagnosis. Participants reported multiple areas of unmet needs and participant satisfaction with the program was high (90%). The findings of this study point toward autistic-delivered peer support as a promising avenue for future development.

Reported quality indicators and implementation outcomes of community partnership in autism intervention research: A systematic review

There is minimal research on the quality of community partnerships in studies of interventions for autistic children. However, building high quality community engagement in autism intervention research may improve implementation outcomes. This systematic review examined studies that report community partnership in autism intervention research. A total of 135 articles were identified and 11 of these articles were included in the final review. Community partnership data were extracted using indicators from the conceptual framework for assessing research-practice partnerships (RPP; Henrick et al., Henrick et al., Assessing research-practice partnerships: Five dimensions of effectiveness, William T. Grant Foundation, 2017) and implementation outcomes data were extracted using the taxonomy of distinct implementation outcomes (Proctor et al., Administration and Policy in Mental Health and Mental Health Services Research, 38:65-76, 2011). Quality of studies were appraised using JBIs critical appraisal tools (Munn et al., JBI Evidence Synthesis, 18:2127-2133, 2020). RPP indicators and implementation outcomes were variably reported across studies. RPP indicators and implementation outcomes more likely to be reported were related to building trust, cultivating partnership relationships, conducting rigorous research to inform action, acceptability, and feasibility. RPP indicators and implementation outcomes less likely to be reported were related to building capacity to engage in partnership work, sustainability, cost, and penetration. Together, these results may suggest the need for increased sustainability and capacity building efforts in partnerships and increased guidelines for reporting outcomes.

The relationship between school mental health service use in high school and educational outcomes of adolescents with psychiatric disorders

This study aimed to examine the relationship between school mental health service use in high school and educational outcomes of adolescents with psychiatric disorders. The sample included 2617 adolescents who were enrolled in eighth grade in a large urban school district in the United States, were enrolled in Medicaid during eighth grade, and had a mental health diagnosis. Psychiatric hospitalization, school enrollment, school absences, out-of-school suspensions, school dropouts, and school exits for negative reasons were examined as mental health and educational outcomes. Compared with adolescents who used school mental health services for 2 years following eighth grade, adolescents who did not use school mental health service during the high school years had a significantly lower annual number of days enrolled in school and higher rates of exiting school for negative reasons such as school dropout and long-term hospitalization. Our findings support the positive role of school mental health care delivery in high schools in preventing negative educational outcomes for adolescents with psychiatric disorder.

"On an island by myself": implications for the inclusion of autistic students in self-contained classrooms in public elementary schools

Introduction

Autistic students have limited access to inclusive classes and activities in their schools. Principals and special education teachers who directly teach and administer programs for autistic elementary students can offer critical insight into factors, such as educators' attitudes, that may impact inclusive opportunities in schools. These attitudes may serve as barriers to or facilitators of promoting an inclusive school setting.

Methods

Semi-structured interviews with 26 elementary school principals and 26 special education teachers explored their experiences implementing evidence-based practices for autistic students (pivotal response training, discrete trial training, and visual schedules) in 26 self-contained classrooms in the United States. Autism-specific culture and inclusion emerged as a theme, which was analyzed for this paper.

Results

An inductive approach to thematic analysis revealed principals' and special education teachers' perspectives regarding the "autism-specific culture" in the school, including attitudes towards and inclusion of autistic students in self-contained classrooms in the broader school environment. Analysis of text related to "autism-specific culture" detailed aspects of inclusion, factors (i.e., barriers and facilitators) affecting inclusion, principals' and special education teachers' attitudes towards autistic students placed in self-contained classrooms, attitudes of other school staff towards teachers in self-contained classrooms, and recommendations to support an inclusive school environment for autistic students.

Discussion

Results suggest that valuing "equal" access to classes and activities for autistic students in self-contained classrooms may not be sufficient for promoting an inclusive school environment, Educators may benefit from targeted strategies to facilitate inclusion. Strategies range from supporting educators' attitudes and knowledge of autism to shifting physical aspects of the school environment (e.g., location of classrooms). Additional implications for supporting the true inclusion (i.e., inclusion that goes beyond physical inclusion) involves of autistic students in self-contained classrooms schools are discussed.

A framework for measuring the cost to families of caring for children's health: the design, methodology, and study population of the r-Kids study

BACKGROUND

All families experience financial and time costs related to caring for their children's health. Understanding the economic burden faced by families of children with chronic health conditions (CHC) is crucial for designing effective policies to support families.

METHODS

In this prospective study we used electronic health records to identify children between 3 and 17 years old with autism spectrum disorder (ASD), asthma, or neither (control) from three Kaiser Permanente regions and several community health centers in the OCHIN network. We oversampled children from racial and ethnic minority groups. Parent/guardian respondents completed surveys three times, approximately four months apart. The surveys included the Family Economic Impact Inventory (measuring financial, time, and employment costs of caring for a child's health), and standardized measures of children's quality of life, behavioral problems, and symptom severity for children with ASD or asthma. We also assessed parenting stress and parent physical and mental health. All materials were provided in English and Spanish.

RESULTS

Of the 1,461 families that enrolled (564 ASD, 468 asthma, 429 control), children were predominantly male (79%), with a mean age of 9.0 years, and racially and ethnically diverse (43% non-Hispanic white; 22% Hispanic; 35% Asian, Black, Native Hawaiian, or another race/ethnicity). The majority of survey respondents were female (86%), had a college degree (62%), and were married/partnered (79%). ASD group respondents were less likely to be employed (73%) than those in the asthma or control groups (both 80%; p = .023). Only 32% of the control group reported a household income ≤ $4,000/month compared with 41% of asthma and 38% of ASD families (p = .006).

CONCLUSIONS

Utilizing a novel measure assessing family economic burden, we successfully collected survey responses from a large and diverse sample of families. Drawing upon the conceptual framework, survey measures, and self-report data described herein we will conduct future analyses to examine the economic burdens related to CHC and the incremental differences in these burdens between health groups. This information will help policy makers to design more equitable health and social policies that could reduce the burden on families.

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.

Supporting the inclusion and retention of autistic students: Exploring teachers' and paraeducators' use of evidence-based practices in public elementary schools

INTRODUCTION

Educators in public schools are required to serve students in their least restrictive environment. While many evidence-based practices (EBPs), defined as practices and strategies shown by research to have meaningful effectson outcomes for autistic students are documented in the literature, less is known about EBP use among educators in public schools.

METHODS

Eighty-six general and special education teachers and para educators completed a survey about familiarity, training, and EBP use for included autistic children.

RESULTS

Across roles, educators reported familiarity (98.8%), use (97.7%), and training (83.7%) in reinforcement. They reported the least familiarity with behavioral momentum (29.1%), training in both video modeling and peer-mediated instruction and intervention (18.6%), and use of video modeling (14.0%). Follow-up interviews (n = 80) highlighted mixed understanding of EBP definitions and use.

DISCUSSION

Implications for inclusive education are discussed including autism-specific EBP training within pre-service teacher preparation programs.

Mental Health Services for Autistic Individuals Across the Lifespan: Recent Advances and Current Gaps

PURPOSE OF REVIEW

This synthesis of recent mental health services research with autistic individuals presents significant advances, current gaps, and recommendations for improving mental healthcare for this population.

RECENT FINDINGS

Recent advances include improved understanding of co-occurring mental health conditions among autistic individuals, a growing evidence base for interventions to address them, the development and implementation of new service models to support mental health for this population, and a substantial increase in mental health services and implementation research focused on autism. Ongoing challenges include a lack of mental health interventions designed for community implementation with autistic individuals, limited workforce capacity, complex and disconnected service systems, and racial, ethnic, and socioeconomic disparities in accessibility and quality of mental health services. Despite the advances in our understanding of mental health needs and mental health services for autistic individuals, several critical gaps remain. We encourage future efforts to develop and test interventions that can be used in community settings, train and incentivize the workforce to provide them, realign policies and funding with best practice, and embrace an equity-focused approach to autism research and care.

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.

Embedding school cultures and climates that promote evidence-based practice implementation for youth with autism: A qualitative study

LAY ABSTRACT

Schools play a major role in providing services to youth with autism; however, not all schools use evidence-based practices, defined as interventions that are proven to improve youth well-being through rigorous research. School culture and climate are strong predictors of whether or not a school uses evidence-based practices; however, little is known about how principals can create school cultures and climates that support the use of these practices. This study interviewed 32 teachers in elementary schools that implemented three closely related evidence-based practices for youth with autism to better understand how principals create school cultures and climates that support effective services. Analysis of the teachers' responses identified seven strategies principals can use to create school cultures and climates that support the implementation of effective practices for youth with autism. The strategies include the following: (a) support teachers to obtain professional development focused on autism, (b) align performance expectations and evaluations with the needs of students with autism and evidence-based practice delivery, (c) allocate resources to ensure adequate staff, materials, and training are available to implement evidence-based practices, (d) be open and flexible to allow teachers to use the building and resources as needed to meet students' needs, (e) provide direct assistance, feedback, and coaching to troubleshoot challenges or involve outside experts to do so, (f) openly value the work of special education teachers and provide recognition to those who develop expertise in evidence-based practices, and (g) look for opportunities to integrate special and general education teachers and students to foster a truly inclusive climate.

Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) to Improve Collaboration in School Mental Health: Protocol for a Mixed Methods Hybrid Effectiveness-Implementation Study

BACKGROUND

Public schools in the United States are the main providers of mental health services to children but are often ill equipped to provide quality mental health care, especially in low-income urban communities. Schools often rely on partnerships with community organizations to provide mental health services to students. However, collaboration and communication challenges often hinder implementation of evidence-based mental health strategies. Interventions informed by team science, such as Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), have the potential to improve treatment implementation and collaboration within schools.

OBJECTIVE

The objective of this study is to improve communication and collaboration strategies among mental health and school staff by adapting an evidence-based team science intervention for school settings. We present a protocol for a hybrid effectiveness-implementation study to adapt TeamSTEPPS using stakeholder feedback, develop a tailored implementation plan, and pilot the adapted content in eight schools.

METHODS

Study participants will be recruited from public and charter schools and agencies overseeing school mental health services in the local metro area. We will characterize current services by conducting a needs assessment including stakeholder interviews, observations, and review of administrative data. Thereafter, we will establish an advisory board to understand challenges and develop possible solutions to guide additional TeamSTEPPS adaptations along with a complementary implementation plan. In aim 3, we will implement the adapted TeamSTEPPS plus tailored implementation strategies in eight schools using a pre-post design. The primary outcome measures include the feasibility and acceptability of the adapted TeamSTEPPS. In addition, self-report measures of interprofessional collaboration and teamwork will be collected from 80 participating mental health and school personnel. School observations will be conducted prior to and at three time points following the intervention along with stakeholder interviews. The analysis plan includes qualitative, quantitative, and mixed methods analysis of feasibility and acceptability, school observations, stakeholder interviews, and administrative data of behavioral health and school outcomes for students receiving mental health services.

RESULTS

Recruitment for the study has begun. Goals for aim 1 are expected to be completed in Spring 2021.

CONCLUSIONS

This study utilizes team science to improve interprofessional collaboration among school and mental health staff and contributes broadly to the team science literature by developing and specifying implementation strategies to promote sustainability. Results from this study will provide knowledge about whether interventions to improve school culture and climate can ready both mental health and school systems for implementation of evidence-based mental health practices.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04440228; https://clinicaltrials.gov/ct2/show/NCT04440228.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/26567.

Spending on Young Children With Autism Spectrum Disorder in Employer-Sponsored Plans, 2011-2017

OBJECTIVE

Rapid increases in the prevalence of autism spectrum disorder (ASD) and increased access to intensive behavioral interventions have likely increased health care spending. This study estimated recent changes in spending among privately insured children with and without current ASD.

METHODS

A repeated cross-sections analysis of 2011-2017 claims data from large-employer-sponsored health plans assessed changes in annual expenditures by service type for children ages 3-7 enrolled for ≥1 year and with two or more claims with ASD billing codes within a calendar year and for all other children.

RESULTS

Mean spending per child with a current-year ASD diagnosis increased by 51% in 2017 U.S. dollars, from roughly $13,000 in 2011 to $20,000 in 2017. Among children who did not meet the current-year ASD case definition, per-child spending increased by 8%. Spending on children with ASD accounted for 41% of spending growth for children ages 3-7 during 2011-2017. Outpatient behavioral intervention-related spending per child with ASD increased by 376%, from $1,746 in 2011 to $8,317 in 2017; spending on all other services increased by 2%. Their share of behavioral intervention-related spending increased from 13.2% in 2011 to 41.7% in 2017. In 2011, 2.5% of children with current-year ASD diagnoses incurred ≥$20,000 in outpatient behavioral intervention-related spending, which increased to 14.4% in 2017.

CONCLUSIONS

During 2011-2017, spending increased six times as much for privately insured children ages 3-7 with current-year ASD as for children without ASD, largely from increased behavioral intervention-related spending. One in seven children received at least $20,000 in services in 2017.

Cross-sector service use patterns among children with developmental disabilities in a district in Canada

BACKGROUND

There is a lack of information about cross-sector service use by children with developmental disabilities despite their need for services from multiple sectors.

METHODS

Responses to service use questions from a parent-completed survey on school-aged children who attended clinics specific for those with developmental disabilities at a Canadian children's hospital were examined.

RESULTS

School meetings were the most common of three professional meeting types attended in the last 12 months (64.9%) for the sample of 205 children. Recreational services were the most common of five service types received in the same time period (79.0%). Using ordinal logistic regression models, a higher number of behavioural difficulties was the only variable consistently related to indices of more meeting types (school, physician, other) attended and more service types received (recreation, respite, etc.).

CONCLUSIONS

The service relationship with behavioural problems, and not socio-demographic variables, is consistent with a needs-based oriented delivery system.

Service deserts and service oases: Utilizing geographic information systems to evaluate service availability for individuals with autism spectrum disorder

LAY ABSTRACT

Autism spectrum disorder and co-occurring symptoms often require lifelong services. However, access to autism spectrum disorder services is hindered by a lack of available autism spectrum disorder providers. We utilized geographic information systems methods to map autism spectrum disorder provider locations in Michigan. We hypothesized that (1) fewer providers would be located in less versus more populated areas; (2) neighborhoods with low versus high socioeconomic status would have fewer autism spectrum disorder providers; and (3) an interaction would be found between population and socioeconomic status such that neighborhoods with low socioeconomic status and high population would have few available autism spectrum disorder providers. We compiled a list of autism spectrum disorder providers in Michigan, geocoded the location of providers, and used network analysis to assess autism spectrum disorder service availability in relation to population distribution, socioeconomic disadvantage, urbanicity, and immobility. Individuals in rural neighborhoods had fewer available autism spectrum disorder providers than individuals in suburban and urban neighborhoods. In addition, neighborhoods with greater socioeconomic status disadvantage had fewer autism spectrum disorder providers available. Finally, wealthier suburbs had good provider availability while few providers were available in poorer, urban neighborhoods. Knowing autism spectrum disorder providers' availability, and neighborhoods that are particularly poorly serviced, presents the opportunity to utilize evidence-based dissemination and implementation strategies that promote increased autism spectrum disorder providers for underserved individuals.

Leadership profiles associated with the implementation of behavioral health evidence-based practices for autism spectrum disorder in schools

Implementation of evidence-based practice (EBP) for autism spectrum disorder (ASD) in the education system is a public health priority. Leadership is a critical driver of EBP implementation but little is known about the types of leadership behaviors exhibited by school leaders and how this influences the context of EBP implementation, particularly for students with ASD. The objectives of this study were to determine (1) the leadership profiles of principals involved in EBP implementation for students with ASD and (2) how these leadership profiles related to school characteristics and implementation climate. The Exploration, Preparation, Implementation, Sustainment (EPIS) framework was used to guide the design and analysis of this study. Participants (n = 296) included principals, teachers, and classroom support staff. They provided demographic information and completed the Multifactor Leadership Questionnaire and Implementation Climate Scale. Using latent profile analysis, a three-pattern solution was identified: Disengaged (6% of sample), Undifferentiated (23% of sample), and Optimal (71% of sample). Principals in schools with higher proportions of students with an individualized education program were more likely to be classified as Undifferentiated than Optimal. The Optimal group was associated with more positive implementation climate than the Undifferentiated or Disengaged groups. Findings suggest that leadership behaviors rated by principals and their staff involved in implementation of common autism EBPs can be meaningfully clustered into three discernible profiles that are shaped by organizational context and linked to strategic implementation climate. Our study findings have implications for leadership training and service delivery in schools by underscoring the critical nature of school leadership during implementation of EBPs for children with autism and the interplay between specific leadership behaviors and strategic implementation climate.

Autism Spectrum Disorders and ADHD: Overlapping Phenomenology, Diagnostic Issues, and Treatment Considerations

PURPOSE OF REVIEW

Autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder (ADHD) are both increasing in prevalence and commonly co-occur with each other. The goal of this review is to outline what has been published recently on the topics of ASD, ADHD, and the comorbid state (ASD+ADHD) with a particular focus on shared phenomenology, differential diagnosis, and treatment considerations.

RECENT FINDINGS

ASD and ADHD have shared genetic heritability and are both associated with shared impairments in social functioning and executive functioning. Quantitative and qualitative differences exist, however, in the phenotypic presentations of the impairments which characterize ASD and ADHD. For ASD interventions to be maximally efficacious, comorbid ADHD needs to be considered (and vice versa). The research on ASD and ADHD suggests some overlap between the two disorders yet enough differences to indicate that these conditions are sufficiently distinct to warrant separate diagnostic categories.

Individual and organizational factors that affect implementation of evidence-based practices for children with autism in public schools: a cross-sectional observational study

BACKGROUND

Children with autism receive most of their intervention services in public schools, but implementation of evidence-based practices (EBPs) for autism varies. Studies suggest that individual (attitudes) and organizational characteristics (implementation leadership and climate) may influence providers' use of EBPs, but research is relatively limited in this area. This study examined individual and organizational factors associated with implementation of three EBPs-discrete trial training, pivotal response training, and visual schedules-for children with autism in special education classrooms in public elementary schools.

METHODS

Participants included 67 autism support teachers and 85 other classroom staff from 52 public elementary schools in the northeastern United States. Participants reported their attitudes toward EBPs (e.g., intuitive appeal, willingness if required, openness, and divergence), implementation leadership and climate of their school, and the frequency with which they deliver each of three EBPs. Linear regression was used to estimate the association of attitudes about EBPs with organizational characteristics and intensity of EBP use. Demographic covariates with a bivariate association with EBP use significant at p < .20 were entered into the adjusted models.

RESULTS

There were significant findings for only one EBP, discrete trial training. Teachers who reported higher perceived divergence (perceived difference of usual practice with academically developed or research-based practices) between EBPs and current practices used less discrete trial training (f2 = .18), and teachers who reported higher appeal (willingness to adopt EBPs given their intuitive appeal) of EBPs used more discrete trial training (f2 = .22). No organizational factors were significantly associated with implementation with any of the three EBPs.

CONCLUSIONS

Attitudes toward EBPs may affect teachers' decisions to use EBPs; however, implementation leadership and climate did not predict EBP use. Future implementation efforts ought to consider the type of EBP and its fit within the context in terms of the EBP's similarities to and differences from existing practices and programs in the setting. Implementation strategies that target individual attitudes about EBPs may be warranted in public schools.

Organizational culture and climate profiles: relationships with fidelity to three evidence-based practices for autism in elementary schools

BACKGROUND

Implementation researchers have typically studied organizational culture and climate by testing whether individual dimensions are linked to the implementation of evidence-based practices (EBPs) rather than examining how the overarching social context influences implementation. This approach may limit implementation theory and strategy development to the extent that individual dimensions of culture and climate interact, mutually reinforce or counteract one another, or exhibit non-linear relationships. This study tests whether empirically identifiable culture and climate profiles emerge in a sample of organizations and examines how these profiles relate to EBP fidelity and work attitudes that support EBP sustainment, focusing on three EBPs for youth with autism delivered in schools as an example.

METHODS

The study included 65 elementary schools in the U.S. that implemented three EBPs-discrete trial training, pivotal response training, and visual schedules-for youth with autism. Organizational culture and climate and work attitudes were assessed using the Organizational Social Context measure at the beginning of the school year. Observations of EBP fidelity occurred mid school-year. We used bias-adjusted stepwise latent profile modeling to (1) identify subpopulations of schools that share similar culture and climate profiles, and (2) test for mean differences across profiles in observed EBP fidelity and teacher and staff work attitudes.

RESULTS

Controlling for region, four profiles best characterized the organizational cultures and climates of schools. Teachers and staff in schools with a comprehensive profile (high proficiency culture, positive climate) exhibited higher fidelity to two of three EBPs (d's = .95 to 1.64) and reported superior work attitudes (d's = .71 to 1.93) than teachers and staff in all other schools. Teachers and staff in supportive schools (low rigidity culture, positive climate) had better work attitudes, but not better fidelity, than those in schools with indifferent (low culture/climate, elevated stress) and constrained (high rigidity and resistance, high stress) profiles.

CONCLUSIONS

Organizational culture and climate profiles are a strong predictor of EBP fidelity and work attitudes that support EBP sustainment, highlighting the importance of an organization's overarching social context when developing implementation theory and strategies. Strategies that foster a comprehensive profile may improve EBP implementation.

'If I was a different ethnicity, would she treat me the same?': Latino parents' experiences obtaining autism services

This article reports on an ethnographic study with 12 Latino families of children on the autism spectrum related to obtaining autism services in Los Angeles County. Using critical discourse analysis of interviews, observations, and records, we consider the experiences of the Latino families in relation to: 1) A discursively constructed 'autism parent' subject position that mandates 'fighting' service systems to 'win' autism services for children, originating from White middle-class parents' socio-economic resources and social capital; 2) A neoliberal social services climate that assumes scarcity of available resources and prioritizes austerity in their authorization; and 3) A media and institutional 'cultural deficit' discourse that attributes disparities in autism services for Latino children to their parents' presumed culturally-based 'passivity.' We argue that parental discourse about fighting, or not fighting, for autism services is engendered by a tension between a parental logic of care, and the logic of competition of the economic market.

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.

Ethnic Disparities in School-Based Behavioral Health Service Use for Children With Psychiatric Disorders

BACKGROUND

We examined racial/ethnic disparities in school-based behavioral health service use for children with psychiatric disorders.

METHODS

Medicaid claims data were used to compare the behavioral healthcare service use of 23,601 children aged 5-17 years by psychiatric disorder (autism, attention deficit hyperactivity disorder [ADHD], conduct/oppositional defiant disorder, and "other") and by race/ethnicity (African-American, Hispanic, white, and other). Logistic and generalized linear regression analyses were used.

RESULTS

Differences in service use by racial/ethnic group were identified within and across diagnostic groups, both for in-school service use and out-of-school service use. For all disorders, Hispanic children had significantly lower use of in-school services than white children. Among children with ADHD, African-American children were less likely to receive in-school services than white children; however, there were no differences in adjusted annual mean Medicaid expenditures for in-school services by race/ethnicity or psychiatric disorders. Statistically significant differences by race/ethnicity were found for out-of-school service use for children with ADHD and other psychiatric disorders. There were significant differences by race/ethnicity in out-of-school service use for each diagnostic group.

CONCLUSIONS

Differences in the use of school-based behavioral health services by racial and ethnic groups suggest the need for culturally appropriate outreach and tailoring of services to improve service utilization.