RESUMO
BACKGROUND AND OBJECTIVE: First-line, nonpharmacological therapy is recommended for many pediatric mental health (MH) conditions prior to initiating antipsychotic prescription therapies. Many children do not receive these recommended services, despite the known association between antipsychotic medications and metabolic dysfunction. The main objective of this study was to quantify the association among children's MH diagnosis categories, sociodemographic characteristics and receipt of first-line psychosocial care among children in Florida Medicaid METHODS: Florida Medicaid enrollment, healthcare and pharmacy claims were used for this multivariate analysis. Children were assigned to condition clusters wherein related diagnoses were grouped into clinically relevant categories. A total of 7704 children were included in the final analysis. RESULTS: Twenty-four percent of children in Florida Medicaid do not receive first-line, nonpharmacological psychosocial care. Age was significantly associated with not receiving psychosocial services, with older children less likely to receive. Non-Hispanic White children as well as those living in rural areas had lower odds of receiving behavioral intervention prior to initiating antipsychotics. Children with mood-disorders, behavior problems, anxiety and stress related disorders were more likely to receive first-line psychosocial care. CONCLUSIONS: This study provides an important understanding of the variability in receipt of first-line psychosocial care before antipsychotic medication initiation among children in Medicaid based on sociodemographic and MH health characteristics. These analyses can be used to develop quality improvement initiatives targeted toward children that are most vulnerable for not receiving recommended care.
Assuntos
Antipsicóticos , Reabilitação Psiquiátrica , Adolescente , Antipsicóticos/uso terapêutico , Criança , Florida , Humanos , Medicaid , Transtornos do Humor/tratamento farmacológico , Estados UnidosRESUMO
OBJECTIVE: We sought to examine the extent to which body mass index (BMI) was available in electronic health records for Florida Medicaid recipients aged 5 to 18 years taking Second-Generation Antipsychotics (SGAP). We also sought to illustrate how clinical data can be used to identify children most at-risk for SGAP-induced weight gain, which cannot be done using process-focused measures. METHODS: Electronic health record (EHR) data and Medicaid claims were linked from 2013 to 2019. We quantified sociodemographic differences between children with and without pre- and post-BMI values. We developed a linear regression model of post-BMI to examine pre-post changes in BMI among 4 groups: 1) BH/SGAP+ children had behavioral health conditions and were taking SGAP; 2) BH/SGAP- children had behavioral health conditions without taking SGAP; 3) children with asthma; and 4) healthy children. RESULTS: Of 363,360 EHR-Medicaid linked children, 18,726 were BH/SGAP+. Roughly 4% of linked children and 8% of BH/SGAP+ children had both pre and post values of BMI required to assess quality of SGAP monitoring. The percentage varied with gender and race-ethnicity. The R2 for the regression model with all predictors was 0.865. Pre-post change in BMI differed significantly (P < .0001) among the groups, with more BMI gain among those taking SGAP, particularly those with higher baseline BMI. CONCLUSION: Meeting the 2030 Centers for Medicare and Medicaid Services goal of digital monitoring of quality of care will require continuing expansion of clinical encounter data capture to provide the data needed for digital quality monitoring. Using linked EHR and claims data allows identifying children at higher risk for SGAP-induced weight gain.
Assuntos
Antipsicóticos , Adolescente , Idoso , Antipsicóticos/efeitos adversos , Índice de Massa Corporal , Criança , Pré-Escolar , Humanos , Medicaid , Medicare , Estados Unidos , Aumento de PesoRESUMO
BACKGROUND AND OBJECTIVES: Metabolic monitoring is important for children taking antipsychotic medication, given the risk for increased BMI, impaired glucose metabolism, and hyperlipidemia. The purpose was to examine the influence of provider specialty on the receipt of metabolic monitoring. Specifically, differences in the receipt of recommended care when a child receives outpatient care from a primary care provider (PCP), a mental health provider with prescribing privileges, or both was examined. METHODS: Medicaid enrollment and health care and pharmacy claims data from 2 states were used in the analyses. Providers were assigned to specialties by using a crosswalk of the National Provider Identifier numbers to specialty type. A total of 41 078 children were included. RESULTS: For both states, 61% of children saw ≥1 provider type and had adjusted odds ratios for receiving metabolic monitoring that were significantly higher than those of children seeing PCPs only. For example, children seeing a PCP and a mental health provider with prescribing privileges during the year had adjusted odds of receiving metabolic monitoring that were 42% higher than those seeing a PCP alone (P < .001). CONCLUSIONS: Shared care arrangements significantly increased the chances that metabolic monitoring would be done. For states, health plans, and clinicians to develop meaningful quality improvement strategies, identifying the multiple providers caring for the children and potentially responsible for ordering tests consistent with evidence-based care is essential. Provider attribution in the context of shared care arrangements plays a critical role in driving quality improvement efforts.
Assuntos
Antipsicóticos/uso terapêutico , Monitoramento de Medicamentos/estatística & dados numéricos , Serviços de Saúde Mental , Atenção Primária à Saúde , Adolescente , Criança , Pré-Escolar , Feminino , Florida , Humanos , Masculino , Medicaid , Equipe de Assistência ao Paciente , Texas , Estados UnidosRESUMO
OBJECTIVE: The objective of this study was to develop and test a measure that estimates unplanned, 30-day, all-cause risk-standardized readmission rates (RSRRs) after inpatient psychiatric facility (IPF) discharge. PARTICIPANTS: We established a retrospective cohort of adults with a principal diagnosis of psychiatric illness or dementia discharged from IPFs to nonacute care settings, using 2012-2013 Medicare fee-for-service claims data. MEASURES: All-cause unplanned readmissions within 3-30 days post-IPF discharge were assessed by constructing then validating a parsimonious logistic regression model of 56 risk factors (selected via empirical data, systematic literature review, clinical expert opinion) for readmission using bootstrapping. RSRRs were calculated from the ratio of predicted versus expected readmission rates for each IPF using hierarchical regression. Measure reliability and validity were assessed via multiple strategies. RESULTS: The measure development cohort included 716,174 admissions to 1679 IPFs and 149,475 (20.9%) readmissions. Most readmissions (>80%) had principal diagnoses of mood, schizoaffective or substance use disorders, delirium/dementia, infections or drug/substance poisoning. Facility RSRRs ranged from 11.0% to 35.4%. The risk adjustment model showed good calibration and moderate discrimination similar to other readmission risk models (c statistic 0.66). Sensitivity analyses solidified the risk modeling approach. The intraclass correlation coefficient of estimated IPF RSRRs was 0.78, indicating good reliability. The measure identified 8.3% of hospitals as having better and 13.4% as having worse RSRRs than the national readmission rate. CONCLUSIONS: The measure provides an assessment of facility-level quality and insight into risk factors useful for informing preventive interventions. The measure will be included in the Centers for Medicare and Medicaid Services (CMS) Inpatient Psychiatric Quality Reporting program in 2019.
Assuntos
Demandas Administrativas em Assistência à Saúde/estatística & dados numéricos , Pacientes Internados , Readmissão do Paciente/estatística & dados numéricos , Unidade Hospitalar de Psiquiatria , Indicadores de Qualidade em Assistência à Saúde , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Medicare , Transtornos Mentais/diagnóstico , Transtornos Mentais/terapia , Pessoa de Meia-Idade , Alta do Paciente , Reprodutibilidade dos Testes , Estudos Retrospectivos , Risco Ajustado , Estados UnidosRESUMO
OBJECTIVE: To describe psychotropic treatment pattern and evaluate the association of socio-demographic factors and psychotropic combination therapy in children with ADHD and oppositional defiant disorder/conduct disorder (ODD/CD). METHOD: This is a cross-sectional drug utilization study based on Medicaid fee-for-service programs in 26 U.S. states (1999-2006). Children aged 4 to 18 with concomitant ADHD and ODD/CD were included. We calculated the prevalence of psychotropic drugs and used logistic regression to evaluate the role of socio-demographic factors in psychotropic combination therapy. RESULTS: We identified 121,740 children with ADHD and ODD/CD (140,777 person-years). The period prevalence of "no psychotropic therapy," psychotropic monotherapy, and psychotropic dual therapy was 38.1%, 44.7%, and 9.0%, respectively. The most common drug class was stimulants. Whites, males, and children in foster care were more likely to use psychotropic combination therapy. State-level variation was observed. CONCLUSION: "No psychotropic therapy" and stimulants dominate treatment choices in children with ADHD and ODD/CD. Socio-demographic characteristics are associated with combination psychotropic therapy.
Assuntos
Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Transtornos de Deficit da Atenção e do Comportamento Disruptivo/tratamento farmacológico , Transtorno da Conduta/tratamento farmacológico , Medicaid/estatística & dados numéricos , Psicotrópicos/uso terapêutico , Adolescente , Transtorno do Deficit de Atenção com Hiperatividade/epidemiologia , Transtornos de Deficit da Atenção e do Comportamento Disruptivo/complicações , Estimulantes do Sistema Nervoso Central/uso terapêutico , Criança , Pré-Escolar , Terapia Combinada , Transtorno da Conduta/epidemiologia , Estudos Transversais , Uso de Medicamentos , Feminino , Humanos , Masculino , Prevalência , Estados UnidosRESUMO
OBJECTIVES: This study estimated the prevalence, time trends, and state-level variation of same- and multiclass psychotropic polypharmacy among youths in Medicaid fee-for-service plans. METHODS: Using pharmacy records from 29 Medicaid states from 1999 to 2010, the authors constructed ten two-year cohorts of beneficiaries between ages 0 and 17 years who received at least one psychotropic to treat a mental disorder. Polypharmacy was defined as any period in which dispensed days' supply of psychotropics overlapped for more than 45 days. Same- and multiclass psychotropic polypharmacy prevalence was stratified by age and state. RESULTS: A total of 692,485 children were included across each two-year cohort. The prevalence of any-class and multiclass psychotropic polypharmacy grew steadily, from 21.2% and 18.8% in 1999-2000 to 27.3% and 24.4% in 2009-2010, respectively. The prevalence increased with older age, with highest estimates for late adolescents. For same-class psychotropic polypharmacy, a constant upward trend was noted over time, except for antidepressants. Polypharmacy increased over the decade for central nervous system stimulants, from .1% to .6%, and for alpha-agonists, from .1% to .4%. Heterogeneous prevalences of psychotropic polypharmacy were noted across states, ranging from 6.9% to 48.8% for any-class psychotropic polypharmacy, from .4% to 6.4% for same-class antidepressant polypharmacy, and from .1% to 4.6% for antipsychotics. CONCLUSIONS: The study found an overall increasing trend of psychotropic polypharmacy coupled with significant variation across the examined states. A more granular assessment that considers patient characteristics and local contextual factors is warranted.
Assuntos
Medicaid , Transtornos Mentais/epidemiologia , Polimedicação , Psicotrópicos/uso terapêutico , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Masculino , Transtornos Mentais/tratamento farmacológico , Fatores de Tempo , Estados UnidosRESUMO
OBJECTIVE: To evaluate the safety of stimulants in children with epilepsy. METHODS: In a retrospective cohort study based on Medicaid Analytic eXtract billing records from 26 U.S. states from 1999 to 2010, we identified incident stimulant use among children with epilepsy through outpatient encounter claims and pharmacy claims. We established a control group of nonusers and used frequency matching to generate index dates. We followed both cohorts for 12 months and calculated hazard ratios [HRs] of current and former use of stimulants versus no use on the outcome of seizure-related hospitalization using multivariate Cox proportional hazard models. RESULTS: We identified 18,166 stimulant users and 54,197 nonusers in children with epilepsy. The incidence of seizure-related hospitalization in current stimulant users, former users, and nonusers was 3.6, 3.5, and 4.3 per 100 patient-years. After adjustment for confounders, we found current and former use of stimulants did not increase seizure-related hospitalizations (HR 0.95, 95% confidence interval [CI]: 0.83, 1.09 and HR 0.99, 95% CI: 0.85, 1.15). Children with cerebral palsy, congenital nervous system anomalies, or intellectual disability did not have significantly higher HRs than those without the already mentioned comorbidities. CONCLUSION: This study has not identified any overall increase in the rate of seizure-related hospitalizations with the use of stimulants in children with epilepsy.
Assuntos
Estimulantes do Sistema Nervoso Central/efeitos adversos , Epilepsia/fisiopatologia , Hospitalização/estatística & dados numéricos , Convulsões/epidemiologia , Adolescente , Estimulantes do Sistema Nervoso Central/administração & dosagem , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Incidência , Masculino , Medicaid , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Estados UnidosRESUMO
OBJECTIVE: To examine incidence of adverse health outcomes and associated factors among preschoolers (under age 6) who received antipsychotic treatment through the Florida Medicaid Prior Authorization (PA) program. METHODS: Using Florida's PA registry linked to the state's Medicaid claims data, we ascertained incident outcomes during PA-approved antipsychotic use between April 2008 and September 2015 (7.5 years). Six outcomes associated with use of antipsychotics included: diabetes, obesity, hyperlipidemia, hyperprolactinemia, cardiovascular disease (CVD) (including hypertension, ventricular arrhythmia, and other CVDs), and extrapyramidal symptoms (EPS) (including dystonia, akathisia, parkinsonism, and tardive dyskinesia). Outcome-specific incidences were stratified by short-term (≤1 year) and long-term (>1-7 years) antipsychotic use. We used multivariate modified Poisson regressions to determine factors associated with these outcomes among preschoolers. RESULTS: The overall crude incidence during PA-approved antipsychotic use was highest for EPS and obesity (57 and 19 cases/1000 children-years, respectively). The rate of these two outcomes differed by duration of antipsychotic use. We observed a higher obesity (23.8 vs. 9.6, p < 0.001) and dystonia incidence (7.2 vs. 2.5, p < 0.05), but lower akathisia incidence (44.4 vs. 60.6, p < 0.05) among long-term antipsychotic users compared with short-term users. Five outcomes-ventricular arrhythmia, other cardiovascular side effects, hyperprolactinemia, parkinsonism, and tardive dyskinesia-occurred rarely (<2.0/1000 children-years). Preschoolers who were younger at baseline (≤2 years old vs. 4-5 years old) and Black (vs. White) were at a higher risk of EPS. CONCLUSION: Risk for EPS and obesity deserves clinical attention during antipsychotic treatment among preschoolers. Controlled studies that allow interpretation of these incidence rates in the context of background risk and that formally quantify the incremental risk associated with antipsychotic initiation during early childhood are needed.
Assuntos
Antipsicóticos/efeitos adversos , Medicaid , Transtornos Mentais/tratamento farmacológico , Acatisia Induzida por Medicamentos/epidemiologia , Pré-Escolar , Discinesia Induzida por Medicamentos/epidemiologia , Feminino , Florida , Humanos , Incidência , Estudos Longitudinais , Masculino , Obesidade/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
OBJECTIVE: This research aimed to quantify the prevalence of psychotherapy among Medicaid-insured patients within six months of initiating psychotropic medication polypharmacy (PMP). METHODS: Using the Medicaid Analytic eXtract database for 29 states from 1999 to 2010, investigators established ten two-year cohorts of pediatric and adult patients who received two or more psychotropic drugs with a 45-day overlapping days' supply. Among PMP initiators, the prevalence of psychotherapy services, identified from encounter claims via Current Procedural Terminology and Healthcare Common Procedure Coding System codes, was calculated for the six months before and the six months after initiation of PMP. RESULTS: PMP prevalence varied from 21.2% to 27.7% and from 48.5% to 58.0% in pediatric and adult Medicaid-insured patients, respectively. Among pediatric patients who started PMP (N=397,728), the proportion who had received psychotherapy before PMP varied from 21.0% in the 1999-2000 cohort to 40.0% in 2005-2007. After PMP initiation, psychotherapy prevalence was higher, with estimates ranging from 25.4% in 1999-2000 to 44.1% in 2005-2007. Among adults (N=773,205), the prevalence of psychotherapy after PMP initiation ranged from 12.6% in 1999-2001 to 19.25% in 2003-2005. Psychotherapy prevalence prior to PMP initiation varied greatly across states. CONCLUSIONS: Although the prevalence of psychotherapy provided immediately before and after initiation of psychotropic polypharmacy has slightly increased in the past decade, it remains low among Medicaid-insured patients, particularly among adults. Reasons for variation in psychotherapy utilization across states deserve further exploration.
Assuntos
Medicaid/estatística & dados numéricos , Polimedicação , Psicoterapia/estatística & dados numéricos , Psicotrópicos/uso terapêutico , Adolescente , Adulto , Criança , Pré-Escolar , Humanos , Pessoa de Meia-Idade , Estados UnidosRESUMO
OBJECTIVE: We describe the trends in antiepileptic drug (AED) use in children and adolescents with epilepsy in the United States. METHODS: We undertook a cross-sectional study based on Medicaid Analytic eXtract data set from 26 US states. Children and adolescents aged three to 18 years with at least one year continuous Medicaid fee-for-service coverage after the second outpatient or the first inpatient diagnosis of epilepsy in each calendar year during 1999 to 2009 were included in the study; therefore, 11 cohorts were established. A patient was defined as being exposed to a specific AED if he or she had at least one-day supply of the AED during the 1-year follow-up period. The annual prevalence of AEDs was reported, stratified by gender and age. The trends in AED use were evaluated through linear regression. RESULTS: The sample sizes of the 11 cohorts ranged between 17,304 and 22,672. The annual prevalence of valproic acid use declined from 42.4% in 1999 to 26.5% in 2009, and the prevalence of carbamazepine use declined from 37.1% to 10.2%. Meanwhile, the prevalence of levetiracetam use increased from 5.1% to about 32.0% in 2009, and the prevalence of oxcarbazepine use increased from 1.3% to 19.1%. Since 2008, levetiracetam (29.6%) has replaced valproic acid (27.8%) as the most commonly used AED in children and adolescents with epilepsy. The prevalence of diazepam use increased from 11.6% to 28.1%. SIGNIFICANCE: Compared with first- and second-generation antiepileptic drugs, third-generation AEDs have fewer adverse side effects, resulting in increased patient treatment adherence. Equally important is the economic impact of these newer AEDs. This first-of-its-kind study underscores the need for large database studies that objectively assess the cost-effectiveness of third-generation AEDs versus first- and second-generation AEDs in the treatment of childhood epilepsy.
Assuntos
Anticonvulsivantes/uso terapêutico , Epilepsia/tratamento farmacológico , Epilepsia/epidemiologia , Medicaid/tendências , Adolescente , Anticonvulsivantes/economia , Criança , Pré-Escolar , Estudos de Coortes , Análise Custo-Benefício , Feminino , Humanos , Masculino , Medicaid/estatística & dados numéricos , Estatística como Assunto , Fatores de Tempo , Estados Unidos/epidemiologiaRESUMO
PURPOSE: To explore changes in stimulant utilization and pre-treatment electrocardiography (ECG) screening in response to cardiovascular (CV) safety concerns. METHODS: Two source populations were established from Florida Medicaid Fee-for-service beneficiaries between 2001 and 2008: approximately 44 571 newly diagnosed attention deficit/hyperactivity disorder patients and 33 000 new stimulant users. Time-series design and Joinpoint analysis were used to describe monthly trend changes in stimulant initiation, persistence, dosing, and pre-treatment ECG screening. RESULTS: Initial and maintenance daily dose declined 6 mg (95% confidence interval [CI] -14 to -1.9) methylphenidate (MPH) equivalent dose from a steady 27 mg after Canada withdrew Adderall XR in February 2005; the trend rebounded to a daily dose of 23 mg, after the remarketing of Adderall XR and a debate in the US over issuing a boxed warning on stimulant CV safety in early 2006. Monthly initiation increased 3.9% (CI -1.0 to 9.1) after the boxed warning debate to 54 per 100 patients per month (CI 44 to 68), but declined 2.4% (CI -3.6 to -1.2) after requirement of medication guides in February 2007. Monthly ECG screening increased 3.2% (CI 2.3 to 4.2) after Adderall XR withdrawal and further increased 13% (CI 4 to 23) after the American Heart Association recommended pre-treatment ECG screening to 40 per 100 patients per month (CI 17 to 48). CONCLUSIONS: The first signal of stimulant CV safety concerns was followed by varying responses depending on the outcome measure used, suggesting that patients and physicians responded at different times after the publicity of safety concerns. Clinical consequences of the changes are uncertain. Copyright © 2015 John Wiley & Sons, Ltd.
Assuntos
Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Doenças Cardiovasculares/prevenção & controle , Estimulantes do Sistema Nervoso Central/administração & dosagem , Metilfenidato/administração & dosagem , Anfetaminas/administração & dosagem , Anfetaminas/efeitos adversos , Doenças Cardiovasculares/induzido quimicamente , Estimulantes do Sistema Nervoso Central/efeitos adversos , Criança , Relação Dose-Resposta a Droga , Rotulagem de Medicamentos , Eletrocardiografia/métodos , Feminino , Florida , Humanos , Masculino , Medicaid , Metilfenidato/efeitos adversos , Avaliação de Resultados em Cuidados de Saúde , Fatores de Tempo , Estados UnidosRESUMO
OBJECTIVE: To examine whether parent perceptions about care (barriers, disorder knowledge, treatment willingness) vary among children who drop out of or stay in publicly funded care for attention-deficit/hyperactivity disorder (ADHD) and to explore whether parent perceptions are predictive of staying in care over time. METHODS: A longitudinal cohort study of 529 children ages 5 to 11 years receiving care for ADHD in primary care or specialty mental health clinics in a large, countrywide, managed-care Medicaid program. Multiple logistic regression analyses were performed to identify parent perceptions associated with the likelihood of staying in care across three 6-month time intervals, controlling for child and parent demographic characteristics, parental distress, clinical need, and recent special education use. RESULTS: At least three-fourths of children had at least 1 contact for any mental health care during a 6-month time interval (75%, 85%, 76%). Parent-perceived barriers, ADHD knowledge, and counseling willingness did not predict staying in care, whereas willingness for medication treatment was predictive at baseline. Minority status, nonmarried parent, parental distress, clinical need, and special education use were predictive of staying in care, but mostly during only one 6-month time interval, and their influence varied over time. CONCLUSIONS: Parent willingness for medication treatment along with several demographic and need factors predicted staying in care but not consistently over time. Future research is needed to develop practical tools for clinicians to elicit parent priorities about ADHD treatment and to integrate them into quality-improvement interventions targeted to improving shared decision-making for longer term ADHD care.
Assuntos
Transtorno do Deficit de Atenção com Hiperatividade/terapia , Conhecimentos, Atitudes e Prática em Saúde , Pais , Cooperação do Paciente , Transtorno do Deficit de Atenção com Hiperatividade/epidemiologia , Criança , Serviços de Saúde da Criança , Pré-Escolar , Estudos de Coortes , Serviços Comunitários de Saúde Mental , Educação Inclusiva , Feminino , Acessibilidade aos Serviços de Saúde , Necessidades e Demandas de Serviços de Saúde , Humanos , Modelos Logísticos , Estudos Longitudinais , Masculino , Medicaid , Grupos Minoritários , Grupos Raciais/estatística & dados numéricos , Pais Solteiros , Estresse Psicológico/epidemiologia , Estados Unidos/epidemiologiaRESUMO
This study evaluated the psychometric properties of the treatment-emergent activation and suicidality assessment profile (TEASAP) in a clinical sample of 56 youth aged 7-17 with obsessive-compulsive disorder (OCD) who participated in a double-blind randomized controlled trial. The 38-item TEASAP demonstrated good internal consistency for its total score (α=0.93) and adequate to good performance for its five subscale scores (α=0.65-0.92). One-week test-retest stability (N=18) was adequate (Intraclass correlation coefficient [ICC]=0.68-0.80) except for Self-Injury (ICC=0.46). Construct validity was supported by total and subscale TEASAP score relationships with related constructs, including irritability, hyperactivity, externalizing behaviors, manic symptoms, and suicidal ideation, and the absence of relationships with unrelated constructs. Predictive validity was established for the Disinhibition subscale through significant associations with subsequent activation events. Furthermore, TEASAP sensitivity to change in activation scores over time was supported by longitudinal associations of TEASAP scores with clinician ratings of activation over the course of treatment. Findings indicate that the TEASAP has acceptable psychometric properties in a clinical sample of youth with OCD and merits further study in larger samples for additional refinement of its measurement approaches.
Assuntos
Transtorno Obsessivo-Compulsivo/psicologia , Agitação Psicomotora/diagnóstico , Ideação Suicida , Adolescente , Ansiedade/diagnóstico , Ansiedade/psicologia , Lista de Checagem , Criança , Comportamento Infantil , Depressão/diagnóstico , Depressão/psicologia , Feminino , Humanos , Masculino , Transtorno Obsessivo-Compulsivo/tratamento farmacológico , Escalas de Graduação Psiquiátrica/normas , Psicometria , Agitação Psicomotora/etiologia , Agitação Psicomotora/psicologia , Reprodutibilidade dos Testes , Inibidores Seletivos de Recaptação de Serotonina/administração & dosagem , Inibidores Seletivos de Recaptação de Serotonina/uso terapêutico , Sertralina/efeitos adversos , Sertralina/uso terapêuticoAssuntos
Psiquiatria do Adolescente/tendências , Psiquiatria Infantil/tendências , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/tendências , Programas Gente Saudável/tendências , Transtornos Mentais/etnologia , Grupos Minoritários/psicologia , Grupos Minoritários/estatística & dados numéricos , Adolescente , Criança , Estudos Transversais , Previsões , Humanos , Delinquência Juvenil/etnologia , Delinquência Juvenil/psicologia , Delinquência Juvenil/estatística & dados numéricos , Transtornos Mentais/prevenção & controle , Transtornos Mentais/psicologia , Papel do Médico/psicologia , Estados Unidos , United States Dept. of Health and Human ServicesRESUMO
OBJECTIVE: To examine whether clinical severity is greater among children receiving attention-deficit/hyperactivity disorder (ADHD) care in primary care compared with those in specialty mental health clinics, and to examine how care processes and clinical outcomes vary by sector across three 6-month time intervals. METHOD: This was a longitudinal cohort study of 530 children aged 5 to 11 years receiving ADHD care in primary care or specialty mental health clinics from November 2004 through September 2006 in a large, countywide managed care Medicaid program. RESULTS: Clinical severity at study entry did not differ between children who received ADHD care in solely primary or specialty mental health care clinics. At three 6-month intervals, receipt of no care ranged from 34% to 44%, and unmet need for mental health services ranged from 13% to 20%. In primary care, 80% to 85% of children had at least one stimulant prescription filled and averaged one to two follow-up visits per year. Less than one-third of children in specialty mental health clinics received any stimulant medication, but all received psychosocial interventions averaging more than five visits per month. In both sectors, stimulant medication refill prescription persistence was poor (31%-49%). With few exceptions, ADHD diagnosis, impairment, academic achievement, parent distress, and parent-reported treatment satisfaction, perceived benefit, and improved family functioning did not differ between children who remained in care and those who received no care. CONCLUSION: Areas for quality improvement are alignment of clinical severity with provider type, follow-up visits, stimulant use in specialty mental health, agency data infrastructure to document delivery of evidence-based psychosocial treatment, and stimulant medication refill prescription persistence.
Assuntos
Transtorno do Deficit de Atenção com Hiperatividade/diagnóstico , Transtorno do Deficit de Atenção com Hiperatividade/terapia , Programas de Assistência Gerenciada/normas , Medicaid/normas , Qualidade da Assistência à Saúde/normas , Estimulantes do Sistema Nervoso Central/uso terapêutico , Criança , Pré-Escolar , Terapia Combinada/normas , Feminino , Necessidades e Demandas de Serviços de Saúde/normas , Pesquisa sobre Serviços de Saúde , Humanos , Estudos Longitudinais , Masculino , Atenção Primária à Saúde/normas , Psicoterapia/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Padrões de Referência , Encaminhamento e Consulta/normas , Estados UnidosRESUMO
This study evaluated the psychometric properties of the attention deficit hyperactivity disorder (ADHD) Stigma Questionnaire (ASQ) among a community sample of 301 adolescents ages 11-19 years at high (n=192) and low risks (n=109) for ADHD. Study subjects were drawn from a cohort study assessing ADHD detection and service use. The 26-item ASQ demonstrated good internal consistency. Confirmatory factor analysis using random parceling supported a three-factor structure with highly correlated subscales of disclosure concerns, negative self image, and concern with public attitudes, and a Schmid-Leiman analysis supported an overall stigma factor. Test-retest stability was assessed after two weeks (n=45) and found to be adequate for all three subscales. Construct validity was supported by relationships with related constructs, including clinical maladjustment, depression, self-esteem, and emotional symptoms, and the absence of a relationship with school maladjustment. Findings indicate that the ASQ has acceptable psychometric properties in a large community sample of adolescents, some of whom met Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for ADHD.
Assuntos
Transtorno do Deficit de Atenção com Hiperatividade/diagnóstico , Transtorno do Deficit de Atenção com Hiperatividade/psicologia , Cristianismo/psicologia , Psicometria , Autoimagem , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Masculino , Escalas de Graduação Psiquiátrica , Reprodutibilidade dos Testes , Estudos Retrospectivos , Inquéritos e QuestionáriosRESUMO
This study describes 4 help-seeking steps among children at high risk for attention deficit hyperactivity disorder (ADHD), and identifies barriers to ADHD symptom detection and treatment. Using a district-wide stratified random sample of 1615 elementary school students screened for ADHD risk, predictors of 4 help-seeking steps among a high-risk group (n = 389) and parent-identified barriers to care among children with unmet need for ADHD care (n = 91) were assessed. Study findings indicate that although 88% of children were recognized as having a problem, only 39% had been evaluated, 32% received an ADHD diagnosis, and 23% received current treatment. Older children and those with more severe behavior problems were more likely to be perceived by their parents as having a problem. Additionally, gender and ethnic disparities in the subsequent help-seeking process emerged. Boys had over 5 times the odds than girls of receiving an evaluation, an ADHD diagnosis, and treatment. Compared to African American youth, Caucasian children had twice the odds of taking these help-seeking steps. For those children with unmet need for ADHD care, poverty predicted lower treatment rates and was associated with the most pervasive barriers. The gap between parental problem recognition and seeking services suggests that thresholds for parental recognition of a child behavior problem and for seeking ADHD services may be different. Future research examining the help-seeking process for ADHD should include a qualitative component to explore the potential mechanisms for gender and ethnic differences.