Mental Health of Youth With Autism Spectrum Disorder and Gender Dysphoria.

BACKGROUND AND OBJECTIVES: Youth with either autism spectrum disorder (ASD) or gender dysphoria (GD) alone have also been shown to be at greater risk for mental health (MH) concerns; however, very little research has considered how cooccurring ASD and GD may exacerbate MH concerns. The purpose of this study was to examine associations between ASD, GD, and MH diagnoses (anxiety, depression, eating disorder, suicidality, and self-harm) among US adolescent populations. METHODS: This is a secondary analysis of a large administrative dataset formed by 8 pediatric health system members of the PEDSnet learning health system network. Analyses included descriptive statistics and adjusted mixed logistic regression models testing for associations between combinations of ASD and GD diagnoses and MH diagnoses as recorded in the patient's electronic medical record. RESULTS: Based on data from 919 898 patients aged 9 to 18 years, adjusted mixed logistic regression indicated significantly greater odds of each MH diagnosis among those with ASD alone, GD alone, and cooccurring ASD/GD diagnoses compared with those with neither diagnosis. Youth with cooccurring ASD/GD were at significantly greater risk of also having anxiety (average predicted probability, 0.75; 95% confidence interval, 0.68-0.81) or depression diagnoses (average predicted probability, 0.33; 95% confidence interval, 0.24-0.43) compared with youth with ASD alone, GD alone, or neither diagnosis. CONCLUSIONS: Youth with cooccurring ASD/GD are more likely to also be diagnosed with MH concerns, particularly anxiety and depression. This study highlights the need to implement developmentally appropriate, gender-affirming MH services and interventions for youth with cooccurring ASD/GD.

An agricultural community's perspectives on COVID-19 testing to support safe school reopening.

Introduction: School-based COVID-19 testing may be an effective strategy for reducing transmission in schools and keeping schools open. The study objective was to examine community perspectives on school-based COVID-19 testing as a mitigation strategy to support safe school reopening. Methods: We conducted a qualitative study in Yakima County, an agricultural region of Washington state, where over half of residents are Hispanic/Latino. From June to July 2021, we interviewed 18 students (13 years old, on average) and 19 school employees, and conducted four focus groups (2 in Spanish, 2 in English) with 26 parents. We audio-recorded the semi-structured interviews and focus group discussions which were then transcribed. We used an inductive, constant comparison approach to code the transcripts and conducted a thematic analysis to generate themes. Results: We identified four main themes. Students, parents, and school employees desired a return to in-person learning (Theme 1). Schools implemented numerous COVID-19 mitigation strategies (e.g., masking) to facilitate a safe return to school but felt that adding testing would not be feasible due to a lack of resources and overworked staff (Theme 2). Parents and school employees' familiarity with COVID-19 testing procedures influenced their support for testing (Theme 3). Parents and school employees felt there were inadequate resources for individuals who test positive for COVID-19 (Theme 4). Discussion: Schools require adequate resources and medical personnel to implement COVID-19 testing. Individuals also need resources after testing positive, including physical space to isolate, financial resources for those without paid time off, and delivery of food and other necessities to households in rural communities.

Racial disparities in youth pretrial detention: a retrospective cohort study grounded in critical race theory.

BACKGROUND AND METHOD: Pretrial detention makes up 75% of juvenile detention admissions and contributes to the disproportionate contact of minoritized youth in the juvenile carceral system. Given that prior evidence largely examines differences between Black and white youth, this study expands research on disproportionate contact in the pretrial detention setting to Hispanic/Latinx, Indigenous, and Asian youth. With a sample of over 44,000 juvenile cases in a northwest state, we used a generalized linear mixed model to estimate the effect of individual level characteristics while accounting for the random effect of differences at the county level. Additionally, we utilized Critical Race Theory (CRT) in formulating our theoretical model and predictions and apply CRT in our analysis and discussion of our results. In doing so we hope to build upon its application in public health discourse for naming and deconstructing processes that lead to unjust social and health stratification. RESULTS: After factoring in gender, age, crime severity, previous offenses, and variation between counties, our analyses show that Black, Hispanic/Latinx, and American Indian/Alaskan Native youth are more likely to experience pretrial detention than white youth. The likelihood of pretrial detention for Asian youth and for youth identified as "Other" or "Unknown" was not significantly different from white youth. CONCLUSIONS: As the iatrogenic effects of detention are disproportionately imposed upon youth of color-particularly Black, Indigenous, and Hispanic/Latinx youth-the disparities present in our study reveal further evidence of institutional racism. In this way, we can see how this carceral process operates as a mechanism of racialized social stratification as put forth by CRT. Considering implications for policy or further research, persistent disparity highlights an enduring need for building or strengthening diversion programs and alternatives to the carceral system, with emphasis on those that are culturally responsive.

Strengthening policy coding methodologies to improve COVID-19 disease modeling and policy responses: a proposed coding framework and recommendations.

BACKGROUND: In recent months, multiple efforts have sought to characterize COVID-19 social distancing policy responses. These efforts have used various coding frameworks, but many have relied on coding methodologies that may not adequately describe the gradient in social distancing policies as states "re-open." METHODS: We developed a COVID-19 social distancing intensity framework that is sufficiently specific and sensitive to capture this gradient. Based on a review of policies from a 12 U.S. state sample, we developed a social distancing intensity framework consisting of 16 domains and intensity scales of 0-5 for each domain. RESULTS: We found that the states with the highest average daily intensity from our sample were Pennsylvania, Washington, Colorado, California, and New Jersey, with Georgia, Florida, Massachusetts, and Texas having the lowest. While some domains (such as restaurants and movie theaters) showed bimodal policy intensity distributions compatible with binary (yes/no) coding, others (such as childcare and religious gatherings) showed broader variability that would be missed without more granular coding. CONCLUSION: This detailed intensity framework reveals the granularity and nuance between social distancing policy responses. Developing standardized approaches for constructing policy taxonomies and coding processes may facilitate more rigorous policy analysis and improve disease modeling efforts.

A Randomized Trial of Voice-Generated Inpatient Progress Notes: Effects on Professional Fee Billing.

BACKGROUND: Prior evaluations of automated speech recognition (ASR) to create hospital progress notes have not analyzed its effect on professional revenue billing codes. As ASR becomes a more common method of entering clinical notes, clinicians, hospital administrators, and payers should understand whether this technology alters charges associated with inpatient physician services. OBJECTIVES: This study aimed to measure the difference in professional fee charges between using voice and keyboard to create inpatient progress notes. METHODS: In a randomized trial of a novel voice with ASR system, called voice-generated enhanced electronic note system (VGEENS), to generate physician notes, we compared 1,613 notes created using intervention (VGEENS) or control (keyboard with template) created by 31 physicians. We measured three outcomes, as follows: (1) professional fee billing levels assigned by blinded coders, (2) number of elements within each note domain, and (3) frequency of organ system evaluations documented in review of systems (ROS) and physical exam. RESULTS: Participants using VGEENS generated a greater portion of high-level (99233) notes than control users (31.8 vs. 24.3%, p < 0.01). After adjustment for clustering by author, the finding persisted; intervention notes were 1.43 times more likely (95% confidence interval [CI]: 1.14-1.79) to receive a high-level code. Notes created using voice contained an average of 1.34 more history of present illness components (95% CI: 0.14-2.54) and 1.62 more review of systems components (95% CI: 0.48-2.76). The number of physical exam components was unchanged. CONCLUSION: Using this voice with ASR system as tested slightly increases documentation of patient symptom details without reliance on copy and paste and may raise physician charges. Increased provider reimbursement may encourage hospital and provider group to offer use of voice and ASR to create hospital progress notes as an alternative to usual methods.

Assessment of a Parent-Child Interaction Intervention for Language Development in Children.

Importance: Parent-child interactions are critical for language development in early life. Objective: To test whether a clinic-based intervention was associated with improved home language environment and language development. Design, Setting, and Participants: A pre-post study of a multifaceted clinic-based intervention called Talk It Up was conducted for 61 English- or Spanish-speaking families with children aged 2 to 12 months. Enrollment took place at a single urban pediatric clinic from January to November 2017, with follow-up data collection through May 2018. Analyses took place from June to August 2018. Interventions: The 6-month multifaceted intervention consisted of delivering Language Environment Analysis word counts with clinician feedback, coaching, and twice-weekly pushes of brief instructional videos via a commercially available smartphone application. Main Outcomes and Measures: Baseline and follow-up z scores for adult word counts, parent-child conversational turns, and child vocalizations and language development as measured by the Developmental Snapshot score were compared and adjusted for confounders. Results: Among 61 families, the mean (SD) child's age at baseline was 5.9 (3.3) months. English was the primary language spoken in the home for 54 families (89%). At follow-up, Talk It Up was associated with significant improvements in adult word counts (mean z score, 0.30; 95% CI, 0.05-0.55), parent-child conversational turns (mean z score, 0.29; 95% CI, 0.002-0.59), and Developmental Snapshot score (mean, 6.59; 95% CI, 0.95-12.23), but there were no improvements in child vocalizations (mean z score, -0.13; 95% CI, -0.49 to 0.24). Conclusions and Relevance: A multifaceted clinic-based approach to promote parent-child interactions holds some promise. Future, larger studies are warranted.

Assessment of Rates of Child Maltreatment in States With Medicaid Expansion vs States Without Medicaid Expansion.

Importance: Physical abuse and neglect affect a significant number of children in the United States. The 2014 Medicaid expansion, in which several states opted to expand their Medicaid programs, is associated with parental financial stability and access to mental health care. Objective: To determine whether Medicaid expansion is associated with changes in physical abuse and neglect rates. Design, Setting, and Participants: This ecological study used state-level National Child Abuse and Neglect Data Systems (NCANDS) data from January 1, 2010, through December 31, 2016, to compare the change in physical abuse and neglect rates in states that chose to expand Medicaid vs those that did not. All cases of physical abuse and neglect of children younger than 6 years during the study period that were referred to state-level Child Protective Services and screened in for further intervention after having met a maltreatment risk threshold were included. Cases with only documented sexual or emotional abuse were excluded. A difference-in-difference analysis was conducted from April 12, 2018, through March 26, 2019. Exposures: State-level Medicaid expansion status. Main Outcomes and Measures: Incidence rate of screened-in referrals for physical abuse or neglect per 100 000 children younger than 6 years per year by state. Results: Data were analyzed for 31 states and the District of Columbia that expanded Medicaid and 19 states that did not during the study period, with baseline neglect counts of 646 463 and 388 265, respectively. After Medicaid expansion, 422 fewer cases of neglect per 100 000 children younger than 6 years (95% CI, -753 to -91) were reported each year after adjusting for confounders for comparison of postexpansion and preexpansion rates in states that expanded Medicaid contrasting with the change during that time in nonexpansion states. From 2013 to 2016, Medicaid coverage for adults with dependent children increased a median 1.9% (interquartile range, 0.4% to 4.3%) in the states that did not expand Medicaid and 4.2% (interquartile range, 0.9% to 6.0%) in the states that did. No associations were found between Medicaid coverage or Medicaid eligibility criteria and physical abuse or neglect rates. Conclusions and Relevance: Medicaid expansion was associated with a reduction in the reported child neglect rate, but not the physical abuse rate. These findings suggest that expanding Medicaid may help prevent child neglect.

Health outcomes in young adults from foster care and economically diverse backgrounds.

BACKGROUND AND OBJECTIVES: Foster youth have high rates of health problems in childhood. Little work has been done to determine whether they are similarly vulnerable to increased health problems once they transition to adulthood. We sought to prospectively evaluate the risk of cardiovascular risk factors and other chronic conditions among young adults formerly in foster care (FC) and young adults from economically insecure (EI) and economically secure (ES) backgrounds in the general population. METHODS: We used data from the Midwest Evaluation of the Adult Functioning of Former Foster Youth (FC group; N = 596) and an age-matched sample from the National Longitudinal Study of Adolescent Health (EI and ES groups; N = 456 and 1461, respectively). After controlling for covariates, we performed multivariate regressions to evaluate health outcomes and care access by group at 2 time points (baseline at late adolescence, follow-up at 25-26 years). RESULTS: Data revealed a consistent pattern of graduated increase in odds of most health outcomes, progressing from ES to EI to FC groups. Health care access indicators were more variable; the FC group was most likely to report having Medicaid or no insurance but was least likely to report not getting needed care in the past year. CONCLUSIONS: Former foster youth appear to have a higher risk of multiple chronic health conditions, beyond that which is associated with economic insecurity. Findings may be relevant to policymakers and practitioners considering the implementation of extended insurance and foster care programs and interventions to reduce health disparities in young adulthood.

Parental cultural attitudes and beliefs regarding young children and television.

IMPORTANCE: Research has shown that preschool-aged children spend considerable time with media, and risks and benefits for cognitive and behavioral outcomes exist depending on what is watched and how it is watched. OBJECTIVE: To examine the associations among child race/ethnicity, parental beliefs/attitudes about television (TV) and child development, and TV viewing habits of young children, and to assess reasons for existing racial/ethnic disparities in children's media use. DESIGN, SETTING, AND PARTICIPANTS: Parents completed demographic questionnaires, reported on attitudes regarding media's risks and benefits to their children, and completed 1-week media diaries where they recorded all of the programs their children watched. Enrollment was from March 13, 2009, to April 12, 2010. The study was conducted at 2 metropolitan Seattle pediatric clinics and an academic practice network, each serving a diverse population of patients, and involved a community-based sample of 596 parents of children aged 3 to 5 years. MAIN OUTCOMES AND MEASURES: Parental beliefs/attitudes regarding screen time and TV viewing habits of young children. RESULTS: Overall, children watched an average (SD) of 462.0 (315.5) minutes of TV per week. African American children watched more TV per week than non-Hispanic white children (mean [SD], 638.0 [450.9] vs 431.0 [282.6] minutes; P < .01); however, these differences were no longer statistically significant after controlling for attitudes and demographic covariates (eg, family socioeconomic status). It is important to note that socioeconomic status confounded the results for race/ethnicity, and the association between race/ethnicity and media time across the sample was no longer statistically significant after adjusting for family socioeconomic status. However, significant differences were found between parents of ethnically/racially diverse children and parents of non-Hispanic white children regarding the perceived positive effects of TV viewing, even when parental education and family income were taken into account. CONCLUSIONS AND RELEVANCE: Differences in parental beliefs/attitudes regarding the effects of media on early childhood development may help explain growing racial/ethnic disparities in child media viewing/habits, but more research is needed to understand the cultural nuances of the observed differences.

Pediatric hospital adherence to the standard of care for acute gastroenteritis.

BACKGROUND: Adherence to published care guidelines for the management of acute gastroenteritis (AGE) is unknown. OBJECTIVES: To evaluate the association of AGE guideline adherence with outcomes and resource use at pediatric hospitals. DESIGN/METHODS: We studied children aged 6 months to 6 years with an International Classification of Diseases, Ninth Edition (ICD-9) discharge code indicative of AGE and without comorbid conditions in the emergency department, observation setting, or hospital. Laboratory studies, antiemetic use, and antibiotic use were evaluated, and the length of stay, mean adjusted total charges, and readmission proportion were documented. Multiple analysis of variance determined if the variance of adjusted charges, length of stay, and diagnostic studies were hospital-related. A regression analysis determined the association between guideline adherence and outcomes. RESULTS: There were a total of 188873 patients; 174594 (92.4%) were not admitted, and 14279 (7.6%) were admitted. There was substantial variation in resource use among hospitals. The mean adjusted total charge for all patients was $863 (SD: 1336). The mean adjusted total charge for nonadmitted patients was $591 (SD: 636). Individual hospitals contributed to the variance of mean length of stay, total adjusted charges, and use of diagnostic studies after controlling for covariates (P < .001). Guideline adherence was associated with a mean decrease in the average adjusted cost ($591) for nonadmitted patients of $296 (95% confidence interval: -399 to -193). CONCLUSIONS: Guideline-adherent hospitals demonstrated 50% lower charges for emergency department or observation patients with uncomplicated AGE without adversely affecting outcomes. Use of resources not routinely recommended by published AGE guidelines remains common in pediatric hospitals.

Inpatients with eating disorders: demographic, diagnostic, and service characteristics from a nationwide pediatric sample.

OBJECTIVE: This study describes the demographic and clinical characteristics of youth hospitalized with an eating disorder, using the Pediatric Health Information System (PHIS) database. METHOD: Descriptive and inferential statistics were used to examine and compare PHIS inpatients (N = 1,713) with a primary discharge diagnosis of anorexia, bulimia, or eating disorder, not otherwise specified. RESULTS: Of pediatric inpatients with eating disorders, 92% were female and 78% were non-Hispanic white. Their mean age was 15.3 years; 71% had anorexia; 68% had one or more comorbid psychiatric disorders; 53% stayed on a psychiatric unit; the mean length of stay was 15.7 days. Private insurance paid for 55% of hospital stays. Patients without private insurance were more likely than patients with private insurance to be Black or Hispanic and to have comorbid psychiatric diagnoses. CONCLUSION: This study provides new information that can be used by hospitals to anticipate developmental and treatment needs of future inpatients with eating disorders.

Aminoglycoside-based triple-antibiotic therapy versus monotherapy for children with ruptured appendicitis.

OBJECTIVE: We conducted a retrospective cohort study to compare the use of triple therapy versus monotherapy for children and adolescents with perforated appendicitis and to determine whether there has been a transition to monotherapy within the freestanding children's hospitals that contribute to the Pediatric Health Information System database. METHODS: We used the Pediatric Health Information System database, which includes billing and discharge data for 32 children's hospitals in the United States, to examine the trend in antibiotic usage and whether the postappendectomy antibiotic regimen was associated with differences in complication-related readmissions, length of stay, or charges in a population of children and adolescents with ruptured appendicitis and discharge dates between March 1, 1999, and September 30, 2004. Pairwise regression analyses were performed to compare the most common monotherapy regimens with the triple therapy. RESULTS: A total of 8545 patients met the inclusion criteria, of whom 58%, over the entire study period, received the aminoglycoside-based triple antibiotic therapy on postoperative day 1. There was, however, a notable transition over this 6-year period, from 69% to 52% of surgeons using aminoglycoside-based combination therapy. There were no significant differences in the odds of readmission at 30 days except for the group receiving ceftriaxone, which was associated with significantly decreased odds. The subgroup receiving piperacillin/tazobactam monotherapy demonstrated significantly decreased length of stay (-0.90 days) and total hospital charges, and the group receiving cefoxitin demonstrated significantly decreased length of stay (-1.89 days), as well as decreased pharmacy and total hospital charges. CONCLUSIONS: Single-agent antibiotic therapy in the treatment of perforated appendicitis is being used with increasing frequency, is at least equal in efficacy to the traditional aminoglycoside-based combination therapy, and may offer improvements in terms of length of stay, pharmacy charges, and hospital charges.

Institutional variation in ordering complete blood counts for children hospitalized with bronchiolitis.

BACKGROUND: In the evaluation of infants with bronchiolitis there is little evidence to support the use of diagnostic testing, particularly complete blood counts (CBCs). However, the extent to which CBCs are ordered in the evaluation of infants with bronchiolitis is unknown. OBJECTIVES: (1) To determine institutional variability in ordering of initial and repeat CBCs in infants hospitalized with bronchiolitis; (2) to examine the relationship between proportion of admissions with CBCs and mean hospital charges. METHODS: We analyzed the Pediatric Health Information System database, which contains demographic and diagnostic data from 30 U.S. children's hospitals. We restricted our analysis to children less than 12 months old with a primary discharge diagnosis of bronchiolitis and an APR-DRG of bronchiolitis/asthma. We performed multivariate ANOVA to examine variability in initial and repeat CBC ordering across hospitals, controlling for potential confounders. We used stratified logistic regression to determine which factors were associated with repeat CBCs. We examined the relationship between proportion of admissions with CBCs and mean hospital charges using t tests. RESULTS: 17,397 children were included in the analysis, and 48.2% had at least 1 CBC, whereas 7.8% had more than 1 CBC. The proportion of admissions with initial (23.2%-70.2%) and repeat (0%-18.6%) CBCs varied significantly across hospitals. Compared to those hospitals with the lowest proportion of admissions with CBCs, hospitals with higher proportions of CBCs had significantly higher mean hospital stay charges. CONCLUSIONS: Given the potential downstream medical and financial consequences associated with CBC ordering in evaluation of infants with bronchiolitis, explanations for institutional variation warrant exploration.

Prevention of deaths from harmful drinking in the United States: the potential effects of tax increases and advertising bans on young drinkers.

OBJECTIVE: Harmful alcohol consumption is a leading cause of death in the United States. The majority of people who die from alcohol use begin drinking in their youth. In this study, we estimate the impact of interventions to reduce the prevalence of drinking among youth on subsequent drinking patterns and alcohol-attributable mortality. METHOD: We first estimated the effect of public health interventions to decrease harmful drinking among youth from literature reviews and used life table methods to estimate alcohol-attributable years of life lost by age 80 years among the cohort of approximately 4 million U.S. residents aged 20 in the year 2000. Then, from national survey data on transitions in drinking habits by age, we modeled the impact of interventions on alcohol-attributable mortality. RESULTS: A tax increase and an advertising ban were the most effective interventions identified. In the absence of intervention, there would be 55,259 alcohol-attributable deaths over the lifetime of the cohort. A tax-based 17% increase in the price of alcohol of dollar 1 per six pack of beer could reduce deaths from harmful drinking by 1,490, equivalent to 31,130 discounted years of potential life saved or 3.3% of current alcohol-attributable mortality. A complete ban on alcohol advertising would reduce deaths from harmful drinking by 7,609 and result in a 16.4% decrease in alcohol-related life-years lost. A partial advertising ban would result in a 4% reduction in alcohol-related life-years lost. CONCLUSIONS: Interventions to prevent harmful drinking by youth can result in reductions in adult mortality. Among interventions shown to be successful in reducing youthful drinking prevalence, advertising bans appear to have the greatest potential for premature mortality reduction.

Cigarette tax increase and media campaign cost of reducing smoking-related deaths.

BACKGROUND: Tobacco use results in 500,000 premature deaths annually. Most smokers begin using tobacco before age 21, so the greatest impact on preventing smoking-related mortality is likely to come from campaigns targeting youths. This study estimates the cost-effectiveness of an anti-smoking media campaign and dollar 1 per pack increase in cigarette taxes on the lifetime decrease in smoking-attributable mortality among the cohort of all 18-year-olds in the United States during the year 2000. METHODS: Cost-effectiveness analysis conducted from a societal perspective. RESULTS: The combined effects of a media campaign and dollar 1 per pack tax increase will result in a societal savings of between dollar 590,000 per life-year saved, at a 3% discount rate and dollar 1.4 million per life year saved, at a 7% discount rate. CONCLUSIONS: A media campaign and $1 per pack cigarette tax increase will reduce overall smoking prevalence, significantly decrease smoking-attributable mortality, and decrease net societal costs.