The Relationships Among Neighborhood Disadvantage, Mental Health and Developmental Disabilities Diagnoses, and Race/Ethnicity in a U.S. Urban Location.

Childhood health disparities by race have been found. Neighborhood disadvantage, which may result from racism, may impact outcomes. The aim of the study is to describe the distribution of mental health (MH) and developmental disabilities (DD) diagnosis across Child Opportunity Index (COI) levels by race/ethnicity. A cross-sectional study using 2022 outpatient visit data for children < 18 years living in the Louisville Metropolitan Area (n = 115,738) was conducted. Multivariable logistic regression analyses examined the association between diagnoses and COI levels, controlling for sex and age. Almost 18,000 children (15.5%) had a MH or DD (7,905 [6.8%]) diagnosis. In each COI level, the prevalence of MH diagnosis was lower for non-Hispanic (N-H) Black than for N-H White children. In adjusted analyses, there were no significant associations between diagnoses and COI for non-White children for MH or DD diagnoses. The odds of receiving a MH [OR: 1.74 (95% CI: 1.62, 1.87)] and DD [OR: 1.69 (95% CI: 1.51, 1.88)] diagnosis were higher among N-H White children living in Very Low compared to Very High COI areas. Current findings suggest that COI does not explain disparities in diagnosis for non-White children. More research is needed to identify potential multi-level drivers such as other forms of racism. Identifying programs, policies, and interventions to reduce childhood poverty and link children and families to affordable, family-centered, quality community mental and physical health resources is needed to ensure that families can build trusting relationships with the providers while minimizing stigma.

Promoting Resiliency and Eliminating Disparities-Best Practices when Working with Child Welfare Involved Youth of Color.

The US child welfare system has a long history of racial disproportionality and subsequent disparities. These disparities have been perpetuated by discriminatory laws and policies in our federal and state governments, coupled with a system of care that is fraught with the risk of biases in child welfare practices and procedures. Child psychiatrists should have a knowledge base of these inequities to help ensure culturally and trauma-informed care for child welfare involved youth and families. As physician leaders with knowledge of child development, child psychiatrists can also help inform inclusive legislation, policies, and programs.

Examination of U.S. national rates of emergency department visits and hospitalizations for depression and suicidal behaviors after the release of the 13 Reasons Why Netflix series by demographic characteristics.

BACKGROUND: To evaluate the impact of the series 13Reasons Why on depression and suicidal behaviors in children and adolescents. METHODS: Data from the 2016 to 2018 Nationwide Inpatient Sample (NIS) and the Nationwide Emergency Department Sample (NEDS) of the Healthcare Cost and Utilization Project (HCUP) from 2016 to 2018 was used to determine the presentation in both settings for depression and suicidal thoughts and behavior. This was compared to predictive modeling for presentations in the same time frame. RESULTS: Following the release of 13 Reasons Why both hospital admissions and presentations to the Emergency Department (ED) increased for complaints of worsening depression or suicidal thoughts and behavior. This was more pronounced for youth aged 10-17 years, Black race, and female sex. There were no significant findings, overall, for females 6-9 years, but in-patient visits for depression increased in May 2017 for Black females 6-9 years. Males 6-9 years had higher rates of ED visits for depression and both ED and in-patient visits for suicidal behaviors. LIMITATIONS: Secondary data analyses have known limitations including inability to track over time, inclusion of only visit-level data, and failure to collect variables of interest. CONCLUSIONS: The series 13 Reasons Why was likely associated with exacerbations of both depressive illnesses and suicidal behavior in youth, particularly for female and Black youth from 10 to 17 years. This study adds to known concerns regarding the role of media in influencing suicidal behavioral in vulnerable children and has important implications for youth monitoring and parent and youth education. More research is needed to identify specific targets for prevention.

Antipsychotic Medications for Low-Income Preschoolers: Long Duration and Psychotropic Medication Polypharmacy.

OBJECTIVE: This study aimed to evaluate prescribing patterns of antipsychotic medication and factors that predict duration of use among low-income, preschool-age children. METHODS: State Medicaid claims from 2012 to 2017 were used to identify antipsychotic medication use for children <6 years old. ICD-9 and ICD-10 codes were used to describe child diagnoses. Descriptive and multivariable analyses were used to determine patterns of antipsychotic medication use and factors that predicted duration of use. RESULTS: In 2012, 316 children <6 years of age started an antipsychotic medication in a southeastern state. Most were non-Hispanic White (N=202, 64%) and boys (N=231, 73%). Diagnoses included attention-deficit hyperactivity disorder (N=288, 91%), neurodevelopmental disorders (N=208, 66%), anxiety and trauma-related diagnoses (N=202, 64%), and autism spectrum disorders (ASDs) (N=137, 43%). The mean±SD duration of exposure to antipsychotic medication for children in the cohort was 2.6±1.7 years, but 86 children (27%) had >4 years of exposure. Almost one-third (N=97, 31%) received polypharmacy of four or more medication classes, and 42% (N=131) received metabolic screening. Being male, being in foster care, and having a diagnosis of ASD or disruptive mood dysregulation disorder were significantly associated with duration of use of antipsychotic medications; race-ethnicity was not significantly associated with duration of use. Emergency department visits (N=277, 88%) and inpatient hospitalizations (N=107, 34%) were observed during the study period. CONCLUSIONS: Many preschoolers received antipsychotic medications for substantial periods. Further research is needed to identify evidence-based practices to reduce medication use and improve outcomes.

High-level psychotropic polypharmacy: a retrospective comparison of children in foster care to their peers on Medicaid.

BACKGROUND: The use of antipsychotic medication and psychotropic polypharmacy has increased in the United States over the last two decades especially for children from low-income families and those in foster care. Although attention has been paid to providing greater insight, prescribing patterns remain concerning since there is a lack of evidence related to safety and efficacy. High-level psychotropic polypharmacy has not been described. We aim to compare the use of HLPP for children receiving Medicaid services and those in foster care and identify factors associated with the duration of use of high-level psychotropic polypharmacy. Additionally, we will examine the frequency of laboratory metabolic screening and emergency department, inpatient, and outpatient visits. METHODS: A cross-sectional, secondary analysis of statewide data describes trends in high-level psychotropic polypharmacy from 2012 to 2017 and the prevalence and predictors of high-level psychotropic polypharmacy duration and resource use in 2017 for all children on Medicaid and those in foster care. High-level psychotropic polypharmacy included concurrent use, at least four classes of medications including an antipsychotic, and at least 30 days duration. RESULTS: High-level psychotropic polypharmacy increased from 2012 to 2014 for both groups but stabilized in 2015-2016. Children in foster care showed a slight increase compared to their peers in 2017. There was no association between duration and demographic characteristics or foster care status. Diagnoses predicted duration. Neither group received metabolic monitoring at an acceptable rate. CONCLUSIONS: Concerning patterns of high-level psychotropic polypharmacy and metabolic monitoring were identified. Cautious use of high-level psychotropic polypharmacy and greater oversight to ensure that these children are receiving comprehensive services like behavioral health, primary care, and primary prevention.

Intentional Discontinuation of Psychostimulants Used to Treat ADHD in Youth: A Review and Analysis.

Objectives: This paper reviews the literature on intentional discontinuation of psychostimulants in ADHD to summarize what is known about clinical course of controlled discontinuation and guide practitioners who are considering stopping these medications for youth with ADHD. Methods: A systematic search was executed in Cochrane CENTRAL, EMBASE, Psychinfo, and MEDLINE databases to identify all articles that addressed the topic of deprescribing of psychotropic medications in children and adolescents. Keywords and search strings were developed using "PICO" framework, involving Population of interest (<18 y.o.), Intervention ("discontinuation," "deprescribing," and synonyms), Comparator (continuation of specific medications), and Outcomes. Ten reviewers conducted the initial screen via a single reviewer system. Articles that met a set of three inclusionary criteria were selected for full text review and identification as specific to discontinuation of stimulants in ADHD. Results: The literature review identified 35 articles specifically addressing intentional deprescribing, discontinuation, tapering, or withdrawal of stimulants for children and adolescents with ADHD. In addition to providing broad support for the efficacy of stimulants to treat ADHD and reduce negative outcomes, there is a distinct population of children and adolescents with ADHD who do not relapse or deteriorate when taken off medications for ADHD. The majority of articles addressed either the re-emergence of ADHD symptoms or side effects, both desired and adverse, following discontinuation of stimulants. While confirming the ability of stimulants to treat ADHD in youth, our results support periodic consideration of trials of stopping medications to determine continued need. Conclusions: This systematic review summarizes the literature on deprescribing stimulants for ADHD in children and adolescents. Further research is needed to determine the optimal duration of treatment, identify patients that may benefit from medication discontinuation, and inform evidence-based guidelines for discontinuation when appropriate. More research is needed to understand and define the subgroup of youth who may succeed with stimulant discontinuation.

Disparities in ADHD Diagnosis and Treatment by Race/Ethnicity in Youth Receiving Kentucky Medicaid in 2017.

Background: Kentucky has among the highest rate of attention deficit/hyperactivity disorder (ADHD) and stimulant use in the United States. Little is known about this use by race/ethnicity and geography. This article describes patterns of diagnosis of ADHD and receipt of stimulants and psychosocial interventions for children aged 6-17 years receiving Kentucky Medicaid in 2017 and identifies factors associated with diagnosis and treatment. Methods: Using Medicaid claims, children with and without ADHD (ICD-10 codes F90.0, F90.1, F90.2, F90.8, and F90.9) were compared and predictors of diagnosis and treatment type were examined. Psychosocial interventions were defined as having at least one relevant CPT code. Chi-squared tests and logistic regression models were used for univariate and multivariable analysis, respectively. Results: The rates of ADHD, stimulant use, and psychosocial interventions in our study population exceeded the national average (14% vs 9%; 75% vs 65.5%; and 51% vs 46.5%, respectively). The distributions varied by sex, race/ethnicity, sex among race/ethnicities, and population density. In general, race/ethnicity predicted ADHD diagnosis, stimulant use, and receipt of psychosocial interventions with non-Hispanic White children being more likely to receive diagnosis and medication, but less likely to receive psychosocial therapy than other children. Differences were also shown for rural compared with urban residence, sex, and sex within racial/ethnic groups. Conclusions: Diagnosis and treatment modalities differed for children by race/ethnicity, population density, and sex. More data are needed to better understand whether differences are due to provider bias, child characteristics, or cultural variations impacting the utilization of different treatment options.

Epidemiology of Treatment for Preschoolers on Kentucky Medicaid Diagnosed with Attention-Deficit/Hyperactivity Disorder.

Objectives: The National Survey of Children's Health reported a concerning increase in children 2-5 years being diagnosed with attention-deficit/hyperactivity disorder (ADHD) in 2016. Concerns include both the increase in diagnosing and potential deviations from published guidelines for the treatment of ADHD in preschoolers. The present study aims to describe the epidemiology and factors associated with receiving the diagnosis and treatment types for low-income preschoolers. Methods: Using Kentucky Medicaid claims from 2012 to 2017, a retrospective cohort study of children 2-5 years of age (n = 337,631) with a diagnosis of ADHD (n = 11,712) was completed. Trends in demographics, comorbidities, and treatment and provider types are presented. Multinomial logistic regression was used to determine predictors of receipt of the diagnosis and treatment type (a stimulant only, an alpha-2 agonist [A2A] only, both, or neither) based on nonmissing 2017 data (n = 2394). Results: The number of children in the cohort diagnosed with ADHD and receiving a stimulant decreased from 2012 to 2017, but the use of A2As increased. Primary care physicians were the most frequent prescribers of both medications. The adjusted odds ratios (AORs) of receipt of an A2A alone, stimulant alone, or both medications over receiving no ADHD medication were associated with specific demographics and comorbid conditions for each medication regimen. Race/ethnicity is associated with receiving the diagnosis of ADHD and treatment with A2A. Comorbid mental health conditions and provider type are associated with treatment type. Conclusion: Use of stimulants for preschoolers in Kentucky has decreased and A2A use has increased since 2012. Continued vigilance and long-term follow-up of preschoolers with ADHD are warranted. The appropriateness of the diagnosis and treatment type could not be determined.

Trends in diagnosis of bipolar and disruptive mood dysregulation disorders in children and youth.

OBJECTIVE: Rates of pediatric bipolar disorders have increased and some are concerned about diagnostic accuracy. Disruptive mood dysregulation disorder (DMDD) was added to the DSM-5 in 2013. The purpose of this study was to assess diagnostic trends of bipolar disorders and DMDD and to identify predictors of receiving the DMDD diagnosis since implementation of DSM-5. METHOD: Kentucky Medicaid claims from 2012-2017 for children under 18 years (N = 814,919; 2012 n = 473,389; 2013 n = 470,918; 2014 n = 499,094; 2015 n = 517,199; 2016 n = 529,048; 2017 n = 535,814) were used. Logistic regression was used to identify predictors of a diagnosis of DMDD in 2015-2017 for a sub-sample (n = 5,071). RESULTS: The use of DMDD rose after 2013 and mood disorder NOS decreased steadily through 2017. This decrease was seen when there was a diagnosis of bipolar and oppositional defiant disorder (ODD) combined with mood disorder NOS. A diagnosis of only mood disorder NOS in 2012 did not predict DMDD in 2015-2017, but the same diagnosis in 2013 was predictive (OR 2.14, p = 0.049). The reverse is true for a diagnosis of only ADHD in 2013, which did not predict DMDD in later years, but its presence in 2012 was predictive (OR 1.36, p = 0.010). CONCLUSIONS: DMDD increased after 2013, and this was associated with a diagnosis of mood disorder NOS, ADHD, as well as with bipolar disorders comorbid with ODD. Given the complexity of comorbid diagnoses, DMDD may be more accurate in classifying some children. Administrative claims data have limitations, which are discussed; and the data represent only children living in Kentucky.

Longitudinal Trends in the Diagnosis of Attention-Deficit/Hyperactivity Disorder and Stimulant Use in Preschool Children on Medicaid.

OBJECTIVES: To describe trends in the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and prescribing of stimulants in preschool-age children receiving Medicaid and to identify factors associated with the receipt of psychosocial care. STUDY DESIGN: Data were extracted from 2012-2016 Kentucky Medicaid claims for children aged <6 years. ADHD was identified using International Classification of Diseases, Tenth Revision codes F90.0, F90.1, F90.2, F90.8, and F90.9. Psychosocial therapy was defined as having at least 1 relevant Current Procedural Terminology code in a claim within the year. A generalized linear model with a logit link and binomial distribution was used to assess factors associated with receipt of psychosocial treatment in 2016. RESULTS: More than 2500 (1.24%) preschool-aged children receiving Medicaid had a diagnosis of ADHD in 2016, with 988 (38.2%) of those receiving a stimulant medication. Children in foster care were diagnosed with and/or treated for ADHD 4 times more often than other Medicaid recipients. Of the 1091 preschoolers receiving stimulants, 99 (9%) did not have a diagnosis of ADHD. There were no significant differences in diagnoses by race/ethnicity, but children reported to be black, Hispanic, or other race/ethnicity received stimulants at a lower rate than white children. Positive predictors for receiving psychosocial therapy in 2016 included having the diagnosis but not receiving a stimulant, having at least 1 prescription written by a psychiatrist, having comorbidities, and age. The use of stimulants in children aged <6 years declined from 0.9% in 2012 to 0.5% in 2016. CONCLUSIONS: Promising trends demonstrate a decreasing use of stimulants in preschoolers; however, continued vigilance is needed to promote the optimal use of psychosocial interventions.

Psychotropic Polypharmacy Among Children and Youth Receiving Medicaid, 2012-2015.

BACKGROUND: The rates of mental health diagnoses in children have increased. Children in poverty have the highest rates. The use of psychotropic medication for children has been increasing, which is concerning because of the unknown long-term effects and the increased burden on the health care system. The state of Kentucky ranks among the highest in the United States for children with mental health problems, children living in poverty, and children receiving psychotropic medication. OBJECTIVE: To examine recent trends and determinants of interclass psychotropic polypharmacy (PP) use for children and youth receiving Medicaid to inform intervention development. METHODS: A retrospective cohort study was conducted using 2012-2015 Kentucky Medicaid claims for children aged 0-17 years, with continuous enrollment for ≥ 90 days with at least 1 behavioral health diagnosis (N = 237,393). Interclass PP was defined as the presence of at least 2 psychotropic medication prescription fills for at least 2 different classes of medication that, if taken as directed, would be used concurrently for at least 90 consecutive days (allowing for a single 15-day lag). The outcome variables were the presence of any interclass PP and the number of months a child received interclass PP. We conducted a descriptive analysis and developed 2 separate generalized linear regression models to test for associations between individual characteristics of children treated with psychotropic medication for ≥ 90 days (n = 75,639) and each outcome of interest. RESULTS: For the sample of children with at least 90 days of psychotropic medication treatment, 38% had at least 3 covered months of PP over the 4 years studied. Children in foster care received alpha agonists (116 vs. 69 per 1,000 children) or antidepressants (225 vs. 176 per 1,000) at a higher rate than other children receiving Medicaid but received stimulants at a lower rate (403 vs. 638 per 1,000). The primary 2-drug class combinations were stimulants with either alpha agonists or antidepressants. Children in foster care (OR = 1.7, 95% CI = 1.58, 1.84, P < 0.001), with a bipolar disorder (OR = 2.24, 95% CI = 2.10, 2.38, P < 0.001), mood disorder not otherwise specified (OR = 1.11, 95% CI = 1.04, 1.17, P < 0.001), or autism spectrum disorders (OR = 1.17, 95% CI = 1.08, 1.26, P < 0.001) had increased the odds of ever receiving PP. Black children had lower odds (OR = 0.72, 95% CI = 0.67, 0.77, P < 0.001) of ever receiving PP. Children aged 6-11 years (beta = 3.08, 95% CI = 2.87, 3.29) and 12-17 years (beta = 1.61, 95% CI = 1.38, 1.83) had more covered months with PP compared with those aged 0-5 years. Black children had fewer covered months of PP compared with white children (beta = -1.36, 95% CI = -1.61, -1.11]. Children in foster care (beta = 1.83, 95% CI = 1.53, 2.13) had more covered months with PP. Children residing in nonurban areas had fewer months with PP (beta = -0.4, 95% CI = -0.54, -0.26) compared with those residing in urban areas, as did those children with depression (beta = -3.32, 95% CI = -3.55, -3.1), impulse control disorder (beta = -2.07, 95% CI = -2.28, -1.85), and conduct disorder (beta = -1.34, 95% CI = -1.64, -1.05). Children with bipolar disorder (beta = 3.62, 95% CI = 3.38, 3.86) and autism (beta = 2.04, 95% CI = 1.75, 2.33) had more covered months with PP. As comorbidity increased, the duration of PP treatment increased (beta = 2.49, 95% CI = 2.36, 2.62). CONCLUSIONS: The rates of PP are concerning, especially for children in foster care and children aged 6-11 years. Efforts to safeguard medication use are needed, as well as future exploration of racial differences in PP. DISCLOSURES: This project was supported by the Kentucky Cabinet for Health and Family Services, Department for Medicaid; Norton Healthcare; and the School of Medicine, Department of Pediatrics; School of Public Health and Information Sciences; and Kent School of Social Work at the University of Louisville. Kentucky Medicaid approved the use of the data and granted permission to publish but played no role in the interpretation of data. Lui is employed by Kentucky Medicaid. The other authors report no potential conflicts of interest. An earlier version of this study was presented at the Pediatric Academic Societies' Annual Meeting in Baltimore, MD, on April 30-May 3, 2016. A poster presentation was given at the Society for Developmental and Behavioral Pediatrics in Cleveland, OH, on October 14-16, 2017.

Providers' Behaviors and Beliefs on Prescribing Antipsychotic Medication to Children: A Qualitative Study.

Fragmentation in behavioral and mental health care to children has resulted in suboptimal care and high rates of psychotropic medication use, especially antipsychotic medications (APM). A qualitative study, based on the Theory of Planned Behavior (TPB), aimed to better understand prescribing practices, barriers to optimal treatment, and potential interventions to safeguard the use of APM for children in Kentucky. The most common barrier to optimal care was access to mental health specialists. Social norms and pressure from families contribute to increased medication use. We identify promising interventions to safeguard the use of APM through the lens of the TPB.

The Screen for Child Anxiety-Related Emotional Disorders Is Sensitive but Not Specific in Identifying Anxiety in Children with High-Functioning Autism Spectrum Disorder: A Pilot Comparison to the Achenbach System of Empirically Based Assessment Scales.

Validated brief screening instruments are needed to improve the detection of anxiety disorders in autism spectrum disorder (ASD). The Screen for Child Anxiety-Related Emotional Disorders (SCARED), a 41-item parent- and self-reported scale measuring anxiety, was compared to the Achenbach System of Empirically Based Assessment (ASEBA) scales. One hundred participants with a clinical diagnosis of high-functioning ASD, aged 8-18 years, and their parents completed the above scales. We hypothesized that the SCARED would be useful in screening for anxiety and its results for total scores of anxiety would converge with ASEBA syndrome scales for anxiety and internalizing disorders. Significant correlations were shown between the SCARED and the Child Behavior Checklist (CBCL) and Youth Self-Report (YSR) across a broad spectrum of scales. The CBCL syndrome scale for anxious/depressed showed the highest correlation and predicted anxiety scores on the SCARED. While many of the YSR scales significantly correlated with child ratings of anxiety, none of the scales predicted the SCARED child scores. Differences in self and parent reports suggest that parents interpret externalizing behaviors as signs of anxiety in ASD, whereas youth may describe internalized symptoms as anxiety. Females were more likely to self-report anxiety than males. Results support the use of the SCARED as a screening tool for anxiety in high-functioning ASD, but it should be supplemented with other tools to increase the specificity of its results.

L-Methylfolate supplementation in a child with autism and methyltetrahydrofolate reductase, enzyme gene C677TT allele.

Errors in folate metabolism may play a role in the pathology of autism spectrum disorders because of increased vulnerability to oxidative stress. We report a case where L-methylfolate supplementation improved symptoms of aggression and disruptive behavior in a child with autism who tested positive for the C677TT allele of the methyltetrahydrofolate reductase enzyme gene. To our knowledge, this is the first report of L-methylfolate administration in this situation. Further controlled studies of L-methylfolate in this population are warranted.

Mental Health Issues in Foster Care.

Children in foster care have exceptional needs due to their histories of abuse, neglect, and increased exposure to violence. The rates of psychiatric symptoms and disorders, such as attention-deficit/hyperactivity disorder, posttraumatic stress disorder, and reactive attachment disorder, are much higher in children in foster care; furthermore, the rate of these children receiving psychotropic medications is 3 times that of children who are not in foster care. Pediatricians, in their role of providing a medical home, play a central role in safeguarding the physical and mental health of these children. By taking a trauma-informed approach to understanding the unique needs and gaps in their health care, pediatricians can improve the mental health and maximize outcome for children in foster care. [Pediatr Ann. 2016;45(10):e342-e348.].

Trends in Atypical Antipsychotics Prescribed to Children Six Years of Age or Less on Medicaid in Kentucky.

OBJECTIVE: Studies have shown an increase in the use of antipsychotics to preschoolers for disruptive behavior and aggression. This study investigated the use of atypical antipsychotics in children ≤6 years of age in Kentucky who were on Medicaid. METHODS: Kentucky Medicaid prescription claims data between 2001 and 2010 were examined for all children ≤6 years of age who had received an atypical antipsychotic. Drug type, diagnosis codes, and geographic trends were analyzed using descriptive statistics. RESULTS: A total of 70,777 prescriptions were written to 6915 distinct children ≤6 years of age. The use of atypical antipsychotics in this age group increased over the years 2001-2010 with a peak ∼ 1.0% in 2004, and averaged 0.75% in 2010. Older male children were more likely to receive atypical antipsychotics, and risperidone accounted for two thirds of the prescriptions written. Mood disorders, primarily bipolar disorder, accounted for almost 75% of the diagnoses provided. Only 32% of the prescriptions were written by child psychiatrists. Geographic analysis showed significantly higher use in the Western part of the state (more than three times the state mean in some counties). CONCLUSIONS: The use of atypical antipsychotics in children ≤6 years of age has declined from its peak, but remains substantial. The prescription rates for atypical antipsychotics by providers other than child psychiatrists, and the marked geographic variation in use across the state of Kentucky suggest that improved systems of mental healthcare for this population are needed.