Mental health care utilization and expenditures by children in foster care.

OBJECTIVE: To determine the percentage of children with mental health diagnoses and utilization and expenditures of mental health services among children in foster care compared with other children receiving Medicaid, including those with disabilities. DESIGN: Analysis of Medicaid claim and eligibility records in southwestern Pennsylvania for fiscal year 1995. POPULATION: A total of 39,500 children between ages 5 and 17 years continuously eligible for Medicaid in southwestern Pennsylvania were included in the analysis. MAIN OUTCOME MEASURES: Percentage of children with mental health diagnoses and mental and general health care utilization and expenditures classified by participation in foster care and Medicaid eligibility. RESULTS: Children in foster care were 3 to 10 times more likely to receive a mental health diagnosis, had 6.5 times more mental health claims, were 7.5 times more likely to be hospitalized for a mental health condition, and had mental health expenditures that were 11.5 times greater ($2082 vs $181) than children in the Aid to Families With Dependent Children (AFDC) program. Overall, utilization rates, expenditures, and prevalence of psychiatric conditions for children in foster care were comparable with those of children with disabilities. CONCLUSIONS: Children in foster care are significantly more likely to suffer from mental health conditions and use more mental health and general health services than AFDC children. Service use and expenditures are comparable with those of disabled children, suggesting that reimbursement rates and care management for children in foster care need to be reexamined.

Uninsured children with psychosocial problems: primary care management.

OBJECTIVE: Nearly 14% of children in the United States are uninsured. We compared the prevalence of psychosocial problems and mental health services received by insured and uninsured children in primary care practices. METHODS: The Child Behavior Study was a cohort study conducted by Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Network. Four hundred one primary care clinicians enrolled an average sample of 55 consecutive children (4-15 years old) per clinician. RESULTS: Of the 13 401 visits to clinicians with 3 or more uninsured patients, 12 518 were by insured children (93.4%) and 883 were by uninsured children (6. 6%). A higher percentage of adolescents, Hispanic children, those with unmarried parents, and those with less educated parents were uninsured. According to clinicians, uninsured children and insured children had similar rates of psychosocial problems (19%) and severe psychosocial problems (2%). For children with a clinician-identified psychosocial problem, we found no differences in clinician-reported counseling, medication use, or referral to mental health professionals. CONCLUSIONS: Among children served in primary care practices, uninsured children have similar prevalence of clinician-identified psychosocial and mental health problems compared with insured children. Within their practices, clinicians managed uninsured children much the same way as insured children. psychosocial problems, uninsured children, pediatrics, family medicine, primary care.

Increasing identification of psychosocial problems: 1979-1996.

OBJECTIVE: To examine the changes in identification of pediatric psychosocial problems from 1979 to 1996. RESEARCH DESIGN: Comparison of clinician-identified psychosocial problems and related risk factors among large primary care pediatric cohorts from 1979 (Monroe County Study) and 1996 (Child Behavior Study). Data were collected from clinician visit questionnaires developed originally for the 1979 study. SETTING: Private practice offices of 425 community-based pediatricians and family practitioners across both studies. PATIENTS: We enrolled all children from 4 to 15 years of age who presented for nonemergent services in primary care offices. The 1979 study included 9612 children seen by 30 clinicians and the 1996 study included 21 065 children seen by 395 clinicians. SELECTION PROCEDURE: Each clinician enrolled consecutive eligible patients for both studies. MEASUREMENTS AND RESULTS: From 1979 to 1996, clinician-identified psychosocial problems increased from 6.8% to 18. 7% of all pediatric visits among 4- to 15-year-olds. We found increases in all categories of psychosocial problems, except for mental retardation. Attentional problems showed the greatest absolute increase (1.4%-9.2%) and emotional problems showed the greatest relative increase (.2%-3.6%). The use of psychotropic medications, counseling, and referral also increased substantially. In particular, the percentage of children with Attention deficit/hyperactivity problems receiving medications increased from 32% to 78%. These increases in psychosocial problems were associated with increases in the proportions of single-parent families and Medicaid enrollment from 1979 to 1996. Changes in clinician characteristics did not appear to be the source of increases in clinician diagnoses of psychosocial problems. CONCLUSIONS: Substantial increases in the identification of psychosocial problems in primary care paralleled demographic changes in children presenting to primary care offices and in the larger population.

Patient race and ethnicity in primary care management of child behavior problems: a report from PROS and ASPN. Pediatric Research in Office Settings. Ambulatory Sentinel Practice Network.

BACKGROUND: Minority persons have less access to many specialty treatments and services, possibly because of clinician biases. It is not clear whether any such biases exist in primary care settings, especially for children with psychosocial problems. OBJECTIVES: The objective was to compare primary care recognition and treatment of pediatric psychosocial problems among African American, Hispanic American and European American patients. DESIGN: A survey was made of parents and respective clinicians in primary care offices in two large practice-based research networks (PROS and ASPN) from 44 states, Canada, and Puerto Rico. Mixed regression analyses were employed to control for patient, clinician, and practice effects. SUBJECTS: The subjects were 14,910 children aged 4 to 15 years seen consecutively for non-emergent care by 286 primary care clinicians in office-based practice. MEASURES: Measures were parents' report for sociodemographics and behavioral symptoms using the Pediatric Symptom Checklist, and clinicians' report of psychosocial problems, type, management, and severity. RESULTS: Of the sample, 8.0% were African American youth, 9.5% were Hispanic American youth, and 82.5% were European American youth. After controlling for other factors, race and ethnicity were not associated with any differences in psychotropic drug prescribing, counseling, referral, or recognition of psychosocial problems. Clinicians reported spending slightly more time with minority patients. CONCLUSION: Race and ethnic status were not related to receipt of mental health services for children in primary care offices, suggesting that clinician biases may not be the primary cause of the racial differences in services noted earlier research. Improving services for minority youth may require increasing access to office-based primary care.

Identification of attentional and hyperactivity problems in primary care: a report from pediatric research in office settings and the ambulatory sentinel practice network.

OBJECTIVES: To 1) determine the frequency of identification of attentional and hyperactivity problems (AHPs) by clinicians, and 2) examine whether minority children or children from less well-educated, lower-income, or lower-functioning families would be more likely to be identified as having AHPs. DESIGN: Prospective cohort study of 22 059 consecutive children 4 to 15 years of age being seen for acute, chronic, and health supervision visits. SETTING: Practices of 401 pediatric and family practice clinicians in 44 states, Puerto Rico, and 4 Canadian provinces. METHODS: Parent questionnaires included demographic information and the Pediatric Symptom Checklist. Clinician questionnaires categorized psychosocial problems and addressed how assessment of problems was made. Analyses compared children with newly identified AHPs with those with other newly identified psychosocial problems. RESULTS: Clinicians identified behavior problems in 18.7% of children, with 9.2% of the entire sample identified as having AHPs. Among those with newly assessed AHPs, clinicians identified minority children and those from low-income or poorly functioning families as having AHPs at the same rate as other children. However, even after controlling for symptoms, males were more likely than females (odds ratio, 2.81) to be identified as having AHPs. Older clinicians were significantly more likely to identify children as having AHPs (odds ratio, 2.09). In assessing AHPs, clinicians used standardized tools such as behavioral questionnaires for only 36.9% of children, and Diagnostic and Statistical Manual criteria for 38.3% of children. CONCLUSIONS: AHPs are highly prevalent in primary care practice. Clinicians do not appear predisposed to label children from disadvantaged backgrounds as having AHPs. Primary care assessment of AHPs lacks standardization.

The family APGAR and psychosocial problems in children: a report from ASPN and PROS.

BACKGROUND: Our study examined whether the lack of social support as measured by the Family APGAR was related to parents' and physicians' identification of child psychosocial problems and sociodemographic and symptom characteristics of the children screened. METHODS: The parents of 9626 children, ages 4 to 15 years, seen for outpatient medical visits participated in this national study. Parents completed the Family APGAR and the Pediatric Symptom Checklist (PSC), a measure of psychosocial dysfunction. Physicians rated the presence of a new or recurrent psychosocial problem in the child. RESULTS: Children from families with a lack of social support were 4.3 times as likely to receive scores indicating impairment on the PSC and 2.2 times as likely to be identified as having psychosocial problems by physician report. Families with low social support were significantly more likely to report low parental educational achievement, single parent status, and a history of mental health services for the child. Fifty percent of children from families with low social support were identified as having a psychosocial problem by either the PSC or physician rating, or both; however, only 21% of the children identified with psychosocial impairment by these two measures had scores indicating poor family functioning on the Family APGAR. CONCLUSIONS: A lack of family social support is associated with child psychosocial dysfunction as assessed by two different measures. However, the Family APGAR was not a sensitive measure of child psychosocial problems, and thus it supplements, but does not replace, information concerning the child's overall psychosocial functioning.

Insurance status and recognition of psychosocial problems. A report from the Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Networks.

OBJECTIVE: To examine the effect of insurance status on clinician recognition of psychosocial problems for pediatric primary care visits. DESIGN: A cohort study of 10,250 visits by children 4 to 15 years old for nonemergent care. SETTING: Two large primary care research networks reported data from 172 primary care clinicians in office-based practice. PATIENTS: Ten thousand two hundred and fifty unique children presenting consecutively to participating physicians for nonemergent services with a parent or caregiver. MAIN OUTCOME MEASURE: Children were classified as positive for psychosocial problems if their score on the parent-reported Pediatric Symptom Checklist exceeded the standard cutoff of 28. Clinician recognition was obtained by report as a dichotomous variable. Insurance status was categorized by payor and plan structure. RESULTS: Clinicians did not recognize psychosocial problems for a substantial number of children with scores suggestive of marked psychosocial dysfunction on the Pediatric Symptom Checklist. Insurance type was not associated with rates of recognition. However, provider familiarity with patients, provider discipline, and patient demographics were associated with increased recognition of psychosocial problems. CONCLUSIONS: Differences in treatment among various insurance groups documented in prior studies are not likely to be related to varying recognition rates, but rather to availability and choices of treatment by insurers, families, and clinicians. Continuity of care was the strongest predictor of clinician recognition.

In vitro and clinical correlates of mefloquine resistance of Plasmodium falciparum in eastern Thailand.

A series of isolates of Plasmodium falciparum from eastern Thailand was collected prior to and after treatment failure with mefloquine. Patterns of drug sensitivity to standard and new antimalarials were characterized by using an in vitro assay based on the inhibition of schizont maturation. In vitro levels of mefloquine sensitivity of isolates were correlated with clinical treatment failures. In vitro parasite resistance to mefloquine is defined as an inhibitory dose-50 value greater than 20 nM. For isolates collected prior to treatment, there was no significant difference in mefloquine sensitivity patterns between subsequent successes and failures, suggesting that mefloquine treatment failures could not be predicted based on in vitro sensitivity of pretreatment isolates. A series of paired isolates were collected both prior to treatment with mefloquine and after recrudescence. Recrudescent isolates showed significant decreases in sensitivity to mefloquine, WR 194965, enpiroline, and halofantrine; no significant changes in sensitivity to amodiaquine, qinghaosu, and pyrimethamine; and an increase in sensitivity to chloroquine.

Mefloquine kinetics in cured and recrudescent patients with acute falciparum malaria and in healthy volunteers.

Mefloquine pharmacokinetics were compared in a randomized clinical trial in Thailand among patients with malaria and healthy volunteers. A single oral dose of 1500 mg mefloquine hydrochloride was administered to 11 patients and 5 volunteers and 750 mg was given to 16 patients and 5 volunteers. Efficacy was 82% for 1500 mg and 63% for 750 mg. In cured patients taking 750 mg mefloquine, peak plasma drug concentration (Cmax) and area under the plasma concentration-time curve (AUC) were significantly greater than in the patients for whom treatment failed (p less than 0.0005 and p less than 0.01, respectively), and plasma mefloquine levels were significantly higher from 8 hours to 18 days after treatment. Mefloquine AUC was reduced and variable in the presence of diarrhea. Compared with noninfected volunteers, clinically ill patients displayed a delayed time to reach peak concentration (p less than 0.01) and significantly higher mefloquine plasma levels in the first 2 days after administration of either the 750 mg or the 1500 mg dose. Mefloquine AUC was similar in patients with malaria and healthy volunteers. Because plasma levels increased in temporal relationship with clinical illness, mefloquine volume of distribution or clearance (or both) was reduced during the acute phase of illness.

A comparison of the in vitro activities of amodiaquine and desethylamodiaquine against isolates of Plasmodium falciparum.

The antimalarial activities of amodiaquine, the desethyl metabolite of amodiaquine, chloroquine, and mefloquine were evaluated against 35 field isolates of Plasmodium falciparum collected from eastern Thailand, October-December 1985, to define patterns of cross-resistance among these compounds. The assay system was based on the in vitro inhibition of schizont maturation. The parasites were generally sensitive to mefloquine (mean 50%-inhibitory concentrations = 9.98 nM) and highly resistant to chloroquine (IC50 = 313 nM). The mean in vitro activity of desethylamodiaquine (67.5 nM) was approximately 3.5 times lower than that of amodiaquine (18.2 nM). There was a significant rank-order correlation between the IC50S of desethylamodiaquine and chloroquine, but not between amodiaquine and chloroquine, which suggests that the apparent cross-resistance between chloroquine and amodiaquine observed in clinical studies may be more closely related to the cross-resistance between chloroquine and the metabolite rather than between chloroquine and the parent compound. Isolates with IC50 values of amodiaquine greater than 20 nM demonstrated a high degree of correlation with values of desethylamodiaquine; however, it was not possible to accurately predict the sensitivity to desethylamodiaquine of isolates which had IC50 values of amodiaquine of less than 20 nM.

Analysis of dose-response curves for the in vitro susceptibility of Plasmodium falciparum to antimalarials using a pocket computer.

A small pocket computer, Sharp PC-1500, was programmed to analyze the dose-response curves generated by the in vitro assay of antimalarials against field isolates of Plasmodium falciparum. Using nonlinear regression the analysis provided an estimate of the 50% inhibitory concentration with 95% confidence limits and a graph of the data points and regression function line. The pocket computer with the nonlinear regression program offers a powerful, portable, and inexpensive data analysis system suitable for field use.

Evaluation of an in vitro assay system for drug susceptibility of field isolates of Plasmodium falciparum from southern Thailand.

An in vitro assay system has been developed to evaluate the susceptibility of field isolates of Plasmodium falciparum to standard and new antimalarials. The assay used drugs which were serially diluted in the field and determined effective drug concentrations by quantitating schizont maturation after a variable incubation period. Based on the ID50 values, a series of isolates from Yala in southern Thailand were shown to be resistant to chloroquine (187 nM) but only moderately resistant to amodiaquine (23.7 nM), a structurally related 4-aminoquinoline. Five aminocarbinols were evaluated. The parasites were resistant to quinine (219 nM), but comparatively much more susceptible to mefloquine (9.04 nM), halofantrine (1.23 nM), and enpiroline (6.23 nM). The isolates were also relatively sensitive to WR 194,965 (9.04 nM). Two dihydrofolate reductase inhibitors (WR 99,210 and pyrimethamine) were tested. The isolates were comparatively sensitive to a dihydrotriazine, WR 99,210 (2.85 nM). The in vitro values for pyrimethamine (1,870 nM) were higher than the values for the other drugs tested, but were less than values from other regions of Thailand. As compared to a survey conducted in this region four years previously, values for chloroquine, pyrimethamine, amodiaquine, and mefloquine have remained relatively unchanged. However, there was a greater than 20-fold rise in the susceptibility values for quinine, suggesting the introduction of quinine-resistant isolates from eastern Thailand into southern Thailand during this period.

In vitro activity of pyronaridine against field isolates and reference clones of Plasmodium falciparum.

Pyronaridine, a 9-substituted 1-aza-acridine, was assayed for in vitro activity against clinical and field isolates as well as characterized clones of Plasmodium falciparum. The in vitro antimalarial activity of pyronaridine was compared to activities of standard antimalarials against multidrug-resistant isolates of P. falciparum from eastern and northern Thailand using an assay based on the inhibition of schizont maturation. Isolates from eastern Thailand (n = 30) were susceptible to pyronaridine (IC50 8.40 nM), mefloquine (IC50 6.97 nM), and amodiaquine (IC50 12.7 nM) and resistant to chloroquine (IC50 361 nM), quinine (IC50 388 nM), and pyrimethamine (IC50 11,800 nM). The isolates from northern Thailand (n = 7) showed no statistical difference in susceptibility to pyronaridine (IC50 10.1 nM), amodiaquine (IC50 7.29 nM), and mefloquine (IC50 5.48 nM); however, isolates were significantly more susceptible to chloroquine (IC50 167 nM), quinine (IC50 248 nM), and pyrimethamine (IC50 1,980 nM). These data suggest a lack of cross-resistance between pyronaridine and either chloroquine, quinine, or pyrimethamine. Using the same assay system the in vitro activity of pyronaridine was evaluated against isolates from treatment failures of mefloquine or enpiroline from eastern Thailand. The IC50 values for mefloquine against five recrudescent isolates were significantly higher (IC50 16.4 nM) than the field isolates collected from the same region (IC50 6.97 nM); however, there was no significant difference in the pyronaridine susceptibility between the isolates from the field study (IC50 8.89 nM) and the isolates from the treatment failures (IC50 8.40 nM). These observations suggest a lack of cross-resistance to mefloquine following treatment failure with either mefloquine or enpiroline.(ABSTRACT TRUNCATED AT 250 WORDS)

In vitro mefloquine resistance of Plasmodium falciparum isolated from the Burmese border region of Thailand.

The in vitro susceptibility of twenty isolates of Plasmodium falciparum from Tha Song Yang, Tak province, Thailand were determined. The isolates were resistant to chloroquine (IC50 = 220 nM; MIC = 762 nM), quinine (IC50 = 252 nM; MIC = 1010 nM), and pyrimethamine (IC50 = 16400 nM; MIC = 43100 nM) but generally sensitive to mefloquine (IC50 = 6.90 nM; MIC = 20.9 nM) and halofantrine (IC50 = 8.73 nM; MIC = 2.71 nM). Two isolates were identified which appeared resistant to mefloquine (IC50 = 23.1 nM; MIC = 56.6 nM). These isolates may represent an extension of a population of parasites from eastern Thailand.

Analogues of N-benzyloxydihydrotriazines: in vitro antimalarial activity against Plasmodium falciparum.

The antimalarial activities of a series of chlorophenyloxyalkoxy and chlorophenalkoxy N-substituted diamino-dihydrotriazines were determined in vitro against three strains of Plasmodium falciparum (Malayan Camp, Vietnam Smith, FCB) with diverse levels of resistance to chloroquine, pyrimethamine, and cycloguanil. Parasite viability was assayed by the inhibition of the uptake of radiolabelled hypoxanthine. Most of the ID-50S of these compounds were less than 1.0 ng ml-1. Consistent differences in sensitivities to these compounds were observed and appeared to be strain related. The Malayan Camp was the most sensitive and Vietnam Smith was the least sensitive. These differences appeared to be related primarily to an inherent sensitivity of a particular strain to the series of analogues examined rather than to a pattern of cross-resistance to chloroquine, pyrimethamine, or cycloguanil.

Analysis of resistance to pyrimethamine/sulphadoxine of isolates of Plasmodium falciparum from Eastern Thailand.

The in vitro susceptibility of five field isolates of Plasmodium falciparum from the region of the Thai-Kampuchean border to pyrimethamine, sulphadoxine, and their combination, was determined using a microtitre test system and media deficient in p-aminobenzoic acid and folic acid. Two-fold serial dilutions of pyrimethamine ranging from concentrations of 8.0 to 0.125 microM and sulphadoxine ranging from 800 to 50 microM were evaluated for antimalarial activity. Viability was based on the maturation of the ring stages to normally-appearing schizonts. Tested singly the parasites had an average ID90 of 3.82 microM for pyrimethamine and greater than 800 microM for sulphadoxine. Analysis of the drugs interaction showed maximum potentiation at approximately 0.8 microM of pyrimethamine and 80 microM of sulphadoxine. These results suggest that resistance to Fansidar is due to the resistance to both components. Although there was a potentiating effect it was probably not sufficient enough for the drugs to be effective in vivo. This may, in part, explain the reduction in clinical cures with the sulphadoxine-pyrimethamine combination in eastern Thailand.

Failure of large-dose erythromycin in combination with a standard dose of chloroquine or quinine in the treatment of human falciparum malaria.

In eastern Thailand, falciparum malaria is highly chloroquine-resistant and is quickly becoming quinine-resistant. In the present study, ten patients with falciparum malaria were given large doses of erythromycin, combined with standard doses of chloroquine; the cure rate was 0 out of 10 (4 RIII failures, 6 RII failures). A further ten patients were given erythromycin with standard doses of quinine; 2 of the 10 patients were cured (8 RI failures). These regimens thus appear to have no appreciable effect against falciparum infections in eastern Thailand.