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Early diagnosis of autism spectrum disorders (ASD) is critical for a number of reasons, (1,2) perhaps most important because interventions to improve the functioning of children with ASD may be [...], Objective. Early diagnosis of children with autism spectrum disorders (ASD) is critical but often delayed until school age. Few studies have identified factors that may delay diagnosis. This study attempted to identify these factors among a community sample of children with ASD. Methods. Survey data were collected in Pennsylvania from 969 caregivers of children who had ASD and were younger than 21 years regarding their service experiences. Linear regression was used to identify clinical and demographic characteristics associated with age of diagnosis. Results. The average age of diagnosis was 3.1 years for children with autistic disorder, 3.9 years for pervasive developmental disorder not otherwise specified, and 7.2 years for Asperger's disorder. The average age of diagnosis increased 0.2 years for each year of age. Rural children received a diagnosis 0.4 years later than urban children. Near-poor children received a diagnosis 0.9 years later than those with incomes >100% above the poverty level. Children with severe language deficits received a diagnosis an average of 1.2 years earlier than other children. Hand flapping, toe walking, and sustained odd play were associated with a decrease in the age of diagnosis, whereas oversensitivity to pain and hearing impairment were associated with an increase. Children who had 4 or more primary care physicians before diagnosis received a diagnosis 0.5 years later than other children, whereas those whose pediatricians referred them to a specialist received a diagnosis 0.3 years sooner. Conclusion. These findings suggest improvements over time in decreasing the age at which children with ASD, especially higher functioning children, receive a diagnosis. They also suggest a lack of resources in rural areas and for near-poor families and the importance of continuous pediatric care and specialty referrals. That only certain ASD-related behaviors, some of which are not required to satisfy diagnostic criteria, decreased the age of diagnosis suggests the importance of continued physician education. Pediatrics 2005;116:1480-1486; autism, developmental delay, medical home, referral/consultation. ABBREVIATIONS. ASD, autism spectrum disorders; PDD-NOS, pervasive developmental disorder not otherwise specified.

Child maltreatment is a medical and public health concern that affects nearly 12 of every 1000 children annually. (1) Victimization rates are highest among children from birth to 3 years [...], Objectives. Early identification of children who are at risk for maltreatment continues to pose a challenge to the medical community. The objective of this study was to determine whether children who are at risk for maltreatment have characteristic patterns of health care use before their diagnosis of abuse or neglect that distinguish them from other children. Methods. We performed a case-control study among Medicaid-enrolled children to compare patterns of health service among maltreated children in the year before a first report for abuse or neglect that led to an immediate placement into foster care, with patterns of health service use among matched control subjects. Exposure variables, obtained from Medicaid claims, included the total number of non-emergency department (ED) outpatient visits, the total number of ED visits, the frequency of injury-related diagnoses, the frequency of nonspecific diagnoses that have been previously linked to abuse, and the number of changes in a child's primary care provider. Multivariate models were performed adjusting for cash assistance eligibility, race, and child comorbidities. Results. We characterized the health service use patterns, during the year before their first maltreatment report, of 157 children with serious and substantiated abuse or neglect. Health service use during the same period was also characterized among 628 control subjects who were matched by age, gender, and number of months of Medicaid eligibility. Sixteen percent of cases changed their primary care providers, compared with 10% of the control subjects. Multivariable modeling demonstrated that maltreated children were 2.62 (95% confidence interval: 1.40-4.91) times more likely than control subjects to have had 1 previous change in primary care provider and 6.87 (95% confidence interval: 1.96-24.16) times more likely to have changed providers 2 or more times during the year before their first maltreatment report. There were no differences between case patients and control subjects in the frequency of ED visits and rates of diagnoses of injury or nonspecific somatic complaints. Conclusions. Victims of serious and substantiated physical abuse and neglect change ambulatory care providers with greater frequency than nonabused children. Recognition of this patient characteristic may allow for earlier identification of children who are at risk for additional or future maltreatment. Pediatrics 2005;116:13031308; child abuse, health service use, Medicaid. ABBREVIATIONS. SMRF, State Medicaid Research Files; ED, emergency department; CPT, Current Procedural Terminology; OR, odds ratio; CI, confidence interval.

The 550 000 children in the US foster care system have significant and often unmet health care needs. (1-6) This population comprises a heterogeneous group of children, whose needs, subsequent [...], Objective. Although prior population-based studies have found that children in foster care use more mental health services than their Medicaid peers, less is known about how different experiences in foster care impact the likelihood of mental health service use. The primary aim of this study is to test the hypothesis that instability of foster care placements is associated with higher costs for mental health care services. The secondary aim is to test the hypothesis that foster care children are also more likely to generate high costs for mental health services if they generate higher costs for non-mental health claims. Methods. Using administrative child welfare data linked to Medicaid claims, we assembled a unique retrospective cohort of adjudicated dependent children >2 years old who entered foster care between July 1993 and June 1995, spent at least 9 months in care, and were Medicaid eligible during a 1-year follow-up period. The primary outcome was high mental health service use, defined as having costs in the top decile of the sample. The primary independent variables were the number of foster care placements during the year and whether placements were interrupted by a return home for at least 1 month during that year (episodic foster care). We used logistic regression to estimate the association between placements and service utilization, with adjustment for age and physical health care costs. Results. Of the 1635 children in the study, 41% had >3 foster care placements, and 5% had episodic foster care during the year of observation. The top 10% of mental health service users accounted for 83% of the $2.4 million in mental health costs. Both multiple placements and episodic foster care increased the predicted probability of high mental health service use. Higher physical health care costs also increased the probability of high mental health use for all children, but this increased probability was most dramatic among children with episodic foster care (probability of high mental health use: 0.78; 95% confidence interval: 0.42-0.94). Conclusions. Foster care placement instability was associated with increased mental health costs during the first year in foster care, particularly among children with increasing general health care costs. These findings high light the importance of interventions that address the global health of children in foster care and may permit better targeting of health care resources to subgroups of children most likely to use services. Pediatrics 2004;113: 1336-1341; foster care, mental health services, health care costs, placement stability. ABBREVIATIONS. CI, confidence interval; OR, odds ratio.

Background. Children with attention-deficit/hyperactivity disorder and asthma incur similar health care costs that are greater than those of most children without these conditions. Preliminary findings suggest that children with emotional behavioral disorders, anxiety and depression, incur even greater costs. Objective. To determine if children with behavioral disorders have similar health services expenditures as children with physical conditions and to assess whether children with emotional behavioral disorders incur greater expenditures than children with disruptive behavioral disorders. Methods. Children 2 to 18 years old who were members of households participating in the 1996 Medical Expenditure Panel Survey were eligible for this retrospective cohort study. Children with common behavioral disorders selected a priori were identified by using truncated International Classification of Diseases (Ninth Revision) codes obtained from household interviews. Children with common physical conditions (asthma, epilepsy, and diabetes) and children without these conditions served as controls. Estimates were weighted to reflect the complex sampling scheme. Expenditures for health services were compared. Results. Of 3955 eligible children weighted to represent >44 million, 7.1% were identified with a behavioral disorder: 4.5% with disruptive disorders; 2.1% with emotional disorders; and 0.5% with miscellaneous disorders. Children with behavioral disorders incurred overall expenditures similar to children with physical conditions (adjusted $1492 vs $1245; P = .18) but greater than children without these conditions (adjusted $1492 vs $834; P = .001). Children with behavioral disorders had greater expenditures for office-based visits (adjusted $410; 95% confidence interval: $146-672) and prescription medications (adjusted $361; 95% confidence interval: $72-648) than those of children in either control group. Among children with behavioral disorders, children with emotional disorders incurred substantially greater overall expenditures (adjusted $2152 vs $1026; P = .003) than children with disruptive disorders. Children with emotional disorders incurred greater hospitalization expenditures ($664 vs $43; P = .01) but lower pharmacy expenditures ($154 vs $307; P = .001) than children with disruptive disorders. Conclusions. In this nationally representative sample, children with behavioral disorders incurred overall health care costs similar to children with physical conditions but greater than children without any of these conditions because of increased costs for office-based visits and prescription medications. However, costs were not uniform among children with behavioral disorders. Children with emotional disorders incurred twofold higher costs than children with disruptive disorders. Greater recognition of children with emotional disorders and efforts to address the high rate of hospitalizations in this population are warranted. Pediatrics 2003;112:e440--e446. URL: http://www.pediatrics.org/cgi/ content/full/112/6/e440; costs, mental health, children.

Objective: The objective of this study was to compare on a national cohort of children with autism spectrum disorder (ASD) the concurrent use of >or=3 psychotropic medications between children in foster care and children who have disabilities and receive Supplemental Security Income, and to describe variation among states in the use of these medications by children in foster care., Methods: Studied was the concurrent use of >or=3 classes of psychotropic medications, identified from the 2001 Medicaid claims of 43406 children who were aged 3 to 18 years and had >or=1 annual claim for ASD. Medicaid enrollment as a child in foster care versus a child with disabilities was compared. Multilevel logistic regression, clustered at the state level and controlling for demographics and comorbidities, yielded standardized (adjusted) estimates of concurrent use of >or=3 medications and estimated variation in medication use within states that exceeded 1 and 2 SDs from the average across states., Results: Among children in foster care, 20.8% used >or=3 classes of medication concurrently, compared with 10.1% of children who were classified as having a disability. Differences grew in relationship to overall use of medications within a state; for every 5% increase in concurrent use of >or=3 medication classes by a state's population with disabilities, such use by children in a state's foster care population increased by 8.3%. Forty-three percent (22) of states were >1 SD from the adjusted mean for children who were using >or=3 medications concurrently, and 14% (7) of the states exceeded 2 SDs., Conclusions: Among children with ASD, children in foster care were more likely to use >or=3 medications concurrently than children with disabilities. State-level differences underscore policy or programmatic differences that might affect the receipt of medications in this population.

Objective: The objective of this study was to provide national estimates of psychotropic medication use among Medicaid-enrolled children with autism spectrum disorders and to examine child and health system characteristics associated with psychotropic medication use., Methods: This cross-sectional study used Medicaid claims for calendar year 2001 from all 50 states and Washington, DC, to examine 60,641 children with an autism spectrum disorder diagnosis. Logistic regression with random effects was used to examine the child, county, and state factors associated with psychotropic medication use., Results: Of the sample, 56% used at least 1 psychotropic medication, 20% of whom were prescribed > or = 3 medications concurrently. Use was common even in children aged 0 to 2 years (18%) and 3 to 5 years (32%). Neuroleptic drugs were the most common psychotropic class (31%), followed by antidepressants (25%) and stimulants (22%). In adjusted analyses, male, older, and white children; those who were in foster care or in the Medicaid disability category; those who received additional psychiatric diagnoses; and those who used more autism spectrum disorder services were more likely to have used psychotropic drugs. Children who had a diagnosis of autistic disorder or who lived in counties with a lower percentage of white residents or greater urban density were less likely to use such medications., Conclusions: Psychotropic medication use is common among even very young children with autism spectrum disorders. Factors unrelated to clinical presentation seem highly associated with prescribing practices. Given the limited evidence base, there is an urgent need to assess the risks, benefits, and costs of medication use and understand the local and national policies that affect medication use.