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Children with autism more likely to visit ED for psychiatric crises
Children with autism spectrum disorder were almost nine times more likely to visit the ED for psychiatric crises compared with children without the disorder, according to study results. Externalizing symptoms and psychotic disorders were the leading cause of ED visits among children with autism spectrum disorder (ASD).
“This finding of higher rates of emergency room visits among children with autism demonstrates that many children with autism aren’t receiving sufficient outpatient mental health care to prevent and manage the type of crises that are driving these families to seek urgent help,” study researcher Roma Vasa, MD, a child psychiatrist at Kennedy Krieger Institute’s Center for Autism and Related Disorders in Maryland, said in a press release.
Vasa and colleagues analyzed data on 3,974,332 ED visits by children aged 3 to 17 years, obtained from the 2008 National Emergency Department Sample. Of all ED visits studied, 13,191 were made by children with ASD.
Results showed that 13% of visits among children with ASD were due to a psychiatric problem, compared with 2% of all visits by youth without ASD. Children with ASD were at a ninefold increased risk for a psychiatric ED visit vs. children without ASD (OR=9.13; 95% CI, 8.61-9.7).
Children with ASD who were covered by private insurance were at greater risk for a psychiatric ED visit compared with children with ASD who had medical assistance (OR=1.58; 95% CI, 1.53-1.63).
“We think this is because private insurance plans often exclude autism from behavioral health coverage, have few in-network providers or place restrictive limits on the amount of mental health expenses that they will reimburse,” study researcher Luther Kalb, MHS, said in the press release.
Results also indicated that children with ASD were more likely to visit the ED for externalizing (OR=1.62; 95% CI, 1.44-1.83) or psychotic disorders (OR=1.93; 95% CI, 1.58-2.35).
The researchers wrote that changes must be adopted in a number of areas to accommodate the health care needs of children with ASD.
“These novel findings highlight the need for more comprehensive, community-based psychiatric systems of care for children with ASD, greater education and training for ED staff surrounding psychiatric and developmental disabilities, and health policy research assessing the influence of mental health insurance benefits on outcomes among individuals with ASD,” they wrote.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Previous studies have suggested a markedly increased rate of psychiatric admissions for children with ASD due to comorbid mental health conditions. This study utilized data from the 2008 National Emergency Department Sample (NEDS) to assess the prevalence and characteristics of psychiatry-related emergency department visits for children with ASD aged 3 to 17 years, and included 13,191 visits for children with ASD out of a total sample size of nearly 4 million visits. Thirteen percent of the ED visits for children with ASD were psychiatry related, as compared to 2% for the rest of the sample. Visits for children with ASD were most often due to externalizing behaviors or psychosis; little difference in rates of suicide or self-harm were seen for the two groups. Somewhat surprisingly, those children with ASD and private insurance were more likely to visit the ED due to psychiatric problems as compared to those on medical assistance. The authors speculate that this may be the result of private insurers’ exclusion of ASD as a coverable mental health entity.
As the authors point out, EDs often serve as the gateway for psychiatric inpatient admissions. The use of the ED for this purpose is not ideal for most children with psychiatric presentations, but particularly not for children with ASD. The long waits and unfamiliar environments, the lack of training of many ED physicians in working with individuals with ASD, and poor follow-up with outpatient appointments are very problematic for this population. The cost of such visits is also a matter of consideration.
This article confirms what many clinicians have experienced in their practices. Children with dual diagnoses of developmental disabilities and mental health problems are underserved, both in outpatient and inpatient settings. Many health care providers do not feel comfortable working with these children due to lack of specific training and expertise. Too often, parents have extended stays in the ED only to be told that there is no inpatient psychiatric facility available that is qualified to care for their child. The situation is even worse for adults with dual diagnoses. Emphasis has to be placed on expanding appropriate outpatient and inpatient services for these children. Ideally, this would involve a family-centered team approach, including not only mental health providers but educators, speech pathologists, primary care providers, etc. As clinicians, it is critical that we communicate with others in our communities about the growing needs presented by these patients and begin a discussion about how to meet these needs.