In the first study to compare mental health-related emergency department (ED) visits between children with and without autism spectrum disorders (ASD), researchers found that ED visits are nine times more likely to be for psychiatric reasons if a child has an ASD diagnosis. Published in the journal Pediatric Emergency Care (Epub ahead of print), the study found externalizing symptoms, such as severe behaviors tied to aggression, were the leading cause of ED visits among children with ASD. Importantly, the likelihood of a psychiatric ED visit was higher if a child carried private health insurance rather than medical assistance.
"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," said Dr. Roma Vasa, senior study author and a child psychiatrist in Kennedy Krieger Institute's Center for Autism & Related Disorders. "These findings should highlight the urgent need for better comprehensive outpatient mental health care and insurance coverage for children with autism, along with greater education and training for emergency medical staff."
Using the 2008 National Emergency Department Sample, the largest all-payer ED database in the US, researchers examined data from a total of 3,974,332 ED visits for patients ages 3 to 17, of which 13,191 visits were from children with ASD. Mental health-related ED visits were based on International Classification of Disease (ICD) billing diagnoses that included mood, anxiety and psychotic disorders, suicide and self-injury, and externalizing behaviors such as aggression.
Researchers also studied the influence of different types of insurance coverage on the likelihood of an ED visit for psychiatric reasons. They found that children with ASD whose families had private medical insurance were 58 percent more likely to visit the ED for mental health-related reasons than those whose health insurance was provided through state medical assistance programs.
"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," said Luther Kalb, MHS, first study author and a research scientist in Kennedy Krieger Institute's Center for Autism & Related Disorders.
With 1 in 88 children in the U.S. diagnosed with ASD, the use of the ED to treat psychiatric behaviors is likely to increase unless changes occur. Dr. Vasa suggests that this trend is especially troublesome because the ED is not an optimal setting for children with ASD since chaotic environments can exacerbate autism-related or comorbid psychiatric symptoms.
"Children with autism, especially those with co-occurring psychotic disorders or severe behaviors, need to have an emergency crisis plan in place," said Kalb. "Everyone involved in the life of a child with autism, from parents to medical professionals to school educators, needs to have routine discussions about what to do in the case of an escalating situation."
This study also suggests that emergency departments should consider adopting new measures to accommodate children with ASD. This includes greater education and training for ED professionals about how to properly assess and interact with children on the autism spectrum. Additionally, researchers suggest that the large numbers of children with autism accessing the ED may necessitate a separate area for children with ASD that is less chaotic and contains less stimulation than found in the otherwise busiest part of any hospital.
Further research on adults with ASD using the ED for psychiatric reasons and general trends associated with mental health care is needed. With more information, medical professionals and insurance providers can have a greater understanding of the gaps in care and work to improve services.
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