Characteristics of psychiatric emergency department use among privately insured adolescents with autism spectrum disorder

Abstract

This study examined differences in the rates of psychiatric-related emergency department visits among adolescents with autism spectrum disorder, adolescents with attention deficit hyperactivity disorder, and adolescents without autism spectrum disorder or attention deficit hyperactivity disorder. Additional outcomes included emergency department recidivism, probability of psychiatric hospitalization after the emergency department visit, and receipt of outpatient mental health services before and after the emergency department visit. Data came from privately insured adolescents, aged 12–17 years, with autism spectrum disorder (N = 46,323), attention deficit hyperactivity disorder (N = 408,066), and neither diagnosis (N = 2,330,332), enrolled in the 2010–2013 MarketScan Commercial Claims Database. Adolescents with autism spectrum disorder had an increased rate of psychiatric emergency department visits compared to adolescents with attention deficit hyperactivity disorder (IRR = 2.0, 95% confidence interval: 1.9, 2.1) and adolescents with neither diagnosis (IRR = 9.9, 95% confidence interval: 9.4, 10.4). Compared to the other groups, adolescents with autism spectrum disorder also had an increased probability of emergency department recidivism, psychiatric hospitalization after the emergency department visit, and receipt of outpatient care before and after the visit (all p < 0.001). Further research is required to understand whether these findings extend to youth with other neurodevelopmental disorders, particularly those who are publicly insured.

Keywords

attention deficit hyperactivity disorder autism spectrum disorders crisis emergency health services

The American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP) have released joint statements addressing the clinical challenges presented by pediatric psychiatric emergencies in the emergency management system (American Academy of Pediatrics, Committee on Pediatric Emergency Medicine et al., 2006; Dolan et al., 2011). These reports were motivated by the sustained increase in the number of psychiatric-related pediatric emergency department (ED) visits in the United States, despite the nationwide decrease in the number of EDs (Dolan et al., 2011). Between 2001 and 2011, the annual rate of pediatric psychiatric ED visits nearly doubled from 13.6 to 25.3 visits per 1000 adolescents, whereas the total number of EDs decreased by 5% during this same period (Dolan et al., 2011; Simon and Schoendorf, 2014).

ED visits have become a topic of particular interest among youth with autism spectrum disorder (ASD) since the sensory, social, and communication deficits inherent to ASD make this environment particularly difficult to tolerate and could exacerbate behavioral issues. The most common reasons for ED use among youth with ASD include epilepsy, respiratory infections, and gastrointestinal issues (Iannuzzi et al., 2015; Zhang et al., 2017). However, psychiatric issues, such as mood and externalizing disorders, are also a leading cause of ED visits among adolescents with ASD (Iannuzzi et al., 2015; Zhang et al., 2017). If a parent uses the ED for psychiatric management, this setting becomes quite challenging since there are few resources available to manage an acute psychiatric event involving a child with ASD (Kalb et al., 2017b). As such, ED physicians may be inclined to prescribe chemical and physical restraints to manage these children (Lunsky et al., 2014). If admission is necessary, they will need to find an inpatient unit for these children, which can be difficult, since most general child psychiatry inpatient units are reluctant or refuse to admit youth with a neurodevelopmental disorder (Siegel and King, 2014). Ultimately, parents may experience stress, frustration, and disillusionment with the medical system as they wait for long periods in the ED and are sent home to manage their child’s psychiatric symptoms with little to no additional mental health resources (Wharff et al., 2011).

Despite the aforementioned concerns, parents of youth with ASD still continue to use the ED for mental health treatment for their child. Using the 2008 National Emergency Department Sample (NEDS), a nationally representative data set of ED visits across the United States, Kalb et al. (2012) found that 13% of ED visits among children with ASD were for psychiatric reasons, compared to 2% of visits among non-ASD youth. Similarly, using the 2010 NEDS, Iannuzzi et al. (2015) and Vohra et al. (2016) reported that psychiatric conditions were among the leading cause of ED visits in adolescents and adults with ASD, respectively. For both studies, psychiatric diagnoses were the primary reason for 15% of all visits. More recently, among a cohort of privately insured youth, Liu et al. (2017) found that the proportion of ED patients with ASD who received behavioral health services during their visit nearly doubled, from 12% in 2005 to 22% in 2013. The largest increases in psychiatric visits were among older youth (15–21 years) and those living in a rural setting. These findings illustrate continued use of the ED for mental health treatment among the ASD population, despite the aforementioned concerns regarding the suitability of this setting to deliver psychiatric care to these youth.

While the literature around ED use in ASD is growing, there are several methodological constraints within this body of work. Most of the research to date has employed the NEDS (see https://www.hcup-us.ahrq.gov/nedsoverview.jsp for more details), which is limited because it contains data at the level of visits, not patients. As a result, it is unknown if a single child contributed to one or multiple visits. The NEDS is also cross-sectional, which precludes understanding patient-level trends. Another limitation is that NEDS data are based solely on ED discharge diagnosis. As a result, the prevalence of ASD in the NEDS is likely underestimated since ED physicians are not trained in detecting neurodevelopmental disorders.

Studies that employ billing claims data (e.g. Liu et al., 2017) will likely result in more accurate ASD prevalence estimates since the child’s history of service use (e.g. outpatient diagnostic evaluations), that was billed under the insurance plan, is available for analysis. However, a major limitation with the study by Liu et al. (2017) is the authors’ definition of a behavioral health visit included the diagnosis of ASD (ICD 299.XX). As a result, all ASD-related visits, even those solely due to medical reasons, were classified as behavioral health related if the provider included an ASD code on the claim. This approach might overestimate the number of behavioral health visits. While this study utilizes the same data set as the study by Liu et al. (2017), visits were classified as psychiatric in nature when the primary diagnosis indicated a mental health disorder. Thus, we believe the findings from this study are likely more conservative than those reported by Liu et al. (2017).

There are several aims of this study. The first compared the rates of psychiatric-related ED visits among adolescents with ASD, adolescents with attention deficit hyperactivity disorder (ADHD), and those without either ASD or ADHD using the MarketScan Claims Database. The ADHD group is an ideal comparison group because, similar to ASD, it is a neurodevelopmental disorder with extensive psychiatric comorbidity. To date, no previous studies have included a comparison group with a neurodevelopmental disorder to better understand the specificity of the findings on psychiatric ED use with respect to ASD. Examining psychiatric ED use among adolescents with ADHD is also important in its own right since this has never been examined.

The second aim assessed group differences in the reason for the psychiatric ED visit. Understanding these reasons will help develop targeted interventions for each condition. The third aim examined the interaction between various service encounters, including the probability of revisiting the ED within 30 or 90 days after the initial psychiatric ED visit, the proportion of ED visits that resulted in psychiatric hospitalization, and connections to outpatient care 30 days before and after the ED visit. This interplay has never been studied in ASD or ADHD. Examining these patterns is critical to better understanding outpatient care models, with the goal of reducing ED visits and inpatient stays.

Methods

Sample

The primary data set used for this study was the Thomson Reuters Truven MarketScan Database (Adamson and Hansen, 2008). Totaling approximately 17 million enrollees per year (and growing over time), the MarketScan Database includes claims covered under a variety of healthcare plans, including fee-for-service, and fully as well as partially capitated health plans, from more than 200 large private insurance firms across the United States (Adamson and Hansen, 2008). Due to confidentiality reasons, information about the employer-sponsored health insurance firms that participate in the MarketScan Database is unavailable.

The MarketScan Database contains all inpatient and outpatient claims for both mental health and general healthcare services for enrollees and their dependents between 2010 and 2013. Variables also contained in MarketScan include procedure codes, service dates, and diagnoses based on International Classification of Disease Version 9 Codes (MediCode, 1996). Unique, anonymous individual identifiers allow researchers to track individuals over year and across medical settings. Basic enrollment information (i.e. age, sex, region) for all insured individuals is available. Given the de-identified nature of the data, the local Institutional Review Board deemed this study exempt from human subjects research review.

Inclusion criteria

Adolescents, 12 and 17 years, were included in this study. This age group represents the developmental period when psychiatric ED use peaks (Iannuzzi et al., 2015; Kalb et al., 2012; Pittsenbarger and Mannix, 2014). Since the unit of analysis was child-calendar year, the child must have been enrolled in their caregiver’s private insurance plan for at least 12 months to eliminate group differences in the days enrolled within each year. The proportion of children who were continuously enrolled within each year (76%) was similar over time (2010–2013) and across diagnostic groups.

The diagnostic coding hierarchy employed in this study allowed for creating three independent groups. First, youth with at least two reimbursed inpatient or outpatient claims that billed the diagnostic code ICD-9 (International Classification of Disease Version 9) 299.XX were included in the ASD group (Burke et al., 2014). Second, adolescents with at least two reimbursed claims that billed an ICD-9 Code 314.XX and no history of any claims that billed a diagnostic code of 299.XX were included in the ADHD group. Thus, youth with ASD were allowed to have a history of ADHD, but not vice versa. This approach was taken since a much greater proportion of youth with ASD meet criteria for ADHD, whereas far fewer youth with ADHD have co-occurring ASD (Faraone et al., 2017; Rao and Landa, 2014). Excluding adolescents with ASD and co-occurring ADHD may have also resulted in a study population that was substantially different from the target population (privately insured adolescents with ASD in the United States). The third group comprised a 20% random sample of children enrolled in MarketScan between 2010 and 2013 who were continuously enrolled for at least 12 months in a single year and did not have any ASD- or ADHD-related claims.

Visit coding

Consistent with previous research methods, psychiatric ED visits and psychiatric inpatient hospitalizations were identified when the primary or first diagnosis billed indicated a psychiatric disorder (ICD-9 290-319.XX) (Carlisle et al., 2012; Durden et al., 2010; Stensland et al., 2012). This diagnosis likely represents the primary reason for the visit (Centers for Disease Control and Prevention, 2011). If ASD or ADHD was listed first, these visits/hospitalizations were considered psychiatric given the nature of these diagnoses. Moreover, psychiatric ED visits that resulted in hospitalization were identified by those visits that were associated with a psychiatric inpatient hospitalization either the day of or the day following the ED visit. Clinical information about the child meeting criteria for hospitalization was not available.

Outpatient mental health visits were identified when a reimbursed claim was submitted by a mental health professional or a mental health–related procedure was billed during the visit. Most of these visits were by psychologists (23%), therapists (24%), psychiatrists (24%), and general physicians (9%). All other visits (20%) were delivered by other providers who billed for a mental health procedure, which included psychiatric diagnostic services, general therapeutic psychiatric services, and individual, family, and group psychotherapy. Only 10% of visits were billed as a psychiatric diagnostic service.

Statistical analysis

Chi-square and analysis of variance (ANOVA) analyses were used to examine differences in demographic variables across the three groups: adolescents with ASD, ADHD, and neither of these diagnoses. If the overall test statistic indicated a significant difference across all three groups (p < 0.05), linear or logistic regression models were used to perform pair-wise contrasts. For the primary study aim, to examine group differences in the rate (or log count) of psychiatric ED visits at the child-calendar year, a negative binomial regression model was employed. This model was selected among other count-based regression models (e.g. Poisson) based on Bayesian and Akaike information criterion values. Moreover, logistic regression models were used to assess differences between groups in (a) the reason for visit, (b) ED recidivism within 30 or 90 days, and (c) probability of the ED visit resulting in a psychiatric admission. To address differences in the rate of outpatient mental healthcare 30 days before and 30 days after the psychiatric ED visit, a negative binomial regression model was used. All regression models adjusted for the five demographic variables shown in Table 1.

Table 1.

Demographic differences between diagnostic groups.

	ASD	ADHD	Neither diagnosis
N	46,343	408,066	2,330,332
Age, M (SD)	13.9 (1.6)^a,b	14.1 (1.6)^c	14.6 (1.6)
Gender (% male)	80^a,b	68^c	49
Years enrolled, M (SD)	2.3 (1.0)^a,b	2.4 (1.0)^c	2.5 (1.0)
Region (%)
Northeas	25^a,b	16^c	18
North Central	26^a,b	27^c	24
South	26^a,b	39^c	34
West	19^a,b	14^c	21

ASD: autism spectrum disorder; ADHD: attention deficit hyperactivity disorder; SD: standard deviation.

p < 0.05 contrast between ASD versus ADHD.

p < 0.05 contrast between ASD versus no ASD and no ADHD.

p < 0.05 contrast between ADHD versus no ASD and no ADHD.

For the analyses examining ED recidivism and access to outpatient care, we only examined the adolescents’ first psychiatric ED visit that did not result in a hospitalization. This approach was taken to avoid survivor treatment selection bias and ensure the child remained in the community where a repeat ED visit or follow-up with outpatient care could be observed (Glesby and Hoover, 1996). Robust standard errors were used to account for the clustering of the data, alpha was set at 0.05 for all variables, and STATA 12.0 (College Station, TX, USA) was used for data management and to conduct the analyses.

Results

Demographics

Table 1 displays the demographic characteristics across the three groups. Adolescents with ASD (β = −0.17, 95% confidence interval (CI): −0.18, −0.12) and adolescents with ADHD (β = −0.13, 95% CI: −0.13, −0.12) were enrolled in their private insurance plan for slightly fewer years, on average, than adolescents without either diagnosis, whereas little difference was observed between adolescents with ASD and adolescents with ADHD (β = −0.05, 95% CI: −0.06, −0.04). Adolescents with ASD (β = −0.66, 95% CI: −0.67, −0.65) and adolescents with ADHD (β = −0.49, 95% CI: −0.50, −0.48) were also slightly younger than adolescents without either diagnosis; little difference in age emerged between those with ASD and ADHD (β = −0.17, 95% CI: −0.18, −0.15). On the other hand, the ASD group had a disproportionately higher percentage of males compared to the ADHD group odds ratio (OR = 1.9, 95% CI: 1.8, 2.0) or the group without either diagnosis (OR = 4.1, 95% CI: 4.0, 4.2). The ADHD group was also predominantly male compared to the group without either diagnosis (OR = 2.1, 95% CI: 2.1, 2.2). Multiple regional differences also emerged across the groups (see Table 1). All group differences reported above were p < 0.01, and each of the variables were included as covariates in the multivariate models discussed below.

Rates of psychiatric ED visits

Table 2 displays the average number of visits across groups and over time. Overall, adolescents with ASD had an increased rate of psychiatric ED visits (M = 5.7 visits per 100 adolescents per year) compared to the other two groups (ADHD: IRR = 2.0, 95% CI: 1.9, 2.1; neither diagnosis: IRR = 9.6, 95% CI: 9.1, 10.0, both p < 0.001). The ADHD group also had more visits (M = 3.1 visits per 100 adolescents per year) compared to adolescents without either diagnosis (IRR = 4.9, 95% CI = 4.8, 5.1), whose rate of visits was very low (M = 0.6 visits per 100 adolescents per year). Between 2010 and 2013, there was no change in psychiatric ED visits among adolescents with ASD (IRR = 0.96, 95% CI = 0.92, 1.0, p = 0.07 for linear time trend). For the ADHD group, there was a slight decrease in visits between 2010 and 2013 (IRR = 0.93, 95% CI = 0.91, 0.95, p < 0.001), while there was a small increase for those without either diagnosis (IRR = 1.05, 95% CI = 1.04, 1.06, p < 0.001).

Table 2.

Characteristics of psychiatric ED visits.

	ASD	ADHD	Neither diagnosis
Total psychiatric ED visits (M visits per 100 youth)
2010	6.6	3.5	0.6
2011	5.3	3.0	0.7
2012	5.5	3.1	0.7
2013	5.7	2.9	0.8
Overall	5.7^a,b	3.1^c	0.7
Psychiatric diagnosis/reason for ED visit (%)
Mood disorder	45^b	54^c	52
Oppositional-defiant/conduct disorder	17^a,b	10^c	4
Psychosis-related disorders	4^a,b	2^c	2
Substance use disorders	2^a,b	16^c	22
All other psychiatric diagnoses	32^a,b	18^c	20
Psychiatric ED visits that resulted in hospitalization^d (%)	15^a,b	14^c	7
Repeat psychiatric ED visit^d (% of ED visits)
Within 30 days	9^a,b	7^c	6
Within 90 days	16^a,b	11^c	8
Outpatient care^d (mean visits)
30 days prior to ED visit	1.9^a,b	1.7^c	1.0
30 days after ED visit	1.1^a,b	0.9^c	0.4

ASD: autism spectrum disorder; ADHD: attention deficit hyperactivity disorder; SD: standard deviation; ED: emergency department.

p < 0.05 contrast between ASD versus ADHD.

p < 0.05 contrast between ASD versus no ASD and no ADHD.

p < 0.05 contrast between ADHD versus no ASD and no ADHD.

Only first visits that did not result in a hospitalization were assessed.

Reasons for psychiatric ED visits

Table 2 displays all of the reasons for visit across groups. Descriptively, the most common reason for visit across all groups was mood disorders. Among the ASD and ADHD groups, “other” psychiatric disorders were the second most common reason for visit, whereas “other” disorders were the third leading reason for visit among the group without ASD or ADHD. Oppositional defiant disorder (ODD)/conduct disorders and substance abuse disorders were the third most common reason for visit among adolescents with ASD and adolescents with ADHD, respectively. Psychosis-related visits were infrequent for all diagnostic groups, substance abuse disorders were uncommon among adolescents with ASD, and visits for ODD/conduct disorders were rare among adolescents without ASD or ADHD.

In the multivariate models, which conditioned on the occurrence of a visit and all covariates in Table 1, adolescents with ASD were more likely to visit the ED for a psychotic disorder (OR = 2.0, 95% CI: 1.7, 2.4), conduct/ODD (OR = 1.5, 95% CI: 1.4, 1.6), and “other” psychiatric disorders (OR = 2.1, 95% CI: 2.0, 2.3) compared to those with ADHD; although, they were less likely to visit the ED for a substance use (OR = 0.1, 95% CI: 0.1, 0.2) or mood disorder (OR = 0.8, 95% CI: 0.8, 0.9) compared to those with ADHD. Compared to those without ASD or ADHD, adolescents with ASD were likely to visit the ED due to a psychotic disorder (OR = 1.6, 95% CI: 1.4, 1.9), ODD/conduct disorder (OR = 3.0, 95% CI: 2.7, 3.3), and “other” psychiatric disorders (OR = 1.95, 95% CI: 1.8, 2.1). On the other hand, they were less likely to visit the ED due to a substance use disorder (OR = 0.1, 95% CI: 0.2, 0.1; all p < 0.001) and equally likely to visit the ED for a mood disorder (OR = 1.0, 95% CI: 0.9, 1.0, p = 0.5) compared to adolescents without either diagnosis. Finally, youth with ADHD were more likely to visit the ED for a mood (OR = 1.3, 95% CI: 1.2, 1.3) or ODD/conduct disorder (OR = 2.0, 95% CI: 1.9, 2.1) and less likely for a psychotic (OR = 0.8, 95% CI: 0.7, 0.9), substance use disorder (OR = 0.6, 95% CI: 0.6, 0.7), or “other” psychiatric disorders (OR = 0.9, 95% CI: 0.8, 0.9; all p < 0.001) compared to adolescents without either diagnosis.

ED recidivism

The 38,041 first ED visits (55% of total visits) that did not result in hospitalization were assessed for ED recidivism within 30 and 90 days. In the multivariate analysis, adolescents with ASD were more likely to have a repeat visit compared to adolescents with ADHD (30 days, OR = 1.3, 95% CI: 1.1, 1.5; 90 days, OR = 1.5, 95% CI: 1.3, 1.5) and those without either diagnosis (30 days, OR = 1.6, 95% CI: 1.4, 1.8; 90 days, OR = 2.2, 95% CI: 1.9, 2.4). Similarly, adolescents with ADHD were more likely to have a repeat visit within 30 days (OR = 1.2, 95% CI: 1.1, 1.4) and 90 days (OR = 1.5, 95% CI: 1.4, 1.6) than adolescents without either diagnosis (all p < 0.001).

Inpatient psychiatric hospitalization

Descriptively, a larger proportion of visits among adolescents with ASD (15%) and adolescents with ADHD (14%) resulted in a psychiatric hospitalization compared to adolescents without either diagnosis (7%). In the adjusted analyses, ED visits among adolescents with ASD (OR = 2.6, 95% CI: 2.4, 2.9) and those with ADHD (OR = 2.1, 95% CI: 2.0, 2.2) were more likely to result in psychiatric hospitalization compared to those without either disorder. Adolescents with ASD were also slightly more likely (OR = 1.2, 95% CI: 1.1, 1.3) to have a psychiatric ED visit result in a psychiatric hospitalization compared to adolescents with ADHD (all p < 0.001).

Outpatient mental health treatment

Adolescents with ASD had more outpatient mental health visits 30 days prior to their first psychiatric ED visit than adolescents with ADHD (IRR = 1.2, 95% CI: 1.1, 1.3) and adolescents without either diagnosis (IRR = 2.1, 95% CI: 1.9, 2.2). A similar trend was observed for those with ADHD compared to those without ASD or ADHD (IRR = 1.8, 95% CI: 1.7, 1.8; all p < 0.001). After 30 days of the first psychiatric ED visit, adolescents with ASD had more outpatient visits than did adolescents with ADHD (IRR = 1.4, 95% CI: 1.3, 1.5) and adolescents without either diagnosis (IRR = 3.2, 95% CI: 3.0, 3.6). A similar relationship was observed for those with ADHD compared to those neither diagnosis (IRR = 2.3, 95% CI: 2.2, 2.5).

Discussion

This study examined the rates and characteristics of psychiatric ED visits involving adolescents with ASD. While prior work has reported on ED visits, this study is the first to include a clinical control group, children with ADHD, and examine the interplay between ED visits, inpatient, and outpatient care. Compared to the two other control groups, adolescents with ASD were more likely to use the ED for psychiatric reasons as well as revisit the ED 30 or 90 days after their first psychiatric ED visit. Based on clinical experience, this finding is somewhat unexpected given parents awareness of long wait times, the highly stimulating environment, and lack of autism specify resources, including discharge disposition. Increased psychiatric ED use may therefore reflect the high level of psychiatric needs and/or the lack of psychiatric services available to immediately address a crisis. Such services include walk-in psychiatric evaluation clinics that can facilitate an inpatient admission, mobilize in home behavioral supports, or access crisis intervention programs such as the START (Systematic, Therapeutic, Assessment, Resources, Treatment) program (Kalb et al., 2016, 2017a, 2017b).

Mood disorders were the most common reason for ED visits among all diagnostic groups. This finding is consistent with developmental trends in typical youth, where mood and anxiety disorders, which increase the risk for self-injury and suicide, are highly prevalent during adolescence (Perna and Schatzberg, 2014). Two other diagnoses that were elevated among adolescents with ASD, compared to adolescents with ADHD and adolescents without either diagnosis, were ODD/conduct disorder and psychotic disorders. Previous research has implicated externalizing disorders as common reason for ED visits among adolescents with ASD (Kalb et al., 2012; Vohra et al., 2016). On the other hand, further research is required to substantiate the finding regarding psychotic disorders since this diagnosis may not be accurate given the complex psychiatric presentation of youth with ASD and the level of clinical acumen require to tease apart psychotic and neurodevelopmental disorders (Kalb et al., 2012).

Counter to intuition, we found that increased psychiatric ED use was associated with increased outpatient mental healthcare, before or after their visit, among youth with ASD as well as those with ADHD. The literature is actually quite mixed in the ability of outpatient mental health care to reduce psychiatric ED visits or hospitalizations (Carlisle et al., 2012; Cheng et al., 2017; Daniel et al., 2004). This finding may be due to group differences in the severity of mental health diagnoses. Youth with a neurodevelopmental disorder who visit the ED may have greater mental health needs that require a continuum of services, which address both chronic (outpatient) and acute (crisis) mental health needs, compared to youth without a neurodevelopmental disorder who also visit ED. These findings may also reflect differences in the quality of care between groups, such that traditional outpatient mental healthcare providers may be less equipped to manage mental health crises involving youth without a neurodevelopmental disorder (Kalb et al., 2017b). We do not believe this finding undermines the utility of outpatient mental health care. Rather, it suggests that further research on factors not included in this study—such as socioeconomic status and ethic/racial factors (Aratani and Addy, 2014), geographic location and rurality (Huffman et al., 2012), residential setting (Lunsky et al., 2012)—is needed. On the other hand, there appears to be room for intervention such as increasing access to respite care (Mandell et al., 2012), structured daytime activities (Lunsky et al., 2012), and reducing parental and family stress (Lunsky et al., 2012). Further research into programs such as the START (Kalb et al., 2016) and ATC (Assertive Community Treatment) (Bond et al., 1991) programs is also warranted since these coordinated, multidisciplinary approaches may be more fruitful in addressing the numerous risk factors for psychiatric ED use than routine outpatient care. Until diversion programs can be put in place, supporting ED providers, who feel under-trained and under-resourced when managing adolescents with ASD in the ED, is warranted (McGonigle et al., 2013; Nicholas et al., 2016).

The findings also showed that the proportion of psychiatric ED visits that resulted in a psychiatric hospitalization was greatest among youth with ASD. This was unexpected given the shortage of specialized psychiatry inpatient units for youth with neurodevelopmental disorders (Siegel and King, 2014). This finding may reflect the providers concern about discharging a patient to their home before fully disentangling the reason for visit and level of acuity. It may also signify the psychiatric and developmental complexity of these visits among this population. Nevertheless, it suggests that adolescents with ASD may be placed on general pediatric psychiatric units where the resources and training required to provide optimal care for this population may not be available. When a child with ASD is placed in a general psychiatric unit, best practice guidelines should be employed to adapt the environment, train professionals, and provide developmentally specific assessments and treatments for this population (Mcguire et al., 2016).

Several limitations of this study should be mentioned. Inherent to the nature of claims-based research, all diagnoses are based solely on clinician billing practices. This raises concerns about diagnostic validity of the groups, due to the lack of gold standard measures, and visit misclassification, due to inconsistent coding patterns. Second, comparability between groups may be compromised due to the lack of information about as well as the inability to control for potential confounders such as family health and well-being, socioeconomic status, and services received outside the insurance plan. Third, these data represent a selected private insurance sample and likely do not generalize to those with Medicaid, the uninsured, or children in the United States as a whole. These limitations are offset by several novel questions addressed by this study, the prospective design, and the use of objective, claims-based data rather than reliance on retrospective recall.

In summary, privately insured adolescents with ASD were more likely to visit the ED for psychiatric reasons compared to adolescents with ADHD and adolescents without either diagnosis. Adolescents with ASD were also more likely to return to the ED, be admitted to the inpatient unit, and have connections to outpatient care. These findings emphasize the burden of mental health problems among youth with ASD, the continued use of the ED to manage these symptoms, and the need for research on outpatient models of care that can manage acute and chronic mental health problems among this population. As youth with ASD age, mental health and psychiatric ED use will remain highly salient given the dire shortage of mental health and psychosocial treatments available to adults with ASD. Further research on this topic among adults with ASD and the various factors contributing to psychiatric ED visits is needed.

Footnotes

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by Johns Hopkins University Wendy Klag Center for Autism & Developmental Disabilities. The funding agency had no role in the study design; the collection, analysis, and interpretation of data; writing of the report; or the decision to submit the article for publication.

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