Emergency Psychiatric Service Use and Continuity of Care Among Youth with Autism Spectrum Disorder

Background: Previous research suggests youth with Autism Spectrum Disorder (ASD) are at increased risk for emergency psychiatric service use, including both inpatient psychiatric hospitalizations and psychiatric emergency department (ED) visits. However, the few studies that have addressed this topic suffer from serious methodological limitations and are quite limited in scope.

Objectives: To examine differences in the probability and conditional rate of both inpatient psychiatric hospitalization and psychiatric ED visits between youth with ASD and youth with Attention Deficit-Hyperactivity Disorder (ADHD). Additional outcomes included differences between groups regarding: 1) the likelihood of readmission within 30 days, 2) length of stay, and 3) probability of an outpatient mental health appointment 30 days before and after service use.

Methods: Data for this study came from 64,700 and 529,662 adolescents (ages 12-17 years) with ASD or ADHD, respectively, enrolled in the 2010-2013 MarketScan Commercial Claims Database. To be included, youth must have at least two ICD-9-CM claims of ASD (299) or ADHD (314), at least 1 year of continuous enrollment, and no history of substance abuse or stay in a long-term residential facility. Psychiatric services were identified by the presence of a primary psychiatric diagnosis (290-314.XX) or E/V code (e.g., suicide). The Area Resource File (ARF) was joined to the Marketscan dataset to provide information on geographical indicators of race, income, and density of outpatient and inpatient services. A multivariate two-part regression model was used to assess the probability (logit) and conditional rate (gamma) of service use while adjusting for demographic, enrollment, and geographic characteristics. All other objectives were addressed using multivariate linear or logistic regression models.

Results: 1 in 12 adolescents with ASD used an urgent psychiatric service, representing greater than a two-fold higher probability of use for psychiatric hospitalization (5% vs. 2%; aOR = 2.5, 95% CI: 2.4-2.6) and for psychiatric ED visits (4% vs. 2%; aOR = 2.2, 95% CI: 2.1-2.3) compared to those with ADHD. Conditional on service use, the ASD group had a 14% and 11% increased rate of hospitalization (IRR = 1.14, 95% CI: 1.1-1.2) and ED (IRR = 1.11, 95% CI: 1.08-1.44) visits, respectively. Longer inpatient and ED stays, and an increased likelihood of re-visiting both settings within 30 days was also found among youth with ASD (all p<.001). Receipt of an outpatient mental health services 30 days before or after an ED visit or hospitalization was high (~80%) and similar between groups (p>.05).

Conclusions: This is the first prospective cohort study to assess the interplay between inpatient, ED, and outpatient psychiatric service use among youth with ASD or ADHD. Youth with ASD used more emergency psychiatric services for longer periods of time compared to youth with ADHD. Increased psychiatric ED use among those with ASD is particularly disconcerting since only 10% of these visits resulted in hospitalization, leaving the family to manage the difficult behavior at home without additional resources or treatment options. These data also challenge the notion that emergency psychiatric services use is simply due to poor connections to outpatient mental health providers.