The conditions of conduct disorder (CD), attention-deficit/hyperactivity disorder and bipolar disorder (BD) are highly comorbid and constitute some of the most prevalent and difficult-to-treat disorders in any mental health care system. Clinicians often struggle with symptom presentation among children and adolescents, differential diagnoses, and their own relative lack of knowledge about the psychosocial and pharmacotherapy treatment of these youths (Kovacs and Pollock, 1995; Wozniak et al., 2001). While there have been many studies of the efficacy of various pharmacotherapies for these disorders, constructing a picture of the care provided to youths with these disorders, especially focusing on gender and ethnic variations in practice, has not been possible, except in specialized academic treatment systems (Wozniak et al., 2001, 1995).
In order to understand how children with these disorders are being assessed and treated in a large public mental health care system, a series of studies was performed in the 17 mental health care centers that constitute the outpatient services system within the South Carolina Department of Mental Health (DMH). Three sampling frames for these studies were chosen among children and adolescents up to 17 years of age who had one of these three disorders as a primary diagnosis.
Patients with a primary diagnosis of CD who were being served in the DMH system in October 1999 were identified (1,111 patients); and a 25% representative sample (based on age, gender and ethnicity) was drawn from this group. The final sample of 252 youths with CD was as follows: 81% male (4:1 ratio), the average age was 14, and 56% were African-American. The most frequently noted co-occurring disorders for these children were ADHD (16.8%), oppositional defiant disorder (ODD) (7.5%) and various mood disorders (4.4%). These demographic characteristics are consistent with previously published data showing that onset of CD peaks in late childhood to early adolescence, the ratio of boys to girls with CD is between 3:1 and 5:1, and African-American youths are more likely to be diagnosed with CD (Steiner, 1997).
Patients (n=1,176) with a primary diagnosis of ADHD who were in the DMH service system between Jan. 1 and April 30, 2000, were identified for another study, and a 20% representative sample was then drawn from this group. The final sample of 164 cases with ADHD was as follows: 82% male (4:1 ratio), with an average age of 9.8, 45% were African-American and 46% had a co-occurring diagnosis (most frequently, ODD). These demographic characteristics are consistent with previously published data showing that the highest percentage of ADHD cases occur in late childhood or early adolescence (10 to 14 years of age), and the ratio of boys to girls with ADHD is typically 9:1 in clinical settings and 4:1 in the general population. However, no data on ethnic differences are available (Dulcan, 1997).
For the third study, children and adolescents (n=83) who had a primary diagnosis of bipolar I disorder (BD-I) and had received treatment in the DMH system as of October 2000 were identified. All of these cases were included in the final sample, which was as follows: 52% male, average age of 15, and 35% African-American. These demographic characteristics are consistent with previously published data showing that the highest percentage of BD cases occurs in adolescence (14 to 18 years of age), and the ratio of boys to girls with BD is about equal. Currently, no data on ethnic differences are available (McClellan and Werry, 1997).
The medical records for the cases in each sample were then audited using a survey instrument that was developed based on the American Academy of Child and Adolescent Psychiatry (AACAP) practice guidelines for treatment of each disorder (Dulcan, 1997; McClellan and Werry, 1997; Steiner, 1997) and the DSM-IV criteria for each disorder. According to AACAP guidelines, a diagnosis of any of these disorders requires that sufficient attention be given to symptom development history, medical history and prenatal history; related disorders in the family, family environment and coping style; use of standardized instruments for symptom assessment in more than one setting; and drug use and medication history.
The protocols for all of these studies were reviewed and approved by the South Carolina DMH Institutional Review Board. Since an important clinical practice and policy issue faced by the service system concerned differential assessment and treatment by gender and ethnicity, specific analyses were performed on the collected data to examine the extent of these differences. Ethnicity was recorded as African-American compared to all other ethnic groups, although the patients in this system are about 40% African-American, and another 2% to 3% are Asian and Hispanic.