Results from three statewide studies of the clinical practices for assessing and treating children and adolescents with a primary diagnosis of conduct disorder, ADHD or bipolar I disorder demonstrate gender and ethnic differences only for those diagnosed with conduct disorder. The implications of these findings and their similarities to the literature on adults with psychiatric disorders are discussed.
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.
The DSM-IV criteria for CD abstracted from the medical record included 15 behaviors, falling into four main groupings: aggressive, non-aggressive, deceitfulness or theft, and serious rule violations. Three or more of these behaviors must have been present in the past 12 months, with at least one behavior in the past six months. The behavior must have caused clinically significant impairment in social, academic or occupational functioning. Results from an extensive analysis of symptom, history and treatment differences by gender and ethnicity indicated that males were not more likely to have the target symptoms of CD documented in their medical charts, but they were four times more likely than females to have co-occurring ADHD. Females were more likely to have run away in the past six months. Furthermore, there were no significant gender differences for documentation of symptom development history and medical history, medication monitoring, ratings of functional impairment, onset criteria prior to age 10, severity ratings, whether DSM- IV criteria were met, use of a standard diagnostic instrument for assessment, drug-use history, or arrests or detention.
There was no greater likelihood for African-Americans to be diagnosed with CD or have co-occurring ADHD, based on the chart documentation. However, African-Americans were less likely to have documentation of the target symptoms of CD present in their chart. There were no ethnic differences in symptom development history, medical history, medication monitoring or for the major symptoms of CD. However, African-Americans were less likely to have lying or conning noted as one of their behavior problems. There also were no ethnic differences noted in ratings of functional impairment, onset criteria prior to age 10, meeting DSM-IV criteria for CD, use of a standard diagnostic instrument in assessment, or arrests or detention. African-Americans were more likely to have a mild/moderate severity rating and were also less likely to have a drug use history. Males and African-Americans were less likely to be prescribed a mood stabilizer or antidepressant in this sample.
The nine criteria for inattention and nine criteria for hyperactivity-impulsivity were abstracted from the medical records in the study of ADHD. At least six of the nine criteria in each category must have been documented as present and persisting for at least six months in order for a subject to meet the first part of the diagnostic criteria for this disorder. Some inattention and/or hyperactivity-impulsivity must have been present before the age of 7, impairment must have been present in more than one setting and interfered with developmentally appropriate functioning, and the symptoms must not have been better accounted for by another mental disorder.
No gender or ethnic differences were detected for meeting the DSM-IV diagnostic criteria for ADHD or presence of information regarding the target symptoms of ADHD or for symptom development history and medical history in the medical record. There also were no gender or ethnic differences in whether a rating of serious functional impairment was present in the chart, whether symptoms present prior to age 7 were noted in the chart or whether a standard diagnostic instrument was used. Likewise, there were no gender or ethnic differences in those prescribed medication, in whether medication monitoring was occurring, or in whether a physical exam was given and the results noted in the chart. Finally, there were no gender or ethnic differences in the prescription of medications by type (stimulants, a-blockers or mood/anxiety medications).
Bipolar I disorder criteria entail either an elated or irritable mood and three or more other symptoms of mania that necessitate hospitalization or significantly impair functioning. This is usually accompanied by a depressed mood or a loss of all interest in pleasurable activities and four or more other symptoms of depression, plus clinically significant distress or functional impairment. In our sample, there was no difference in the likelihood of males or African-Americans to meet the criteria for any affective disorder or be prescribed any antipsychotic, mood stabilizer or antidepressant medication.
Overall, these results are encouraging because they suggest that clinicians are not assessing and treating males or African-American patients differently across diagnostic subgroups, despite the challenges faced in most mental health care systems, including the rapidly increasing numbers of children being seen, especially for ADHD and CD; the complexity of assessing and treating these disorders; and the relative lack of knowledge about "best" or most effective clinical practices for these disorders.
There are, however, some noteworthy findings, especially from the CD study. Males were four times more likely to have a co-occurring diagnosis of ADHD. This may be another indicator of severity or difficulty in diagnosis, because this comorbidity is associated with a worse and more persistent course of the illnesses (Wozniak et al., 1995). Furthermore, there has been other evidence in the literature that an early diagnosis of CD or ADHD may be a marker for the development of BD, which also has a persistent and severe clinical course (Faraone et al., 1997; Kovacs and Pollock, 1995).
The other striking finding is that African-American youths with a CD diagnosis were less likely to have their symptoms documented and less likely to have lying, conning or substance abuse documented for their diagnosis. We cannot tell from these results whether these symptoms were simply not present and the child should not have been diagnosed with CD, or whether the pre-sentation was for ADHD symptoms with added behavioral disturbance features.
The final finding that African-American youths are less likely to have a mood stabilizer or antidepressant medication prescribed is comparable to the extensive literature on African-American adults being more likely to be diagnosed with schizophrenia and less likely to have the affective component of their illness diagnosed or treated appropriately (Chen et al., 1996; Lawson, 1996; Strickland et al., 1991). These results may indicate that differential care patterns are in place early for ethnically diverse youths.
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