Ethnic Minority Children
Running Head: MINORITY CHILDREN AND PES
Ethnic Minority Children's Use of Psychiatric Emergency Care
In California's Public Mental Health System
Lonnie R. Snowden Ph.D.
Mary C. Masland Ph.D.
Kya Fawley MSW
Anne M. Libby Ph.D.
Neal Wallace Ph.D.
Drs. Snowden and Masland and Ms. Fawley are with the Center for Mental Health Services
Research, School of Social Welfare, University of California, Berkeley. Dr. Libby is with the
School of Medicine, Departments of Pediatrics and Psychiatry, University of Colorado. Dr.
Wallace with the Mark O. Hatfield School of Government, Portland State University. Supported
by National Institute of Mental Health award R01 MH067871. Address correspondence to
Lonnie R. Snowden, 120 Haviland Hall, University of California, Berkeley, CA, 94720-7400.
email: snowden@berkeley.edu.
1
Ethnic Minority Children
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Abstract
This study used fixed-effects regression for a controlled assessment of ethnic disparities in
children and youth’s use of hospital-based services for the most serious mental health crises
(‘crisis stabilization services”) and community-based services for other crises (“crisis
intervention services”). The sample consisted of Medicaid claims for 351,174 African American,
Asian American, Latino, Native American and White children and youth who received specialty
mental health care from California’s 57 county public mental health systems between July 1998
and June 2001. African American children and youth were more likely than Whites to use both
kinds of crisis care and made more visits to hospital-based crisis stabilization services after initial
use. Asian and Native American children and youth were more likely than Whites to use
hospital-based crisis stabilization services but, along with Latinos, made fewer hospital-based
crisis stabilization visits after an initial visit. African American children and youth use both kinds
of crisis services more than Whites and Asians and Native Americans make episodic crisis visits
only when experiencing the most disruptive and troubling kind of crisis.
Ethnic Minority Children
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Ethnic Minority Children's Use of Psychiatric Emergency Care
In California's Public Mental Health System
While research on ethnic and cultural disparities in children and youth’s mental health
treatment has grown and become ever more rigorous (Kataoka, Zhang & Wells, 2002; Yeh,
McCabe, Hurlburt, Hough, Hazen, Culver et al., 2002), little attention has been paid to services
that attempt to stabilize children and youth in crisis. If it occurs, excess minority use of
emergency care is important to document and understand because emergency services do not
promote monitoring of troubling conditions, access to all necessary treatments, or continuity of
care (U.S. Department of Health and Human Services, 2001, p. 68).
Minority youth are at increased risk for factors that lead to psychiatric emergency
services use. Adversity increases youth’s chances of experiencing a crisis (Joffe, Offord, &
Boyle, 1988; Morano, Cisler, & Lemerond 1993) and minority youth are more likely to face
adversity of certain kinds: Socioeconomic disadvantage (U.S. Department of Health and Human
Services, 2001), residence in poverty neighborhoods (Brody et al., 2003), racism (Clark,
Anderson, Clark, & Williams, 1999), acculturative stress (Hovey & King, 1996), and care by
distressed and pressured family members (Repetti, Taylor, & Seeman, 2002). Moreover,
minority children and youth are underrepresented in alternative sources of specialized mental
health assistance that might avert a crisis, including outpatient treatment (Buda and Tsuang,
1990; Schwab-Stone et al., 1995). These factors contribute to suicidal ideation and suicide
attempts, which are the most frequent reason children and youth use emergency services
(Halamandaris & Anderson, 1999; Breslow, Erickson, & Cavanaugh, 2000). Rates of suicidal
behavior are higher among Latino, Asian, and Native American than among White children and
youth. Among African Americans, suicide-related problems occur at a lower but increasing rate.
Ethnic Minority Children
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(Joe & Marcus, 2003).
The limited research available to date indicates that minority children and youth are
increasingly using emergency services (Blitz, Solomon, & Feinberg, 2001) but the evidence is
mixed as to whether they are over represented. Along with sample size and statistical power
differentials, differences between treatment programs, services, and systems might explain
discrepant findings. To resolve this uncertainty the present study examined ethnic disparities in
psychiatric emergency services (PES) use in a large, ethnically diverse, multiyear sample, of
children and youth participants in California’s public mental health care services system.
Services were funded by Medi-Cal, California’s version of the Medicaid insurance program for
the poor (incomes below $19,350 for a family of four in 2005, American Academy of Pediatrics,
2005).
Under Medi-Cal, children and youth’s psychiatric emergency services are divided into two
categories, crisis stabilization and crisis intervention. Crisis stabilization services are based in a
24-hour facility, usually a hospital; they are designed for the most serious crises and aim to
alleviate the need for inpatient care. Crisis intervention services are provided in the community,
include assessment, evaluation, collateral care, and therapy, and are for clients needing urgent
assistance but whose crisis is not severe enough to warrant removal from the community.
We hypothesized that minority children and youth and would be more likely than Whites
to use crisis stabilization and crisis intervention services initially, and that they would use them
more frequently after initial use. We expected greater minority children and youth’s crisis
services use because of the greater stress facing minorities and their lesser access to nonemergency care.
Ethnic Minority Children
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Methods
Participants and Procedures
We obtained Medi-Cal paid claims for mental health services delivered to youth under
age 18, between July 1, 1998 and June 30, 2001, from the California Department of Mental
Health. The service record listed the child’s age, gender, ethnicity, primary diagnosis, as well as
the date/s, cost and type of the service. Children and youth with marked and severe functional
limitations due to mental illness or other disabling conditions qualify for Supplemental Social
Security payments. This qualification is included in the Medi-Cal claims file, and youth so
adjudicated were considered disabled.
To obtain child welfare participation data we merged Medi-Cal claims data with child
welfare records obtained from The California Department of Social Services via probabilistic
matching techniques, resulting in child welfare participation data for each child welfare-involved
mental health client in our data set. Unique encrypted identifiers allowed tracking of each child
throughout all three years.
Approval to use these data for research purposes was obtained from the University of
California Berkeley’s Institutional Review Board and the California Health and Human Services
Agency’s Committee for the Protection of Human Subjects.
Analysis
Our final sample included 351,174 children and youth under age 18. This represents nearly
all children receiving Medi-Cal specialty mental health care between July 1998 and June 2001.
We followed a standard “two-part model” econometric approach (Mullahy, 1998), permitting
us to address our two central questions—whether services were used and if they were used, how
much they were used. We first used the entire sample to estimate differences in the odds that a
Ethnic Minority Children
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child or youth in the public mental health system used any crisis stabilization or crisis
intervention services within the year (part 1). We used logistic regression to estimate part 1
equations.
We then isolated sub samples of persons who used crisis stabilization or crisis intervention
services, and estimated how many times during the year the child or youth used crisis
stabilization and/or crisis intervention services (part 2). We used ordinary least squares (OLS)
regressions estimated with robust standard errors after first transforming dependent variables into
logarithmic form to adjust for skewed response distributions.
We controlled for variables that have been shown to correlate with ethnicity or PES use and
therefore possibly are correlated with both: age, gender, diagnosis, if the child was disabled, if
the child was in regular foster care, kinship care, or had no child welfare involvement, county of
residence, and year of observation. We included presence of a disability and child welfare
involvement in the control variables because disabled youth (Witt, Kasper, & Riley, 2003;
DosReis, Zito, Saefer & Soeken, 2001; Harman, Childs, & Kellcher, 2000) and children in foster
care (Hurlburt, Leslie, Landsverk, Barth, Burns, Gibbons Slymen, Zhang, 2004) are more likely
to receive mental health treatment. Additionally, African and Native American youth are more
likely to reside in foster care of all kinds including in kinship care (Hines, Lemon, Wyatt, &
Merdinger, 2004). We controlled for the type of foster care because children in kinship care
receive less mental health treatment than other foster care children (Leslie, et al., 2000).
We also employed a cross-sectional fixed effect dummy variable for each person’s county of
residence because in California, mental health services are decentralized to the county level and
county systems vary greatly in how they organize their mental health care including per-capita
numbers and types of crisis services. Finally, we included a longitudinal fixed effect variable
Ethnic Minority Children
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indicating year of observation because policy-related developments and underlying state-wide
trends are associated with emergency services use (Snowden, Masland, Wallace & Evans
Cuellar, 2006).
Results
Descriptive Statistics
The demographics for each ethnic group are shown in Table 1 and the diagnoses are
shown in Table 2. In Table 3, the raw percentage of youth in the public mental health system
who received crisis intervention and stabilization services, and the unadjusted mean number of
visits per user, are shown by the child's race/ethnicity. Whereas 10.7% of children and youth
used the less-intensive community-based crisis intervention service, only 1.6% used the more
intensive hospital-based crisis stabilization service.
Logistic Regression Results –Likelihood of Crisis Use
The results from the logistic regression estimating likelihood of emergency services use
are presented in Table 4. Analysis of the more intensive hospital-based crisis stabilization
service showed that, controlling for covariates, African American (OR=1.11, p<.01), Asian
American (OR= 1.20, p<.01), and Native American (OR=1.94, p<.01) children and youth had
greater odds than White children and youth of using the service. Differences between Latinos
(OR=1.06, p<.14) and White youth were not significant.
Analysis of the less intensive community-based crisis intervention service showed that,
controlling for covariates, only African American children and youth (OR=1.09, p<.01) had
greater odds than White children and youth of using the service, while Latinos (OR=0.94, p<.01)
and Asians (OR=0.90, p<.01) had lesser odds than White of using the service. Differences
between Native Americans and Whites (OR=1.08 p<.19) were not significant.
Ethnic Minority Children
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Ordinary Least Squares Regression Results – Level of Crisis Use
The results from the regression estimating number of crisis visits per client are presented
in Table 5. Looking only at the children and youth who received any hospital-based crisis
stabilization, our analysis showed that African Americans (β=.035, p<.05) used a greater number
of crisis stabilization visits per child than Whites while Latinos (β=-.031, p<.05), Asians (β=.078, p<.01) and Native Americans (β=-.093, p<.05) children and youth had a fewer number of
crisis stabilization visits than White children and youth.
Looking only at the children and youth who received any community-based crisis
intervention, our analysis showed that African Americans (β= -.051, p<.01), Latinos (β= -.061,
p<.01) and Asians (β=-.107, p<.01) had fewer crisis intervention visits per client than
Caucasians. The differences between Native Americans (β=.036, p<.23) and Whites were not
significant.
Discussion
African American children and youth were more likely to use crisis care targeting both
more and less severe crises, and for services targeting the most serious crises they showed more
repeat use. Our hypotheses were largely confirmed for African American children and youth who
proved, like African American adults (Snowden, Catalano, & Shumway, 2006), to use
emergency services disproportionately.
Asian Americans and Native Americans also proved more likely to require emergency
intervention of the most serious kind. These findings are consistent with studies that report high
rates of suicidal behavior (U.S. Department of Health and Human Services, 1999) and alcohol
abuse (Lamarine, 1988) among some Native American groups, and high rates of suicidal ideation
and suicide attempts among Asian youth (Halamandaris & Anderson, 1999; Breslow et al.,
Ethnic Minority Children
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2000).
Otherwise, and contrary to our hypotheses, Asian, Native, and Latino children and youth
did not participate more than Whites in crisis-related mental health services. They were not
repeat users of crisis stabilization and did not make greater use of less severe community based
crisis intervention. Asian Americans children and youth’s sporadic use of only the most serious
kind of crisis care resembles that of Asian American adults, who appear in treatment only when
suffering from the most serious mental health problems (U.S. Department of Health and Human
Services, 2001).
We cannot fully explain disparities uncovered in the present study. It is possible that
African American children and youth are more likely to use psychiatric emergency services
because they have less access to outpatient treatments, but more research is needed to evaluate
this hypothesis. For Latino, Asian and Native American children and youth cultural factors
believed to act as barriers to mental health treatment--differing definitions of what constitutes a
mental health problem and what is considered an appropriate form of intervention (Roberts,
Alegria, Roberts & Chen, 2005), high levels of stigma associated with mental illness in minority
communities (Pumariega, Rogers & Rothe, 2005), mistrust of the mental health system
(Thompson, Bazile, & Akbar, 2004), and limited proficiency in English (Fiscella, Franks,
Doescher, & Saver, 2002)--appear to apply to crisis care except for isolated instances where need
is great and possibly unmanageable.
One limitation of our study is that crisis stabilization users may also have used crisis
intervention services and vice versa. We cannot determine this because we did not divide our
sample into mutually exclusive groups based on use. Such an analysis is beyond the scope of
the present study but should be carried out in future research.
Ethnic Minority Children
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Another limitation is that the R2 for model of crisis intervention use intensity is fairly
low suggesting that the model omitted many determinants of emergency services use. These
variables are especially important to identify and include if they relate to ethnicity as well as
emergency services use and therefore represent possible confounds.
Community outreach interventionists and clinical crisis care workers (Snowden,
Masland, Ma, & Ciemens, 2006) should seek to inform minority youth and their caregivers about
how to recognize signs of an impending crisis and, when possible, deescalate these situations
before they become dangerous enough to warrant emergency intervention. Furthermore, crisis
service workers who work with children and families who seek their help for non-urgent
problems should encourage their clients to use more appropriate forms of treatment, and provide
referrals to less-intensive services. Through mass-media, community health workers and other
intermediaries, and culturally aware clinician can help to craft such messages to suit cultural
lenses for viewing minority youth mental health problems and responding to them in culturally
sensitive ways.
Ethnic Minority Children
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Ethnic Minority Children
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Table 1
Description of Independent Variables: Percent Demographic Characteristics by Race/Ethnicity
Caucasian
African
Latino
Asian
Native
Total
American
American
(n=171090) (n=69438) (n=92293) (n=15365)
(n=2988) (n=351174)
Independent Variables
%
%
%
%
%
%
Male
59.1
61.1
59.4
62.1
55.5
Not in Foster Care
89.1
89.6
89.4
91.1
87.0
Kinship Foster Care
3.2
2.4
3.4
1.9
3.4
Non-Kinship Foster Care
7.7
7.0
7.2
7.0
9.6
Disabled
9.8
22.0
4.2
30.0
11.4
Age 0-3
3.1
2.7
3.1
2.4
2.2
Age 4-5
7.2
6.4
7.4
4.8
7.0
Age 6-11
42.6
45.6
43.2
34.5
40.9
Age 12-17
47.2
45.3
46.4
57.8
49.9
Note: Percents add up to more than 100 because subjects can be in multiple categories.
59.7
89.4
3.1
7.5
11.7
3.0
7.0
43.0
47.1
Ethnic Minority Children
Table 2
Description of Independent Variables: Percent Diagnosis by Race/Ethnicity
Caucasian
African
Latino
Asian
American
(n=171090) (n=69438) (n=92293) (n=15365)
Diagnosis
%
%
%
%
Mood Disorder
25.5
21.7
25.2
24.5
Adjustment Disorder
16.8
14.7
17.6
15.3
ADHD
15.4
17.1
12.1
13.0
Disruptive Behavior Disorder
11.7
15.9
15.4
15.1
Anxiety Disorder
10.9
8.9
10.6
7.8
Developmentally Disabled
3.2
3.5
2.6
4.7
Psychosis
1.4
2.4
1.3
3.7
Other
6.1
7.1
5.6
6.4
None or Missing
8.9
8.6
9.6
9.4
16
Native
Total
American
(n=2988) (n=351174)
%
%
22.0
24.6
22.5
16.6
11.3
14.7
12.0
13.6
10.4
10.3
2.1
3.1
1.1
1.7
7.1
6.3
11.4
9.1
Ethnic Minority Children
Table 3
Description of Dependent Variables: Probability and Level of Psychiatric emergency Use by
Race/Ethnicity
Psychiatric Number of visits
Psychiatric Number of visits
emergency
among
emergency
among
intervention
psychiatric stabilization
psychiatric
use
intervention
use
emergency
users
stabilization
users
%
Mean
SD
%
Mean
SD
Caucasian
(n=171090)
African American
(n=69438)
Latino
(n=92293)
Asian
(n=15365)
Native American
(n=2988)
Total
(n=351174)
10.86
1.98
2.45
1.51
1.52
1.40
11.39
2.03
2.87
1.84
1.50
1.06
9.53
1.79
2.38
1.51
1.40
1.11
10.93
1.91
2.66
2.58
1.37
0.99
15.09
1.89
1.92
2.91
1.23
0.56
10.65
1.94
2.54
1.64
1.47
1.23
17
Ethnic Minority Children
Table 4
Regression Results: Probability of Psychiatric emergency Use Among Ethnic Children
Compared to Caucasian Children by Type of Psychiatric emergency
Model
Psychiatric Emergency
Stabilization
(n= 336,934)
OR
95% CI
Caucasiana
African American
Latino
Asian
Native American
Femalea
Male
Kinship Foster Carea
Nonkinship
In Foster Carea
Non Foster
Age 12-17a
Age 0-3
Age 4-5
Age 6-11
Not Disableda
Disabled
No Diagnosisa
Developmentally Disabled
ADHD
Disruptive
Adjustment
Anxiety
Psychotic
Mood
Personality
Eating
Substance Abuse
Somatization
1.00
1.11***
1.06
1.20***
1.94***
1.00
.81***
1.00
2.65***
1.00
2.03***
1.00
0.15***
0.10***
0.34***
1.00
1.31***
1.00
0.77
1.24
1.94***
3.54***
2.16***
24.61***
11.90***
8.96
9.96***
36.12***
4.39***
1.03-1.21
.982-1.15
1.05-1.37
1.49-2.53
.763-.862
2.01-3.50
1.56-2.64
.095-.251
.069-.146
.312-.366
1.20-1.42
.445-1.34
.911-1.68
1.48-2.57
2.72-4.60
1.63-2.87
18.74-32.41
9.25-15.30
2.48-32.36
4.99-19.89
26.67-48.90
1.34-14.34
Psychiatric
Emergency
Intervention
(n=336,894)
OR
95% CI
1.00
1.09***
0.94***
0.90***
1.08
1.00
0.84***
1.00
1.62***
1.00
0.70***
1.00
0.26***
0.41***
0.68***
1.00
1.25***
1.00
0.90**
1.26***
1.45***
1.47***
1.42***
5.72***
3.38***
4.04***
3.12***
6.31***
3.58***
1.05-1.13
.912-.968
.846-.953
.962-1.22
.817-.857
1.51-1.74
.659-.749
.227-.289
.384-.438
.658-.693
1.21-1.30
.808-.999
1.19-1.34
1.38-1.54
1.39-1.55
1.34-1.51
5.31-6.17
3.23-3.54
2.52-6.49
2.32-4.20
5.60-7.11
2.50-5.14
Note: a indicates the comparison group. ***=p<.01, **=p<.05, * =p<.1. Dummy variables
omitted for year and county.
18
Ethnic Minority Children
Table 5
Regression Results: Number of Visits by Psychiatric Emergency Users
Log level of use among Psychiatric
Emergency Stabilization users
(n=4,788)
Variable
Caucasiana
African American
Latino
Asian
Native American
Femalea
Male
Kinship Foster Carea
Nonkinship
In Foster Carea
Non Foster
Age 12-17a
Age 0-3
Age 4-5
Age 6-11
Not Disableda
Disabled
No Diagnosisa
Developmentally Disabled
ADHD
Disruptive
Adjustment
Anxiety
Psychotic
Mood
Personality
Eating
Substance Abuse
Somatization
Log level of use among
Psychiatric Emergency
Intervention users
(n= 33,304)
β
SE β
t
β
SE β
t
.035
-.031
-.078
-.093
.017
.015
.023
.038
2.08**
2.03**
3.38***
-2.43**
-.051
-.061
-.107
.036
.009
.008
.015
.030
5.62***
7.55***
6.93***
1.21
.008
.012
0.64
-.023
.007
3.39***
.145
.052
2.80***
.140
.016
8.66***
.049
.047
1.03
.020
.015
1.29
-.154
-.094
-.006
.040
.057
.017
-.150
-.100
-.028
.019
.014
.007
8.08***
6.98***
3.90***
.031
.017
1.87*
.096
.010
9.56***
.257
.074
.040
.067
.169
.237
.194
.058
.539
.275
.451
.115
.041
.026
.023
.034
.028
.020
.033
.188
.043
.171
2.23**
1.80*
1.57
2.98***
5.04***
8.42***
9.87***
1.79*
2.87***
6.46***
2.64***
.083
.127
.171
.078
.200
.367
.310
.215
.370
.333
.135
.026
.015
.014
.013
.016
.021
.013
.132
.081
.030
.079
3.25***
8.51***
11.78***
6.17***
12.59***
17.24***
24.61***
1.62
4.55***
11.03***
1.71*
3.89***
-1.65
-0.35
Note: Model 1: Psychiatric Intervention Use: F78,33225= 34.65, p<.000, R =.069.
Model 2: Psychiatric Stabilization Use: F67,4715= p< , R2=.115.
***=p<.01, **=p<.05, * =p<.1
Dummy variables omitted for year and county
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