This research focused on race/ethnicity differences in psychotropic medication use in children served in public sector service systems. The primary finding is that African-American and Latino youths had a reduced likelihood of using psychotropic medications compared with white children in regression analyses that controlled for age, gender, income, insurance status, involvement in the public mental health system at enumeration, need, and impairment. While several of these variables showed some interrelatedness with the race/ethnicity variables, the regression analyses indicated that race/ethnicity as a unique variable still demonstrated a significant impact on use of medication, over and above any shared variance with the other variables included in the model.
The analyses presented here could not address the appropriate use of medication by children of different racial/ethnic backgrounds. The issue of medication overuse versus underuse among children and adolescents has been deliberated in the research literature, with a particular focus on the use of stimulant medications for ADHD (Angold et al., 2000
; Jensen et al., 1999
). While the research presented here did not focus on the use of stimulants, the question of appropriate use of medication is important in any discussion of differential use by racial/ethnic groups. Both regression models included two independent variables as proxies for appropriateness of medication use (specifically, functional impairment as measured by the CIS, and the presence of a diagnosis for which there is an evidence base for the use of medications). Even when these two factors were controlled for, the analyses generated findings of differential use of medications by race/ethnicity.
In addition, each of the independent variables controlled for in the model was found to predict psychotropic medication use. Older age has been found to correlate with use of mental health services in high-risk children (Garland et al., 1996
; Halfon et al., 1992
; Leslie et al., 2000
), yet older age was associated with less psychotropic medication use in this study. Our findings are consistent with those of Zito et al. (1998)
, who found decreased use of methylphenidate with increasing age in a Medicaid-eligible sample. Decreased psychotropic medication use in females in the present study is consistent with rates reported in Medicaid samples (Zito et al., 1996
With respect to enabling factors, private insurance independently predicted psychotropic medication use. Studies on psychotropic medication use to date have been mixed, with one study finding lower prescription rates (Zito et al., 1998
) under managed care plans and another finding higher rates (Hoagwood et al., 2000
). An interaction between private insurance and high socioeconomic status may account for the private insurance effect in this subpopulation of children. Not surprisingly, involvement with mental health at enumeration, impairment as measured by the CIS, and the presence of a mood, anxiety, or attentional disorder on the DISC also predicted medication use, indicating that medication use in these children was based on perceived need.
Of primary concern is the cause or causes of the observed lower rates of psychotropic medication use among minority groups. One explanation for discrepant rates could be due to differences in the prevalence of psychiatric conditions. However, studies examining the prevalence of diagnoses among children and adolescents have found comparable (Costello et al., 1996
) or in some cases higher (Bird, 1996
; Glover et al., 1999
; Shaffer et al., 1996
; Yeh et al., 2002
) rates of psychiatric conditions among African Americans and/or Latinos. Although white children appeared to show higher rates of diagnoses in this sample, this likely does not account for the pattern of findings, as diagnostic status as measured by the DISC was controlled for in analyses.
Other explanatory factors have been postulated to explain the lower use of medication among minorities, such as unequal access to care (Zito et al., 1998
). Fewer behavioral pediatricians and child psychiatrists practice in economically disadvantaged neighborhoods (Fossett et al., 1992
; Yudkowsky et al., 1990
), and poor access to physicians may limit access to psychopharmacological interventions for children. However, in the current study, the majority of children were likely to experience similar socioeconomic-related barriers to accessing treatment. Further, income and insurance status were included in the analyses, and race/ethnicity differences were observed even when these factors were controlled.
Explanations for the discrepant rates of medication use between minorities and whites, apart from access barriers, have also included unequal quality of care received. Disparities have been linked to uneven and/or poor-quality side effect management (Young and Sullivan, 1999
), failure to provide psychoeducational information (Bussing et al., 1998a
), and high rates of failure to meet minimum standards of treatment (Melfi et al., 1998
). Provider biases regarding explanations for behavioral problems and viable treatment options in children from different racial/ethnic backgrounds would also hypothetically affect the quality of care received. This study did not include quality-of-care indicators, so quality of services as an explanatory factor could not be addressed.
Discrepant rates in medication use could be influenced by cultural factors. Different beliefs about the causes of illness and the acceptability of and expectation for treatment by patients of varied cultural backgrounds have been shown to alter diagnostic and treatment patterns for psychiatric disorders (Sussman et al., 1987
; Westermeyer, 1987
). Parent and/or care-giver beliefs and their impact on efforts to seek care and accept certain treatment plans have not been well studied for child and adolescent mental health disorders.
Cultural factors may also affect acceptance of and adherence to treatment plans proposed by providers (Adebimpe et al., 1982
; Hu et al., 1991
; Lopez, 1989
). Recent studies in the physical health sector demonstrated poorer compliance among minority adults in the treatment of HIV (Mehta et al., 1997
) and renal disease (Curtin et al., 1999
) and among minority children in the treatment of asthma (Krishnan et al., 2001
), even after adjusting for factors such as age, education, employment, access to insurance, and symptom frequency (Krishnan et al., 2001
). Similarly, adherence may also relate to the ability of consumers and providers to communicate with one another. The role of language may be particularly crucial in the treatment of mental health conditions, because changes in thoughts and moods that accompany psychiatric disorders are primarily detected by a patient’s ability to verbalize what is often nonobservable behavior.
Hypothetically, genetics might also differentially affect the efficacy of psychotropic medications, their side effect profiles, and treatment adherence among children and youths of varied ethnic backgrounds. While not studied in childhood mental health disorders, genetic differences in racial groups with respect to both the efficacy and side effects associated with medications for other medical disorders such as hypertension have been found (Jamerson, 2000
). These genetic differences could potentially affect treatment response and adherence. Clearly, each of these factors—unequal access, uneven quality of care, cultural factors, and genetics—deserve further exploration to elucidate mechanisms for addressing differential medication use among children of different racial/ethnic backgrounds.
There are five primary limitations of this study. First, this study could not address any of the access, quality, cultural, and genetic factors that may have affected treatments offered to children/families. Second, although involvement in the public mental health sector was an attempt to control for access to services, it is difficult to gauge the degree to which accessibility and appropriateness of services may have played a role in lower rates of medication use. Families may have had access to services through other sources (Burns et al., 1992
), such as primary care, private behavioral health plans, community groups, and/or schools, and there is no information regarding the nature of mental health services received. Third, the racial/ethnic categories in this study did not allow for examination of the heterogeneity within each group. Fourth, due to a number of different factors, such as frequently outdated address information and the difficulty of locating potential participants, recruitment of children receiving services and their families was more challenging than anticipated. However, a number of follow-up analyses using administrative data that were available for all children in the sampling frame, suggest that families participating in the study did not differ from those that were not located or those who refuse to participate. Lastly, this sample represents high-risk children in a single service system area, which may reduce the generalizability of the findings; therefore, estimates of unmet need as a function of race/ethnicity need to be interpreted with caution. However, this study has an important role in documenting disparities among racial/ethnic groups among youths served in public service sector systems.
This study examined psychotropic medication use among children served in public sector service systems. The findings indicate that psychotropic medication use is associated with multiple factors, specifically younger age, male gender, private insurance type, elevated household income, and white race/ethnicity. We were not able to separate out the unique aspects of clinician, child, and family factors that might result in these discrepancies. Clinicians who interact on a daily basis with children and families have a unique role to play in disentangling these factors. As clinicians, it behooves us to understand any biases we may bring into the clinician–patient encounter that may lead to selective decision-making regarding medication use and/or referrals to physicians prior to any discussions with a child and/or family member. We also need to initiate discussions with children and families regarding factors that may result in lack of interest in medication use or nonadherence to medication treatment regimens proposed. Findings gleaned from self-reflection and clinician–patient encounters need to be shared with policy makers, administrators, and researchers to identify mechanisms for addressing these differences in medication use.
This study examined psychotropic medication use among children with high rates of demonstrated need. The current findings complement those from community epidemiological studies, documenting a racial/ethnic disparity for the reported past-year and lifetime psychotropic medication use between white and minority children, even when the effects of potential confounds were taken into account. This study was not able to disentangle the potential contributors of the observed disparity. It is likely that the cumulative weight and interplay of a variety of barriers to care, and not any single factor, is responsible for mental health disparities. Further, barriers to care may differ among groups. Characteristics that may mediate the relationship between race/ethnicity and service use, such as access and quality of care issues, cultural factors, and genetics, need to be addressed in future studies to allow for the delivery of services most responsive to the needs of racial and ethnic minorities.