Timing of Mental Health Service Use After a Pediatric Firearm Injury

We conducted a retrospective cohort study of Medicaid-enrolled children with nonfatal firearm injuries, using the injury date as an anchor point to identify MH service use during the 6 months before and after injury. We used the IBM Watson Marketscan Medicaid claims database, which contains deidentified patient-level demographic, enrollment, and health care claims data for Medicaid enrollees in 11 geographically dispersed and deidentified states.²⁰  This study was deemed exempt by the lead author’s institutional review board.

We included children aged 5 to 17 years^1,21  with a firearm injury encounter between 2010 and 2018 who were enrolled in Medicaid for at least 5 of 6 months before injury and for 6 months after injury. Firearm injury encounters were defined as emergency department (ED) or inpatient encounters with a firearm injury diagnosis code (Supplemental Table 4).²²  To study acute injuries, we excluded children with firearm injury diagnoses in the previous year (Supplemental Fig 2).

We defined MH service use as any outpatient, ED, or inpatient encounter with a primary diagnosis code in the Child and Adolescent MH Disorders Classification System^23,24  by any provider type, including primary care physicians. We determined the MH service type (outpatient, ED, or inpatient) by place of service codes. We defined intensity of MH service use as the number of MH encounters during the 6-month period before or after injury.

Sociodemographic characteristics were age group (5–9, 10–14, 15–17 years),¹  sex, race and ethnicity (Hispanic, non-Hispanic Black, non-Hispanic white, other), and insurance type (fee-for-service or managed care Medicaid). Using a health equity framework, race and ethnicity were considered social constructs rather than biologic determinants.²⁵  We included race and ethnicity in the analysis because of previously described inequities in access to MH services.¹⁴  Clinical characteristics included location of bodily injury (traumatic brain injury/back/spinal, extremity, torso, >1 location, other, unknown),²⁶  injury severity score,²⁷  firearm injury encounter level of care (ED, observation or nonintensive inpatient care, intensive care), having an MH diagnosis during the firearm injury encounter, and new complex chronic condition²⁸  in the 6 months after injury, as a marker of probable new physical health disability. A complex chronic condition is expected to last at least 12 months, involves several different organ systems, and requires ongoing specialty pediatric care.²⁸ 

We described rates of MH service use, along with type and intensity of MH service use, before and after injury. We described frequency of MH diagnosis groups before and after injury on the basis of Child and Adolescent MH Disorders Classification System classification,^23,24  considering a new MH diagnosis group as one that was not present before injury.

We used multivariable logistic regression to determine sociodemographic and clinical characteristics associated with MH service use in the 6 months after injury. We constructed a model using the full cohort and then performed stratified analyses among children with and without previous MH service use.

Among children with any outpatient MH service use in the 6 months after firearm injury, we evaluated variation in the time to first outpatient MH visit using Cox proportional hazards multivariable models, adjusted for sociodemographic and clinical characteristics. We constructed models using the full cohort and then stratified analyses by previous MH service use. We performed all analyses using SAS 9.4 (SAS Institute, Cary, North Carolina), and P values <.05 were considered statistically significant.

We identified 2613 children with firearm injuries during the study period (Table 1). Approximately two-thirds (64.5%) were aged 15 to 17 years and non-Hispanic Black (68.7%). Most children (73.1%) were discharged from the ED, whereas 5.5% required intensive care. The most common location of injury was the extremities (52.6%). In the 6 months after injury, 6.8% of children had a new complex chronic condition.

In the 6 months before injury, 29.9% (n = 781) of children accessed MH services. Of children with firearm injuries, 28.6% received previous outpatient MH services, 3.5% had previous MH ED visits, and 1.7% had previous MH hospitalizations. Of children who used outpatient MH services before injury, the median number of visits was 6 (interquartile range [IQR] 2–22) over 6 months. The most frequent MH diagnoses before injury were attention-deficit/hyperactivity disorder (12.9%, n = 337) and disruptive, impulse control, and conduct disorders (10.2%, n = 266) (Supplemental Table 5). A MH diagnosis was documented during the firearm injury encounter for 15.9% (n = 416) of children, of which 44.0% (n = 183) had no previous MH service use.

In the 6 months after injury, 36.7% (n = 958) of children received any MH services, of which 39.5% (n = 378) had no previous MH service use. Of children with firearm injuries, 34.0% received outpatient MH services, 4.6% had MH ED visits, and 3.9% had MH hospitalizations in the 6 months after injury. Of 781 children with previous MH service use, 70.9% (n = 554) received outpatient MH services, 8.2% (n = 64) had MH ED visits, and 6.3% (n = 49) had MH hospitalizations after injury. Of 416 children with a MH diagnosis during the firearm injury encounter, 63.7% (n = 265) received outpatient MH services, 10.8% (n = 45) had MH ED visits, and 7.2% (n = 30) had MH hospitalizations after injury. Of 1832 children with no previous MH service use, 17.6% (n = 323) received outpatient MH services, 3.0% (n = 55) had MH ED visits, and 3.0% (n = 54) had MH hospitalizations after injury.

Children who received outpatient MH services had a median of 4 visits (IQR 1–12) in the 6 months after injury, with more visits among children with previous MH service use (median, 6 visits; IQR, 2–17) than children without previous MH service use (median, 2 visits; IQR, 1–5). The most common new MH diagnoses after injury were substance-related and addictive disorders (11.1%, n = 289) and trauma and stressor-related disorders (7.4%, n = 194). After injury, the percentage of children diagnosed with bipolar disorder, schizophrenia spectrum disorders, and suicidal ideation/self-injury nearly doubled (from 1.5% to 2.2%, 0.7% to 1.2%, and 1.2% to 2.4%, respectively).

Non-Hispanic white children had higher adjusted odds of MH service use after injury (adjusted odds ratio [aOR], 1.29; 95% confidence interval [CI], 1.02–1.63) compared with non-Hispanic Black children. The adjusted odds of MH service use after injury were higher among children with previous MH service use (aOR, 10.41; 95% CI, 8.45–12.82), among children with an MH diagnosis during the firearm injury encounter (aOR, 3.07; 95% CI, 2.34–4.02), and among children with a new complex chronic condition after injury (aOR, 1.99; 95% CI, 1.36–2.92) (Table 2).

In stratified analyses, among children with previous MH service use, the adjusted odds of MH service use after injury were higher among non-Hispanic white children (aOR, 1.55; 95% CI, 1.01–2.39) compared with non-Hispanic Black children, and among children with a MH diagnosis during the firearm injury encounter (aOR, 3.28; 95% CI, 2.09–5.14) (Supplemental Table 6).

Among children without previous MH service use, the odds of MH service use after injury did not differ by race and ethnicity. There were higher adjusted odds of MH service use among children with observation or nonintensive inpatient care (aOR, 1.36; 95% CI, 1.00–1.85) compared with those discharged from the ED, among children with a MH diagnosis during the firearm injury encounter (aOR, 3.11; 95% CI, 2.21–4.37), and among children with a new complex chronic condition after injury (aOR, 2.30; 95% CI, 1.50–3.52) (Supplemental Table 7).

Among 887 children with outpatient MH service use in the 6 months after injury, 55.0% (n = 488) had their first outpatient MH visit within 1 month of injury, 24.7% (n = 219) between 1 and 3 months, and 20.3% (n = 180) from 3 to 6 months. Of 564 children with previous MH service use, 65.1% (n = 367) had their first outpatient MH visit within 1 month of injury. Of 323 children without previous MH service use, 37.5% (n = 121) had their first outpatient MH visit within 1 month of injury.

The strongest predictor of timing of the first MH outpatient visit after a firearm injury was previous MH service use. Children with previous MH service use had a shorter time to first MH outpatient visit after injury (adjusted hazard ratio [aHR], 6.32; 95% CI, 5.45–7.32) compared with children without previous MH service use (Table 3; Fig 1). Among children without previous MH service use, the time to first MH outpatient visit was shorter for children with a MH diagnosis during the firearm injury encounter (aHR, 2.72; 95% CI, 2.04–3.65) and for children with a new complex chronic condition after injury (aHR, 1.66; 95% CI, 1.14–2.42). Among children with previous MH service use, receipt of intensive care was associated with a longer time to first outpatient MH visit (aHR, 0.64; 95% CI, 0.42–0.97) compared with an ED discharge.

Among Medicaid-enrolled children with nonfatal firearm injuries, more than 3 out of 5 did not receive any MH services in the 6 months after injury. Children with MH diagnoses detected before or during the firearm injury encounter were more likely to access MH care and receive more timely care after injury. In particular, children with a new MH diagnosis identified during the firearm injury encounter had over twice the odds of timely connection to outpatient MH care. Some of these children likely had undetected MH conditions preceding the injury, whereas others may have a new onset MH condition after injury, such as acute stress disorder.²⁹  For some children, dedicated MH screening during injury encounters, as recommended by the American College of Surgeons, may have facilitated more timely connection to MH care.^30,31  Together, these findings suggest that greater efforts are needed to connect children without an established medical home for their MH care with MH services after injury.

Findings from this study also suggest a relatively high rate of preceding MH service use among firearm-injured children, with ∼30% having previous MH service use, which is double the rate of MH service use among US children generally.³²  The most frequent MH diagnoses before a firearm injury were attention-deficit/hyperactivity disorder and disruptive behavior disorders, which may increase injury risk because of associated impulsivity.^33,34  Additionally, 1 in 7 Medicaid-enrolled children had new MH service use in the 6 months after a firearm injury. These rates are higher than after hospitalization for any traumatic injury,³⁵  but lower than previously described rates of MH service use after firearm injuries, which have ranged from 18% to 26% in the year after injury.^8,9  Our shorter follow-up time frame of 6 months may be a reason for this difference. Medicaid-enrolled youth often face multifactorial barriers to accessing MH services after a firearm injury, including underrecognition of need,³⁵  competing time and financial priorities of families,³⁶  and workforce shortages of MH professionals.³⁷ 

Although rates of severe mental illness (bipolar disorder, schizophrenia, and suicidal ideation/self-injury) nearly doubled after injury, the most frequent new MH diagnoses after injury were substance use and trauma-related disorders. In a study comparing pediatric firearm injuries against motor vehicle collisions, increased rates of substance use and trauma-related disorders were also identified after firearm injuries.⁹  Thus, pediatricians might consider prioritizing screening for these conditions after firearm injuries. An example of an evidence-based approach to identify substance use is Screening, Brief Intervention, and Referral to Treatment (SBIRT).^38,39  For trauma-related disorders, brief screening tools include the Childhood Stress Disorders Checklist-Short Form,^31,40  the Screening Tool for Early Predictors of Posttraumatic Stress Disorder,⁴¹  and PsySTART.⁴²  Screening for MH sequelae of firearm injuries may facilitate greater detection of needs and more prompt initiation of treatment.

Among children with preceding MH service use, MH service use dropped after injury, with only three-quarters of children continuing to receive MH services. A previous study similarly found that children with high outpatient MH expenditures before a firearm injury experienced a decline in outpatient MH utilization and expenditures after injury.^7,43  Perhaps some families may prioritize physical health needs over MH care after injury. Also, some children, such as those with severe traumatic brain injuries, may no longer be able to participate meaningfully in MH services after injury. However, in our study, we did not find an association between bodily location of injury and subsequent MH service use.

Children without previous MH service use who developed a new complex chronic condition (which may indicate a new physical health disability) were also more likely to access MH services and receive more timely MH care. This could be because of adverse MH outcomes associated with developing a new disability.⁴⁴  In addition, children with complex chronic conditions have more frequent interaction with the health system,⁴⁵  yielding more opportunities to detect MH symptoms and initiate MH services.

Further, use of MH services after a firearm injury varied by race, with higher odds of MH service use after injury among white compared with Black children. Our finding contrasts with a study using propensity matching that found Black children were 1.6 times more likely to use MH services in the year after a firearm injury than white children.⁵  Overall, in the United States, Black children are less likely than white children to have MH visits and to receive psychotropic medications.^21,46,47  Mechanisms underlying these inequities may include stigma and costs related to accessing care, limited diversity in the MH workforce, and shortages of MH professionals in areas where Black children live.¹⁴  Attention is needed to address barriers at the individual, health system, and societal levels that may prevent Black youth from accessing MH services.

Overall, our findings suggest opportunities are available for trauma centers and pediatricians within the medical home to take a comprehensive approach to postinjury care that uses a broader definition of recovery, encompassing psychosocial health and well-being.^48–50  Trauma centers can employ brief screening tools that prompt referrals for early treatment, or they may choose to include a dedicated MH professional on the interdisciplinary trauma team.^31,42  For pediatricians, evidence-based screening practices for MH conditions should be prioritized after firearm injuries.⁵¹  Treatment approaches involving stepped collaborative care are effective in reducing posttraumatic stress disorder and substance use after traumatic injuries.^29,52 

This study has several limitations. The data source was Medicaid claims; thus, misclassification may have occurred for race and ethnicity or the reason for visit. Severity of mental illness was missing, which could influence prioritization for MH services. Similarly, the extent of misclassification of intent of firearm injury in administrative data sets precluded its inclusion in our models.^53,54  Although data from 11 deidentified states across US regions were used, the results may not be generalizable to all states, nor can the results be generalized to children without public insurance. Most importantly, we could not assess need for MH services, or unsuccessful attempts at connection to MH services, because we were only able to measure completed MH service utilization. The need for MH care related to exposure to firearm injuries is also likely underestimated because this study did not include children who witnessed firearm violence.^55,56  To address these limitations, prospective studies using more complete data sources are needed to understand the impact of poor access and delayed MH care after pediatric firearm injuries.

Comprehensive care for children injured by firearms should address both physical and MH needs. However, our findings suggest that more than 3 out of 5 children enrolled in Medicaid do not receive any MH services in the 6 months after a firearm injury, and that access to MH care is inequitable. Children identified as having a MH diagnosis before or during the firearm injury encounter were more likely to access care and receive more timely care. To mitigate the adverse effects of firearm injuries on child health outcomes, public health strategies should prioritize early detection of MH needs, equitable access to MH care, and timeliness of care.

aHR

adjusted hazard ratio

aOR

adjusted odds ratio

CI

confidence interval

ED

emergency department

IQR

interquartile range

MH

mental health