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Child Sex Differences in Primary Care Clinicians' Mental Health Care of Children and Adolescents
William Gardner, PhD;
Kathleen A. Pajer, MD, MPH;
Kelly J. Kelleher, MD, MPH;
Sarah Hudson Scholle, DrPH;
Richard C. Wasserman, MD, MPH
Arch Pediatr Adolesc Med. 2002;156:454-459.
ABSTRACT
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Background Sex differences in the medical and mental health care of adults are
well established.
Objective To study the effect of child patient's sex on whether primary care clinicians
(PCCs), including pediatricians, family physicians, and nurse practitioners,
found or treated mental health problems in primary care settings.
Design The data were collected by clinicians and parents from 21 065 individual
child visits (50.3% girls) in 204 primary care practices.
Methods Each PCC enrolled a consecutive sample of approximately 55 children
and adolescents aged 4 to 15 years. Parents filled out questionnaires, including
the Pediatric Symptom Checklist, before seeing the clinician. Clinicians completed
a survey after the visit about the psychosocial problems and recommended treatments,
but they did not see the results of the Pediatric Symptom Checklist or any
other data collected from the parents.
Results Boys were more likely to be seen for a mental health–related visit
and by a clinician who identified them as "my patient." Boys with parent-reported
symptom profiles that were similar to those of girls were more likely to be
identified as having attention-deficit/hyperactivity problems or behavior
or conduct problems and less likely to be identified as having internalizing
problems. Adjusting for parent-reported symptoms, PCCs were more likely to
prescribe medications for boys. Child sex differences in referrals to mental
health specialists and the provision of counseling to families were not statistically
significant.
Conclusion There are substantial sex differences in the mental health care of children
in the primary care system.
INTRODUCTION
MOST CHILDREN with mental health problems do not receive evaluative
services or treatment in specialty care settings; rather, they are seen in
primary care settings.1-2 Previous
studies have shown that boys are more likely than girls to receive a mental
health diagnosis in the primary care setting3
and to receive specialty mental health services until late adolescence.4 However, these studies have not examined whether boys
and girls with a similar degree and type of mental health problem are labeled
similarly or receive comparable care, nor have they explored the roles of
clinicians or practice-related factors in the differential care that boys
and girls receive.
There are many reports of sex differences in the diagnosis and treatment
of adult medical and psychiatric symptoms. For example, women with end-stage
renal disease are less likely to be referred for a transplant than men with
similar diagnoses or severity of illness.5-8
A parallel bias occurs in the treatment of cardiovascular disease.9-17
However, physicians are more likely to prescribe activity restrictions for
women with acute illnesses.18
In mental health care, women are more likely than men to receive the
diagnosis of depression and anxiety for the same symptoms.19-22
Some assessment instruments are biased against women in the sense that they
include items on which women are more likely to be scored as dysfunctional
even though the items do not correlate with a gold-standard measure of dysfunction.23 Women are also treated more aggressively with psychopharmacologic
medication than men, even after adjustment for rates of health care utilization
or morbidity.24-25
We have few data on sex differences in the diagnosis and treatment of
pediatric medical disorders with the exception of asthma; studies have reported
that relative to boys, girls with this condition are underdiagnosed and undertreated.26-27 Sex differences in the identification
and treatment of mental health problems in the primary care setting would
significantly affect the mental health services that children and adolescents
receive.
We carried out a study on the effect of patient sex on primary care
clinicians' (PCCs') identification of mental health problems in children and
adolescents and the consequent effect on treatment recommendations. Although
we have reported sex differences in earlier studies of these data (the Child
Behavior Study),28-30
in this one we examined whether PCCs identified similar mental health problems
in boys and girls when these children had similar parent-reported mental health
symptoms. We have previously shown that when PCCs identify a child as having
a mental health problem, they are equally likely to offer counseling to the
family, prescribe a medication, or refer the child to a specialist.29 That study showed that PCCs are unbiased with respect
to sex in their treatment decision making (they are similarly unbiased with
respect to race and ethnic status31). However,
bias in the identification of problems could still result in a disparity in
the treatment children receive for mental health problems. Therefore, we asked
whether boys and girls with similar profiles of mental health symptoms were
equally likely to receive mental health treatment regardless of whether PCCs
had identified them as having a problem. We also studied factors that might
help explain sex differences in PCCs' care of children's mental health problems,
such as the clinician's sex,30 or visit characteristics
that could influence care. For example, PCCs are more likely to recognize
psychosocial problems in their own patients,28, 32
and they are more likely to treat a problem during a visit that they perceive
to be mental health related.29
METHODS
SITES AND SETTINGS
Several primary care research networks participated in this study: the
Ambulatory Sentinel Practice Network (Denver, Colo),33
Pediatric Research in Office Settings (Elk Grove Village, Ill),34
the Wisconsin Research Network (Madison), and the Minnesota Academy of Family
Physicians (St Paul). Of the 204 practices included in this analysis, 30%
were urban, 38% were suburban, and 32% were rural.
This report includes 395 of the 401 clinicians participating in these
practices (the other 6 were dropped because they followed the study procedures
incorrectly). Prior research from the 2 largest networks, the Ambulatory Sentinel
Practice Network and Pediatric Research in Office Settings, supports the comparability
of patients, clinicians, and practices in primary care network studies with
that identified in national samples.35-38
In addition, we compared participating pediatricians with a random sample
of pediatricians from the American Academy of Pediatrics on demographics and
practice characteristics.39 We found no important
differences between participants and other physicians.28
SAMPLE
Each clinician enrolled a consecutive sample of approximately 55 children
and adolescents aged 4 to 15 years (mean ± SD, 8.8 ± 3.2 years)
requiring nonemergency care with the consent of a parent or primary caretaker.
We enrolled a child only once and excluded children seen for procedures only.
There were 24 183 eligible children, of whom 22 059 participated
in the study. Eligible children were not recruited if the parent refused (63%
of eligible but nonparticipating children), the office staff overlooked the
opportunity to recruit (25%), or the family dropped out of the study (12%).
In addition, we examined clinician or practice characteristics that
might affect patient participation, including clinician's discipline, geographic
region, practice population size, percentage of managed care patients, and
clinician's attitudes toward mental health treatment. Clinicians located in
the West and South seemed to include a higher percentage of their eligible
participants (89%-94% for each). None of the other measured sources of selection
bias were statistically significant.
Of the 22 059 children in the study, 909 (4.1%) had missing data
sufficient to preclude further analyses, resulting in a study sample of 21 065
children (10 588 girls and 10 477 boys). Children were most frequently
accompanied by their mothers (86.0% of visits). The children were 6.4% African
American and 7.8% Hispanic. In 55.4% of families, at least 1 parent had more
than a high school education, and in 21.6%, at least 1 parent had an education
above the college level. In 28.5% of families, the parents were unmarried
or separated. We compared the ages and sexes of participating children with
those of eligible but nonparticipating children and found no differences.
PROCEDURE
Parents filled out a parent visit questionnaire while waiting to see
the clinician. The questionnaire included demographic data and the Pediatric
Symptom Checklist (PSC), a mental health screening instrument.40-41
The clinician did not see the completed PSC or other data from the parent
visit questionnaire.
MEASURES
Pediatric Symptom Checklist
The PSC is a 35-item questionnaire for parents about a child's symptoms
and behaviors.42-43 Parents rate
each symptom as occurring "often" (2 points), "sometimes" (1 point), or "never"
(0 points). Parents completed the PSC after providing informed consent and
before their visit with the PCC. We used 3 recently developed subscales44 of the PSC: (1) attention-deficit/hyperactivity problems
(eg, "Does this child have trouble concentrating?"); (2) externalizing problems
that primarily involve conflicts with others ("Does this child fight with
other children?"); and (3) internalizing problems that mainly involve inner
distress on the part of the child ("Does this child feel hopeless?"). These
subscales have high internal consistency (  79) and strong agreement
with diagnoses based on the Screen for Child Anxiety Related Emotional Disorders45 and Inattention/Overactivity With Aggression (IOWA)
Conners46 parent report instruments (areas
under the receiver operating characteristic curves ranged from 82% to 90%).
Clinician-Identified Mental Health Problems
Clinicians completed a survey after seeing the patient. They checked
whether the child "is my primary care patient" and wrote down their understanding
of the reason for the visit, including whether the visit was mental health
related. Finally, the survey included a checklist of child psychosocial problems
that the clinician might have found (clinicians could check more than 1 problem).
For this analysis, we included only mental health problems, such as "attention-deficit/hyperactivity
problems," "behavior or conduct problems," and internalizing problems (either
"adjustment reaction/reaction to stress" or "other emotional problems [eg,
anxiety or sadness]"). We excluded "childhood psychosis" because only 42 cases
were identified. For each problem, the PCC indicated whether it was new or
had been previously recognized.
Clinicians' Treatments
The clinicians also answered 3 questions about treatments administered
during the visit: (1) "Was counseling provided in your office today?" (hereafter,
"counseling"); (2) "Were psychotropic medications prescribed for this patient
for this problem today?" ("medication"); and (3) "Did you refer this patient
for mental health treatment today?" ("referral").
STATISTICAL ANALYSIS
We calculated logistic regressions using Stata statistical software
version 7 (Stata Corp, College Station, Tex). Odds ratios are reported with
95% confidence intervals (CIs) instead of significance values. We examined
sex differences in parent-reported symptoms by computing mixed-models analysis
of variance using SAS statistical software version 8 (SAS Institute Inc, Cary,
NC). All analyses included corrections for the clustering of patients within
PCC.
RESULTS
CHILD SEX DIFFERENCES IN PCC AND VISIT CHARACTERISTICS
Boys and girls had similar family demographics and insurance coverage.
Children were likely to be seen by a PCC of the same sex (56.9% of girls were
seen by women, and 55.7% of boys were seen by men; odds ratio [OR] = 1.66;
95% CI, 1.52-1.82). Primary care clinicians were also more likely to say that
a boy was "my patient" (61.7% of boys vs 56.3% of girls; OR = 1.25; 95% CI,
1.16-1.35). One reason was that boys were more likely to be seen by male clinicians,
and male clinicians described 66.0% of their patients as "my patient" compared
with 51.1% for female clinicians (the OR for the association between "my patient"
and child sex, adjusted for PCC's sex, was 1.16; 95% CI, 1.09-1.24).
There were also striking differences in the way PCCs characterized visits.
Primary care clinicians were more likely to characterize boys' visits as being
explicitly for mental health (3.7% of boys vs 1.3% of girls; OR = 1.67, adjusted
for parental reports of attention problems, externalizing symptoms, and internalizing
symptoms; 95% CI, 1.36-2.04). Among children in whom clinicians identified
a mental health problem, for 80.5% of the boys, clinicians said that the problem
had been identified on a previous visit, vs 70.7% of the girls (OR = 1.51,
adjusted for parental reports of child symptoms; 95% CI, 1.29-1.76).
CHILD SEX DIFFERENCES IN THE MENTAL HEALTH PROBLEMS FOUND BY CLINICIANS
Next, we asked whether PCCs were equally likely to find mental health
problems in boys and girls. Table 1
presents the unadjusted rates at which PCCs found problems and the rates adjusted
for PCC's sex, parent-reported symptoms (ie, scores on the subscales of the
PSC) (Table 2), whether the visit
was mental health related, whether the problem was previously known, and whether
the clinician considered the child "my patient." Primary care clinicians were
more likely to find attention-deficit/hyperactivity problems in boys than
girls (adjusted OR = 2.31; 95% CI, 1.95-2.73). Similarly, PCCs were more likely
to find behavior or conduct problems in boys (adjusted OR = 1.29; 95% CI,
1.12-1.48). However, PCCs were less likely to find internalizing problems
in boys than in girls (adjusted OR = 0.74; 95% CI, 0.63-0.86).
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Table 1. Mental Health Problems Found by PCCs: Percentage by Child
Sex and Age, Unadjusted and Adjusted*
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Table 2. Parental Reports of Symptoms on the Pediatric Symptom Checklist*
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SEX DIFFERENCES IN RECEIPT OF MENTAL HEALTH TREATMENT
Table 3 indicates the proportions
of children receiving referrals to mental health specialists, counseling,
or medication, both unadjusted and adjusted for parent-reported symptoms,
PCC's sex, whether the visit was mental health related, whether the problem
was previously known, and whether the clinician considered the child "my patient."
At every age, the unadjusted data showed that boys were more likely to receive
counseling, medication, or a referral to a specialist than girls. After adjusting
for these factors, however, the sex differences in referral rates were not
statistically significant (adjusted OR = 0.95; 95% CI, 0.79-1.15). Similarly,
after adjustment there were no sex differences in the rates at which children
received counseling (adjusted OR = 1.05; 95% CI, 0.91-1.20). Nevertheless,
after adjusting for these factors, PCCs were substantially more likely to
prescribe medication for boys than for girls (adjusted OR = 1.67; 95% CI,
1.35-2.07).
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Table 3. Mental Health Treatments Delivered by PCCs: Percentages by
Child Sex and Age, Unadjusted and Adjusted*
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COMMENT
SEX DIFFERENCES IN THE PRIMARY MENTAL HEALTH CARE OF CHILDREN
Prior studies of sex disparities in health care have paid little attention
to visit characteristics. Compared with girls, we found that boys with similar
parent-reported symptoms were more likely to have a visit that the PCC perceived
as mental health related. This may have occurred because parents were more
likely to label a boy's behavior as a mental health problem. Alternately,
whereas parents may have labeled boys' and girls' behavior similarly, they
may have been more likely to seek medical care for such behavior when exhibited
by a boy. Finally, because we relied on the PCC's report, it is possible that
the clinician was more likely to label the visit as mental health related
when the patient was a boy.
Both sexes were more likely to seen by a PCC of the same sex, consistent
with surveys of adolescents' preferences47
and presumably parents' preferences. We have previously shown that PCC's sex
has little direct effect on the recognition or treatment of mental illness.30 However, there is a small but interesting indirect
effect of clinician's sex on recognition. Boys were more likely to be seen
by a clinician who identified them as "my patient." This appears to be a consequence
of the tendency for children to be seen by PCCs of the same sex. Male clinicians
are more likely to practice full-time and to work in settings that permit
more continuous relationships with patients.48
Thus, sex differences in the career opportunities or choices of clinicians
may have led to sex differences in patient care because patients self-selected
PCCs based on this criterion.
We found that when PCCs examined boys and girls with similar levels
of parent-reported problems and in a similar visit context, they were more
likely to find attention-deficit/hyperactivity or behavior or conduct problems
in boys. These are stereotypically "boy" problems. Similarly, they were more
likely to find internalizing problems (stereotypically "girl" problems) in
girls. However, we cannot say whether PCCs or parents are the source of these
apparent biases. How patient sex affects the identification of disorders in
children is poorly understood.49-50
To our knowledge, this is the first study to document this problem in child
and adolescent mental health care. Future research should investigate the
roles of the clinician, parent, and patient in the categorization of mental
health problems.
We also found that when a boy and a girl had similar levels of parent-reported
symptoms, PCCs were much more likely to provide medication to the boy. However,
in previous studies we found that when a PCC had discovered a mental health
problem in a child, there were no sex differences in how the problem was treated.29 Hence, PCCs were not sex-biased in their treatment
decision making about children. The sex differences in how children with similar
levels of parent-reported symptoms were treated appeared to result from the
higher rates at which PCCs found attention-deficit/hyperactivity problems
and behavior or conduct problems in boys. The medication difference, in particular,
was almost entirely a result of higher rates of apparent attention-deficit/hyperactivity
problems among boys because stimulants were the only psychotropic medications
prescribed by the PCCs.29, 51
LIMITATIONS
The Child Behavior Study was designed to obtain a large sample size
and to be conducted in working office settings. Therefore, we were not able
to use gold-standard diagnostic procedures, nor did we determine whether any
of the participating PCCs were qualified to make such diagnoses; we knew that
very few PCCs have such training. Thus, we cannot say whether PCCs underidentified
or overidentified mental health problems for either sex. Moreover, we cannot
determine whether a particular pattern of bias represents undertreatment or
overtreatment of either sex (for example, are girls undertreated for attention
problems, or are boys overtreated?). A report from a third party such as a
teacher might have helped clarify this issue. Clinicians were aware that a
study of PCC care of child psychosocial problems was in progress, and this
may have affected their behavior. Finally, the participating clinicians may
not be fully representative of all PCCs in the United States. Although we
have some evidence that the participating pediatricians resembled larger samples
of pediatricians, we have no evidence concerning family physicians or nurse
practitioners.
CONCLUSIONS
We found substantial disparities in PCCs' identification of boys and
girls with similar parent-reported symptoms. These disparities in the identification
of mental health problems produce differences in their treatment.
Our findings do not identify the source of the apparent sex bias in
the identification of mental health problems in children. The bias may result
from how parents describe these children; perhaps they are more urgent in
seeking services for boys. Alternately, it may result from how PCCs process
information about these children in finding problems: they may see a problem
as corresponding to a stereotype about sex-typical mental disorders. The bias
could also result from both parent and clinician factors. These problems may
be termed the direct consequences of child sex on
PCCs' finding and treatment of mental health problems. There were also indirect
consequences. We found that boys were more likely than girls to be seen during
visits that PCCs viewed as mental health related and that PCCs were more likely
to find and treat mental health problems during such visits. Moreover, we
found that boys were more likely than girls to be seen by PCCs who considered
them their own patients. This occurred in part because boys were seen by male
clinicians, who are more likely to practice in a setting that supports continuity
of care. Clinicians who saw their own patients were, in turn, substantially
more likely to find and treat mental health problems. Thus, one component
of the sex disparity in the rates at which PCCs found and treated mental health
problems is an indirect result of patients' preferences to be treated by a
physician of the same sex. This shows that sex differences in career opportunities
for clinicians create sex equity issues for patients as well.
To remedy the disparities in the finding and treatment of children's
mental health problems, we need to consider how to improve both the screening
and identification processes used by PCCs and communication between parents
and clinicians about these issues.52 To these
ends, we believe that clinicians should resist the trend toward practice patterns
that depersonalize care.53 Each child should
be considered "my patient" by some physician, who will then be better prepared
to recognize, track, and effectively treat mental health problems if they
do occur.
| What This Study Adds
Sex differences in the medical and mental health care of adults are
well established. We also know that there are higher rates of identification
and treatment of mental health problems in boys compared with girls. However,
we do not know whether boys and girls with similar problems have comparable
chances of being identified and treated by PCCs.
We found evidence of sex biases in the identification and treatment
of children's mental health problems: boys with parent-reported symptom profiles
that were similar to those of girls were more likely to be identified as having
attention-deficit/hyperactivity problems or behavior or conduct problems and
less likely to be identified as having internalizing (ie, depression or anxiety)
problems. In addition, PCCs were more likely to provide medication for boys
compared with girls with the same level of symptoms. Future research is needed
to clarify whether these important sex differences result from parents' presentation
of boys' and girls' problems or the way clinicians differentially process
information about boys and girls.
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AUTHOR INFORMATION
Accepted for publication January 28, 2002.
This study was supported by grant MH50629 from the National Institute
of Mental Health, Bethesda, Md (Dr Kelleher); grant MCJ-177022 from the Health
Resources and Services Administration Maternal and Child Health Bureau, Rockville,
Md; and by the Staunton Farm Foundation, Pittsburgh, Pa.
We are grateful to the Pediatric Research in Office Settings network
of the American Academy of Pediatrics (Elk Grove Village, Ill), the Ambulatory
Sentinel Practice Network (Denver, Colo), the Wisconsin Research Network (Madison),
and the Minnesota Academy of Family Research Physicians Network (St Paul).
We also thank John Farmer, DO, and David Olson, MD, for comments, and Diane
Comer, BA, for analytical assistance.
Corresponding author: William Gardner, PhD, Center for Research on
Health Care Data Center, 1212 Lilliane Kaufmann Bldg, University of Pittsburgh,
Pittsburgh, PA 15213-2593 (e-mail: gardnerwp{at}msx.upmc.edu).
From the Departments of Medicine (Dr Gardner), Psychiatry (Drs Gardner,
Pajer, Kelleher, and Scholle), and Pediatrics (Drs Kelleher and Scholle),
University of Pittsburgh School of Medicine, Pittsburgh, Pa; Pediatric Research
in Office Settings, American Academy of Pediatrics, Elk Grove Village, Ill
(Dr Wasserman); and the Department of Pediatrics, University of Vermont College
of Medicine, Burlington (Dr Wasserman).
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