Prescription Use among Children with Autism Spectrum Disorders in Northern New England: Intensity and Small Area Variation

The use of psychotropic medications in autistic individuals (21 years and younger) in Western Australia: A preliminary investigation

LAY ABSTRACT

Prescriptions and use of medications to treat mental health conditions in young autistic populations are inconsistent worldwide. This makes it hard to compare findings from international studies to the Australian autistic population, where there are limited relevant studies. Apart from risperidone, there are no other medications specified for direct use in autistic persons. This study aims to gain initial broad understanding of the use of medications, commonly prescribed for mental health conditions, specifically by autistics under the age of 21 years. We analysed data that were previously collected as part of the Western Australian Autism Biological Registry between 2011 and 2015 which amounted to 239 surveys completed on young persons with diagnosed autism. The questionnaires included information on co-occurring conditions, current or previous use of medications and reasons for use of the medications. Only one-quarter of the participants in this study reported using at least one mental health-related medication in their lifetime. The most reported medications were stimulants, antidepressants and antiepileptics. The reasons for using medication included managing attention deficit hyperactivity disorder, challenging behaviours, seizures, sleep difficulties and symptoms of anxiety and depression. The number of individuals reporting medication use in this study was lower compared to other developed countries. Nevertheless, these medications should be monitored due to limited understanding of their use to manage co-occurring symptoms in young autistic persons. The findings highlight the importance of ongoing research to better understand mental health-related medications and inform best practice.

Early-life differences in the gut microbiota composition and functionality of infants at elevated likelihood of developing autism spectrum disorder

Evidence from cross-sectional human studies, and preliminary microbial-based intervention studies, have implicated the microbiota-gut-brain axis in the neurobiology of autism spectrum disorder (ASD). Using a prospective longitudinal study design, we investigated the developmental profile of the fecal microbiota and metabolome in infants with (n = 16) and without (n = 19) a family history of ASD across the first 36 months of life. In addition, the general developmental levels of infants were evaluated using the Mullen Scales of Early Learning (MSEL) test at 5 and 36 months of age, and with ADOS-2 at 36 months of age. At 5 months of age, infants at elevated-likelihood of ASD (EL) harbored less Bifidobacterium and more Clostridium and Klebsiella species compared to the low-likelihood infants (LL). Untargeted metabolic profiling highlighted that LL infants excreted a greater amount of fecal γ-aminobutyric acid (GABA) at 5 months, which progressively declined with age. Similar age-dependent patterns were not observed in the EL group, with GABA being consistently low across all timepoints. Integrated microbiome-metabolome analysis showed a positive correlation between GABA and Bifidobacterium species and negative associations with Clostridium species. In vitro experiments supported these observations demonstrating that bifidobacteria can produce GABA while clostridia can consume it. At the behavioral level, there were no significant differences between the EL and LL groups at 5 months. However, at 36 months of age, the EL group had significantly lower MSEL and ADOS-2 scores compared to the LL group. Taken together, the present results reveal early life alterations in gut microbiota composition and functionality in infants at elevated-likelihood of ASD. These changes occur before any behavioral impairments can be detected, supporting a possible role for the gut microbiota in emerging behavioral variability later in life.

Classifying children with ASD by service utilization and treatment type: A cluster analysis of a nationally representative United States survey

BACKGROUND

If there are patterns of the distribution of services and treatments across the population of people with ASD, these patterns should be based along clinical characteristics or other service needs and not sociodemographic characteristics unrelated to evidence-based care. We examined how individuals in a broad, nationally representative sample "grouped together" based on service utilization and services needed but not covered by insurance. By understanding various treatment patterns, clinicians, researchers, policymakers, and self-advocates and their families can better advocate for high-quality, evidence-based services to be provided equitably.

METHODS

Using the 2011 Survey of Pathways to Diagnosis and Services, a cluster analysis was performed to explore patterns in this population based on medication use, private services use, school-based service use, and services not covered by insurance. Differences in clusters were then explored through multinomial logistic regression.

RESULTS

Six clusters emerged, showing differences in the level of service/medication usage and insurance coverage. Differences across clusters were associated with the level of functional limitation and age at ASD diagnosis. Disparities by insurance type, functional limitation, and age at diagnosis exist among patterns of ASD service provision.

CONCLUSIONS

Our analysis showed that intervention for children with ASD can be across several scales - high and low users of services (both private and school-based), high and low users of medications, and high and low levels of reported non-covered services. The differences were clustered in multiple ways. Further research should incorporate longitudinal and nationally representative data to explore these relationships further.

Heterogeneity in Autism Spectrum Disorder Case-Finding Algorithms in United States Health Administrative Database Analyses

Strengthening systems of care to meet the needs of individuals with autism spectrum disorder (ASD) is of growing importance. Administrative data provide advantages for research and planning purposes, including large sample sizes and the ability to identify enrollment in insurance coverage and service utilization of individuals with ASD. Researchers have employed varying strategies to identify individuals with ASD in administrative data. Differences in these strategies can limit the comparability of results across studies. This review describes implications of the varying strategies that have been employed to identify individuals with ASD in US claims databases, with consideration of the strengths and limitations of each approach.

Unwarranted geographic variation in paediatric health care in the United States and Norway

AIM

We present the four US and Norwegian paediatric and neonatal health atlases and discuss the concept and causes of unwarranted geographic variation in paediatric health care.

METHODS

The four atlases analyse data from both publicly owned health registers, registers of insurance claims and quality registers. Healthcare utilisation is counted per recipient in predefined hospital service areas, adjusted for relevant confounders and presented as extremal ratios between the highest and lowest rate.

RESULTS

The atlases describe geographic variation in rates for primary health care, hospital admissions, outpatient visits, treatment procedures and diagnostic testing. A difference in extremal ratios from 2 to 4 between health service areas are common, and for some procedures extremal ratios is even higher.

CONCLUSION

Variation in healthcare utilisation of the magnitude described in these four atlases cannot be explained by differences in population morbidity or patient preferences and are therefore characterised as unwarranted variation. Individual provider preferences or supply of resources such as hospital beds may explain the observed variation.

Self-rated familiarity with autism spectrum disorders among practicing nurses: a cross-sectional study in the palestinian nursing practice

Background

Autism spectrum disorders (ASDs) are one of the most prevalent neurodevelopmental disabilities of early childhood. Practicing nurses are in a key position to help patients with ASDs and/or their caregivers/families. This study was conducted to assess self-rated familiarity with ASDs among practicing nurses in Palestine. The study also aimed to identify the sociodemographic and practice variables that could predict high self-rated familiarity scores.

Methods

This was a cross-sectional study using a questionnaire. The study was conducted in the period between January 2019 and May 2019. The questionnaire collected: 1) the sociodemographic, pedagogic, and practice variables of the nurses, 2) their self-rated familiarity with signs and symptoms, treatment options, and community resources of ASDs, 3) their self-rated confidence in their abilities to provide counseling for parents/family/caregivers on the drugs prescribed for children/patients with ASDs and their potential adverse effects, and 4) their willingness to receive education/training on issues in ASDs.

Results

The questionnaire was completed by 357 practicing nurses. The practicing nurses self-reported inadequate familiarity with symptoms, treatment, and community resources of ASDs. The mean familiarity score was 35.8% (SD: 18.9%). The nurses also expressed low confidence in their ability to provide counseling services to caregivers/families of children with ASDs. About 75% of the nurses agreed that they could benefit from taking a continuing educational/training program in the area of ASDs and about 82% of the nurses agreed that the nursing school curriculum should include courses in the area of ASDs. The multiple linear regression model showed that higher familiarity scores were predicted by having longer practical experience, having a higher academic degree in nursing, and having a continuing educational course/program on ASDs.

Conclusion

Findings of this study highlighted inadequate familiarity with issues of ASDs among practicing nurses. Higher familiarity was predicted by the length of practical experience, higher academic degree in nursing, and having continuing educational course/program on ASDs. Specifically designed pedagogic interventions might be helpful in increasing familiarity of practicing nurses on ASDs. More investigations are still needed to evaluate if these interventions can improve familiarity and services provided to patients with ASDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00764-3.

Psychotropic Use Among Youths With Intellectual and Developmental Disabilities

OBJECTIVE

The authors examined the prevalence and correlates of psychotropic medication prescribing among outpatient youths with intellectual and developmental disabilities.

METHODS

The authors reviewed cross-sectional data on medications for 1,333 youths (ages 5-21 years) with intellectual and developmental disabilities who were referred to a community-based mental health crisis service. Descriptive statistics and regression analysis were used to describe the study group and to identify correlates of psychotropic polypharmacy, antipsychotic use, and anticonvulsant use in the absence of a seizure disorder.

RESULTS

Most youths were taking psychotropic medications (N=1,139, 86%), often three or more medications (N=733, 55%) from two or more drug classes (N=919, 69%). Most youths received antipsychotics (N=863, 65%), and a third (N=432, 32%) were taking anticonvulsants in the absence of a seizure disorder. Greater severity (number of psychiatric diagnoses and recent psychiatric hospitalization), older age, and living in a group home were significantly correlated with these practices.

CONCLUSIONS

Polypharmacy, antipsychotic use, and anticonvulsant use in the absence of seizure disorders were common among youths with intellectual and developmental disabilities referred to the crisis service. Older age, number of psychiatric diagnoses, living in a group home, and psychiatric hospitalization correlate with these prescribing practices. These elevated prescribing rates in a very vulnerable population warrant further study.

Psychotropic Polypharmacy Among Children and Youth with Autism: A Systematic Review

Objectives: Majority of youth with autism are taking two or more medications (psychotropic or nonpsychotropic) simultaneously, also known as polypharmacy. Yet the efficacy and the potential outcomes of polypharmacy in this population are widely unknown. This systematic literature review described the trends of polypharmacy among autistic youth, and identified factors associated with polypharmacy. Methods: Sixteen studies were included, encompassing over 300,000 youth with autism. Results: Rates of polypharmacy varied quite substantially across studies, ranging from 6.8% to 87% of autistic youth. Having psychiatric comorbidities, self-injurious behaviors, and physical aggression, as well as being male and older, were associated with higher rates of polypharmacy. Conclusion: Findings emphasize the importance of further research to determine appropriate practices related to the monitoring of adverse side effects, and the long-term impact of polypharmacy among autistic youth.

Who is prescribing psychotropic medications in a public developmental-behavioural clinical service and how often?

AIM

Psychotropic prescribing by paediatricians is increasingly common, and there is considerable variation in care provided. The aims of this study were to examine current rates of psychotropic prescribing in the developmental-behavioural outpatient clinics at the Royal Children's Hospital's Centre for Community Child Health, and to compare rates between paediatric consultants and advanced trainees.

METHODS

Data were extracted for appointment encounters from electronic medical records across 12 months in 2017. Patient demographics, provider and medication order data were analysed using Excel and STATA to calculate logistic regression, standard deviation, percentages and means.

RESULTS

From 5069 encounters, there were 847 (16.7%) that included psychotropic prescribing. Advanced trainees prescribed psychotropic medications in only 4.4% of their encounters compared with consultants who prescribed these medications in 23% of encounters (P < 0.001). Stimulants were the most commonly prescribed psychotropic medication (62%), either alone (86.3%) or in combination (13.7%).

CONCLUSIONS

Psychotropic prescribing rates were lower than expected. Advanced trainees may need more experience in psychotropic prescribing.

Inequalities in prescription rates of anti-osteoporosis drugs in primary care in England: A practice-level prescribing data analysis in 2013-2018

OBJECTIVE

To investigate potential variations in prescription rates of anti-osteoporosis drugs at the general practitioner (GP) practice level in England, analysing associations of prescription rates with key demographic and socio-economic variables, and its evolution over time.

METHODS

A retrospective database analysis was conducted using prescription data from all GP practices in England between April 2013 and September 2018. Potential associations between prescription rates and other variables (sex, age, ethnicity, rural-urban classification and income deprivation) were analysed using mixed-effects Poisson regressions and concentration indices.

RESULTS

Alendronic acid was the most frequently prescribed anti-osteoporosis drug. Exploratory and regression analyses showed the association between GP prescriptions and the characteristics of the population they serve. Income deprivation had a statistically significant and negative effect on prescription levels of alendronic acid, denosumab, ibandronic acid and risedronate sodium. Since 2013, denosumab prescriptions exhibited a steep surge in the least income-deprived areas, compared with a modest rise in the most income-deprived areas. Concentration indices indicated a disproportionate concentration of denosumab and, to a lesser extent, ibandronic acid prescriptions among the least income-deprived. The analyses demonstrated that different prescribing behaviours may exist across GPs according to the Clinical Commissioning Group (CCG) to which they belong.

CONCLUSIONS

Variation in the prescription of anti-osteoporosis drugs exists across GPs and CCGs in England, this being more prominent for certain drugs (e.g. denosumab) compared with others (e.g. alendronic acid). Inequalities exist in English primary healthcare and we advocate our findings could support the efforts of decision-makers towards a more equitable system.

The Association between Autism Spectrum Disorder and Pre- and Postnatal Antibiotic Exposure in Childhood-A Systematic Review with Meta-Analysis

Autism spectrum disorder (ASD) is a developmental disorder that begins in early childhood and has been associated with several environmental and genetic factors. We aimed to conduct two-side meta-analyses to determine the association between ASD and pre- and postnatal antibiotic exposure in childhood. We searched PubMed, Embase, Web of Science, and Cochrane Library for articles published up to February 2019. We evaluated observational studies that assessed the association between ASD and antibiotic exposure. Of 1459 articles, nine studies were used in the meta-analysis. We found that early antibiotic exposure, including pre- and postnatal, significantly increased the ASD risk in children. Furthermore, early antibiotic exposure, including pre- and postnatal, was significantly increased in children with ASD. Specifically, prenatal antibiotic exposure was significantly increased in children with ASD; however, postnatal antibiotic exposure was not. Our results indicate an association between ASD and early antibiotic exposure; specifically, that prenatal antibiotic exposure is an important risk factor of ASD in children.

Gastrointestinal Symptoms and Oral Antibiotic Use in Children with Autism Spectrum Disorder: Retrospective Analysis of a Privately Insured U.S. Population

A retrospective analysis of administrative claims data from a large U.S. health insurer was performed to study a potential association between oral antibiotic use during early childhood and occurrence of later gastrointestinal (GI) symptoms in children with autism spectrum disorder (ASD). Among 3253 children with ASD, 37.0% had a GI-related diagnosis during the last 2 years of their 5-year health coverage enrollment period, compared to 20.0% of 278,370 children from the general population without an ASD diagnosis. Greater numbers of oral antibiotic fills during the first 3 years of enrollment were found to significantly increase the hazard rate of having a later GI-related diagnosis (adjusted hazard ratio 1.48; 95% confidence interval 1.34, 1.63) in children both with and without ASD.

Prescription Trends of Psychotropics in Children and Adolescents with Autism Based on Nationwide Health Insurance Data

Children with autism are often medicated to manage emotional and behavioral symptoms; yet, data on such pharmacotherapy is insufficient. In this study, we investigated the Korean National Health Insurance Claims Database (NHICD) information related to autism incidence and psychotropic medication use. From the 2010-2012 NHICD, we selected a total of 31,919,732 subjects under 19 years old. To examine the diagnostic incidence, we selected patients who had at least one medical claim containing an 10th revision of International Statistical Classification of Diseases and Related Health Problems (ICD-10) code for pervasive developmental disorder, F84, not diagnosed in the previous 360 days. Psychotropics were categorized into seven classes. Then, we analyzed the data to determine the mean annual diagnostic incidence and psychotropic prescription trends. Diagnostic incidence was 17,606 for the 3 years, with a mean annual incidence per 10,000 population of 5.52. Among them, 5,348 patients were prescribed psychotropics. Atypical antipsychotics were the most commonly used, followed by antidepressants. An older age, male sex, and the availability of medical aid were associated with a higher rate of prescription than observed for a younger age, female sex, and the availability of health insurance. Psychotropic drugs were used for less than one-third of patients newly diagnosed with autism, and prescription differed by sex and age. Increased diagnostic incidence is associated with an increased prescription of psychotropic drugs. Therefore, medication-related safety data and policies for psychotropic drugs in autism should be prepared.

How does autism spectrum disorder affect the risk and severity of childhood asthma?

BACKGROUND

Autism spectrum disorder (ASD) and asthma are among the most common chronic disorders in childhood. Both are associated with altered immune regulation and share several risk factors. The effects of ASD on risk for later asthma and asthma severity remain unclear.

OBJECTIVE

To determine whether ASD in children increases the risk of incident asthma and worsens asthma severity.

METHODS

We performed 2 distinct analytic designs (case-control and retrospective longitudinal cohort) using a multistate electronic health records database to assess the odds of new asthma and asthma severity among children with ASD. In both designs, children with ASD were matched with children without ASD according to sex, age, race, ethnicity, location, and insurance status. Pulmonary function, controller medication prescriptions, asthma exacerbations, and asthma-related hospitalizations were collected. The effects of ASD on asthma risk and severity were assessed using multivariable linear and logistic regression.

RESULTS

Among children with asthma, ASD was associated with reduced exacerbations (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.54-0.92), better forced expiratory volume in 1 second/forced vital capacity ratio (0.876 vs 0.841, P < .001), and lower odds of airflow obstruction (OR, 0.53; 95% CI, 0.31-0.90) but had higher odds of asthma controller prescription (OR, 2.18; 95% CI, 1.62-2.93). In a longitudinal analysis of children without asthma, ASD was found to be protective for new asthma (OR, 0.44; 95% CI, 0.26-0.74).

CONCLUSION

Among children with asthma, concomitant ASD is associated with better asthma-related outcomes but a higher controller treatment burden. In addition, our data did not support ASD as a risk factor for incident asthma.

Use of psychotropic drugs in patients with autism spectrum disorders: a systematic review

OBJECTIVE

The objective of this review was to examine prevalence and patterns of psychopharmacotherapy in individuals with autism spectrum disorder (ASD).

METHOD

A systematic literature search in PubMed, CINAHL, and PsycINFO was performed, including articles published up to November 18, 2015.

RESULTS

A total of 47 studies (data collection: 1976-2012), encompassing >300 000 individuals with ASD, were included. The prevalence of psychopharmacotherapy ranged from 2.7% to 80% (median (overall): 45.7%; median (children): 41.9%; median (adults): 61.5%), with psychotropic polypharmacy occurring in 5.4-54% (median: 23.0%). Regarding drug classes, antipsychotics were most frequently used, followed by attention-deficit/hyperactivity disorder (ADHD) medication and antidepressants. Both older age and psychiatric comorbidity were associated with higher prevalences of psychopharmacotherapy and psychotropic polypharmacy. There were no time trends in psychopharmacotherapy prevalence observable.

CONCLUSION

Despite a lack of pharmacological treatment options for ASD core symptoms, the prevalence of psychopharmacotherapy and polypharmacy in ASD patients is considerable, which is probably due to the treatment of non-core ASD symptoms and psychiatric comorbidities. While there is some evidence for the use of antipsychotics and ADHD medication for these indications, the use of antidepressants should be limited to selected cases.