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O'Brien MJ, Pauls AM, Cates AM, Larson PD, Zorn AN. Psychotropic Medication Use and Polypharmacy Among Children and Adolescents Initiating Intensive Behavioral Therapy for Severe Challenging Behavior. J Pediatr 2024; 271:114056. [PMID: 38615943 DOI: 10.1016/j.jpeds.2024.114056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/27/2024] [Accepted: 04/08/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVE To evaluate the prevalence, trends, and factors associated with psychotropic medication use and polypharmacy among children and adolescents initiating intensive behavioral therapy for severe challenging behavior over a 10-year period. STUDY DESIGN In this retrospective observational study, we examined data from caregiver interviews and patient medical records on the number and types of psychotropic medications prescribed to patients initiating intensive behavioral therapy between January 1, 2013, and December 31, 2022. Trends in medication use and polypharmacy across the 10-year period were analyzed using regression analysis, while differences in demographics and clinical factors for patients with use and polypharmacy were analyzed using nonparametric statistical analysis with odds ratios presented for significant factors. RESULTS Data from all 302 pediatric patients initiating intensive behavioral therapy across the 10-year period were analyzed. Among all patients and all years, 83.8% were taking at least 1 psychotropic medication and 68.2% experienced polypharmacy. There were no changes in the prevalence of use, mean number of medications taken, or polypharmacy across the 10-year period. Patients diagnosed with attention-deficit/hyperactivity disorder or anxiety disorder, as well as those exhibiting self-injurious behavior had higher use of psychotropic medication and polypharmacy and were taking more medications overall. CONCLUSIONS Psychotropic medication use and polypharmacy were extremely high for children and adolescents with severe challenging behavior, but use and polypharmacy did not change over the 10-year period of data collection. Further research is needed to establish the generality of these findings to other regions of the US.
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Affiliation(s)
- Matthew J O'Brien
- The University of Iowa, Iowa City, IA; The University of Iowa Stead Family Department of Pediatrics, Iowa City, IA.
| | | | | | - Priya D Larson
- The University of Iowa, Iowa City, IA; The University of Iowa Department of Child and Adolescent Psychiatry, Iowa City, IA
| | - Alithea N Zorn
- The University of Iowa, Iowa City, IA; Center for Public Health Statistics, Iowa City, IA; College of Public Health, Iowa City, IA
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Colvin MK, Truba N, Sorensen S, Henricson E, Kinnett K. Dystrophinopathy and the brain: A parent project muscular dystrophy (PPMD) meeting report November 11-12, 2021, New York City, NY. Neuromuscul Disord 2022; 32:935-944. [PMID: 36323606 DOI: 10.1016/j.nmd.2022.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Mary K Colvin
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
| | - Natalie Truba
- Department of Psychology and Neurology, Nationwide Children's Hospital, Columbus, OH, USA
| | | | | | - Kathi Kinnett
- Parent Project Muscular Dystrophy, Washington DC, USA
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Keller AR, Kanaley RL, Starr T, Strollo B, Scharf M, Massachi S, Angell L, Clough CD, Schriefer J. Mitigating Pediatric Inpatient Aggression: A Quality Improvement Initiative. Hosp Pediatr 2022; 12:499-506. [PMID: 35476133 DOI: 10.1542/hpeds.2021-006431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patient aggression in the health care workplace has increased significantly, and the impact of workplace violence can be profound, including psychological trauma and lost productivity. We suspect these safety events are often unreported, leading to missed opportunities to design interventions to reduce harm. The primary aim of the interdisciplinary quality improvement team was to increase staff reporting of safety events utilizing our event reporting system related to the care of verbally and/or physically aggressive pediatric patients by 10% over a 12-month period. METHODS An interdisciplinary quality improvement team addressed existing gaps in the care of pediatric inpatients with escalating behavior. Interventions included a survey of staff knowledge, use of the care guideline for management, updates to the electronic medical record, patient aggression screening tool, an electronic order set, and an online education module. The primary outcome measure was the number of reported staff safety events related to the care of aggressive patients. Compliance with the use of the pediatric aggression risk screening tool was tracked as a process measure. RESULTS The reporting of safety events related to the care of aggressive patients increased from just <1.0 events per 1000 patient days to 3.0 with special cause variation observed on a statistical process control chart. The compliance with the use of the pediatric aggression risk screening tool improved during the time of the project, nearing 90%. CONCLUSIONS A variety of interventions aimed to address pediatric inpatient aggression can improve the reporting of events related to workplace violence and foster a culture of employee safety.
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Affiliation(s)
- Amy R Keller
- aGolisano Children's Hospital, Rochester, New York.,bColumbia Memorial Health, Albany Medical Center, Hudson, New York
| | - Rebecca L Kanaley
- aGolisano Children's Hospital, Rochester, New York.,bColumbia Memorial Health, Albany Medical Center, Hudson, New York
| | - Taylor Starr
- aGolisano Children's Hospital, Rochester, New York.,bColumbia Memorial Health, Albany Medical Center, Hudson, New York
| | - Bonnie Strollo
- aGolisano Children's Hospital, Rochester, New York.,bColumbia Memorial Health, Albany Medical Center, Hudson, New York.,cStrong Memorial Hospital, Rochester, New York
| | - Michael Scharf
- aGolisano Children's Hospital, Rochester, New York.,bColumbia Memorial Health, Albany Medical Center, Hudson, New York
| | | | - Luke Angell
- eChildren's Medical Group, Poughkeepsie, New York
| | | | - Jan Schriefer
- aGolisano Children's Hospital, Rochester, New York.,bColumbia Memorial Health, Albany Medical Center, Hudson, New York
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Penfold RB, Thompson EE, Hilt RJ, Schwartz N, Robb AS, Correll CU, Newton D, Rogalski K, Earls MF, Kowatch RA, Beck A, Yarborough BJH, Crystal S, Vitiello B, Kelleher KJ, Simon GE. Development of a Symptom-Focused Model to Guide the Prescribing of Antipsychotics in Children and Adolescents: Results of the First Phase of the Safer Use of Antipsychotics in Youth (SUAY) Clinical Trial. J Am Acad Child Adolesc Psychiatry 2022; 61:93-102. [PMID: 34256967 PMCID: PMC8566327 DOI: 10.1016/j.jaac.2021.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 03/24/2021] [Accepted: 04/01/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To develop a new approach to prescribing guidelines as part of a pragmatic trial, Safer Use of Antipsychotics in Youth (SUAY; ClinicalTrials.gov Identifier: NCT03448575), which supports prescribers in delivering high-quality mental health care to youths. METHOD A nominal group technique was used to identify first- to nth-line treatments for target symptoms and potential diagnoses. The panel included US pediatricians, child and adolescent psychiatrists, and psychopharmacology experts. Meeting materials included information about Medicaid review programs, systematic reviews, prescribing guidelines, and a description of the pragmatic trial. Afterward, a series of 4 webinar discussions were held to achieve consensus on recommendations. RESULTS The panel unanimously agreed that the guideline should focus on target symptoms rather than diagnoses. Guidance included recommendations for first- to nth-line treatment of target mental health symptoms, environmental factors to be addressed, possible underlying diagnoses that should first be considered and ruled out, and general considerations for pharmacological and therapeutic treatments. CONCLUSION Prescribing guidelines are often ignored because they do not incorporate the real-world availability of first-line psychosocial treatments, comorbid conditions, and clinical complexity. Our approach addresses some of these concerns. If the approach proves successful in our ongoing pragmatic trial, Safer Use of Antipsychotics in Youth (SUAY), it may serve as a model to state Medicaid programs and health systems to support clinicians in delivering high-quality mental health care to youths. CLINICAL TRIAL REGISTRATION INFORMATION Safer Use of Antipsychotics in Youth; http://clinicaltrials.gov/; NCT03448575.
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Affiliation(s)
- Robert B Penfold
- Drs. Penfold, Simon, and Ms. Thompson are with Kaiser Permanente Washington Health Research Institute, Seattle.
| | - Ella E Thompson
- Drs. Penfold, Simon, and Ms. Thompson are with Kaiser Permanente Washington Health Research Institute, Seattle
| | - Robert J Hilt
- Dr. Hilt is with Seattle Children's Hospital, Washington
| | - Nadine Schwartz
- Drs. Schwartz, Kowatch, and Kelleher are with Nationwide Children's Hospital, Columbus, Ohio
| | - Adelaide S Robb
- Dr. Robb is with Children's National Hospital, Washington, DC
| | - Christoph U Correll
- Dr. Correll is with The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York; Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York; The Feinstein Institute for Medical Research, Manhasset, New York; and Charité Universitätsmedizin Berlin, Germany
| | - Douglas Newton
- Dr. Newton is with Sondermind, Denver, Colorado. At the time of the study, Dr. Newton was with Optum Behavioral Health, Denver, Colorado
| | - Kelly Rogalski
- Dr. Rogalski is with Henry Ford Health System, Detroit, Michigan
| | - Marian F Earls
- Dr. Earls is with Community Care of North Carolina, Raleigh
| | - Robert A Kowatch
- Drs. Schwartz, Kowatch, and Kelleher are with Nationwide Children's Hospital, Columbus, Ohio
| | - Arne Beck
- Dr. Beck is with Kaiser Permanente Colorado Institute for Health Research, Denver
| | - Bobbi Jo H Yarborough
- Dr. Yarborough is with Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Stephen Crystal
- Dr. Crystal is with Rutgers University, Brunswick, New Jersey
| | | | - Kelly J Kelleher
- Drs. Schwartz, Kowatch, and Kelleher are with Nationwide Children's Hospital, Columbus, Ohio
| | - Gregory E Simon
- Drs. Penfold, Simon, and Ms. Thompson are with Kaiser Permanente Washington Health Research Institute, Seattle
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Stutzman DL. Long-term use of antidepressants, mood stabilizers, and antipsychotics in pediatric patients with a focus on appropriate deprescribing. Ment Health Clin 2021; 11:320-333. [PMID: 34824957 PMCID: PMC8582767 DOI: 10.9740/mhc.2021.11.320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/09/2021] [Indexed: 11/13/2022] Open
Abstract
It is estimated that 8% to 12% of youth are prescribed psychotropic medications. Those in foster care, juvenile justice systems, residential treatment facilities, and with developmental or intellectual disabilities are more likely to be prescribed high-risk regimens. The use of psychotropic medications in this age group is often off-label and can be associated with significant risk, warranting critical evaluation of their role. Landmark trials, pediatric-specific guidelines, and state-driven initiatives play critical roles in supporting evidence-based use of psychotropic medications in children. Overall, there is a lack of literature describing the long-term use of psychotropic medications in youth—particularly with regard to neurobiological, physical, and social changes that occur throughout development. Deprescribing is an important practice in child and adolescent psychiatry, given concerns for over-prescribing, inappropriate polytherapy, and the importance of reevaluating the role of psychotropic medications as children develop.
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Spence O, Camelo Castillo W, Reeves G, dosReis S. Psychiatric Services Preceding Initiation of Antipsychotic Medication Among Youth in Foster Care. J Child Adolesc Psychopharmacol 2019; 29:276-284. [PMID: 30882232 DOI: 10.1089/cap.2018.0109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objectives: To characterize psychotropic use preceding antipsychotic initiation in a population of youth in foster care and to determine whether the use of intensive psychiatric services before initiating an antipsychotic differs across subgroup of youth defined by past psychotropic use. Methods: We identified youth in foster care in one U.S. State who initiated an antipsychotic from 2010 to 2015 and were aged ≤21 years at initiation. No antipsychotic use 1-year before the index prescription defined new use. Psychotropic class use in the year preceding the index antipsychotic prescription distinguished three subgroups: no psychotropic use, single-class use, and concomitant (>1 class) use. The temporal association of antipsychotic initiation with intensive services (psychiatric hospitalizations or emergency department visits) was estimated through regression models adjusted for psychiatric diagnoses and demographic characteristics. Logistic regression models assessed the interaction between psychotropic class subgroup and psychiatric diagnosis with the odds of hospitalization. Results: Of the 753 youth initiating an antipsychotic, 279 (37%) had no psychotropic use, 304 (40%) had single-class use, and 170 (23%) had concomitant use in the year before. In the year preceding antipsychotic initiation, 183 (24%) were hospitalized and 118 (16%) were hospitalized 1 month before antipsychotic initiation. The number of days between hospital discharge and antipsychotic initiation was 47 (SE = 19) days longer in concomitant users relative to youth with no psychotropic use (p = 0.01). In the year preceding antipsychotic initiation, concomitant users with severe mental illness were less likely to have a hospitalization (OR = 0.24; 95% CI = 0.06-0.93) than youth with no psychotropic use diagnosed with severe mental illness. Conclusions: Variation in psychotropic medication treatment, hospitalizations, and psychiatric diagnosis before antipsychotic initiation distinguished subgroups of youth initiating an antipsychotic. Single-class and concomitant users may have initiated an antipsychotic to augment existing regimen, whereas youth with no psychotropic use may have initiated an antipsychotic following a first episode crisis.
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Affiliation(s)
- O'Mareen Spence
- 1 Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Wendy Camelo Castillo
- 1 Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Gloria Reeves
- 2 Division of Child and Adolescent Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland
| | - Susan dosReis
- 1 Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland
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Leckman-Westin E, Finnerty M, Scholle SH, Pritam R, Layman D, Kealey E, Byron S, Morden E, Bilder S, Neese-Todd S, Horwitz S, Hoagwood K, Crystal S. Differences in Medicaid Antipsychotic Medication Measures Among Children with SSI, Foster Care, and Income-Based Aid. J Manag Care Spec Pharm 2018; 24:238-246. [PMID: 29485947 PMCID: PMC10397713 DOI: 10.18553/jmcp.2018.24.3.238] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Concerns about antipsychotic prescribing for children, particularly those enrolled in Medicaid and with Supplemental Security Income (SSI), continue despite recent calls for selective use within established guidelines. OBJECTIVES To (a) examine the application of 6 quality measures for antipsychotic medication prescribing in children and adolescents receiving Medicaid and (b) understand distinctive patterns across eligibility categories in order to inform ongoing quality management efforts to support judicious antipsychotic use. METHODS Using data for 10 states from the 2008 Medicaid Analytic Extract (MAX), a cross-sectional assessment of 144,200 Medicaid beneficiaries aged < 21 years who received antipsychotics was conducted to calculate the prevalence of 6 quality measures for antipsychotic medication management, which were developed in 2012-2014 by the National Collaborative for Innovation in Quality Measurement. These measures addressed antipsychotic polypharmacy, higher-than-recommended doses of antipsychotics, use of psychosocial services before antipsychotic initiation, follow-up after initiation, baseline metabolic screening, and ongoing metabolic monitoring. RESULTS Compared with children eligble for income-based Medicaid, children receiving SSI and in foster care were twice as likely to receive higher-than-recommended doses of antipsychotics (adjusted odds ratio [AOR] = 2.4, 95% CI = 2.3-2.6; AOR = 2.5, 95% CI = 2.4-2.6, respectively) and multiple concurrent antipsychotic medications (AOR = 2.2, 95% CI = 2.0-2.4; AOR = 2.2, 95% CI = 2.0-2.4, respectively). However, children receiving SSI and in foster care were more likely to have appropriate management, including psychosocial visits before initiating antipsychotic treatment and ongoing metabolic monitoring. While children in foster care were more likely to experience baseline metabolic screening, SSI children were no more likely than children eligible for income-based aid to receive baseline screening. CONCLUSIONS While indicators of overuse were more common in SSI and foster care groups, access to follow-up, metabolic monitoring, and psychosocial services was somewhat better for these children. However, substantial quality shortfalls existed for all groups, particularly metabolic screening and monitoring. Renewed efforts are needed to improve antipsychotic medication management for all children. DISCLOSURES This project was supported by grant number U18HS020503 from the Agency for Healthcare Research and Quality (AHRQ) and Centers for Medicare & Medicaid Services (CMS). Additional support for Rutgers-based participants was provided from AHRQ grants R18 HS019937 and U19HS021112, as well as the New York State Office of Mental Health. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ, CMS, or the New York State Office of Mental Health. Finnerty has been the principle investigator on research grants/contracts from Bristol Myers Squibb and Sunovion, but her time on these projects is fully supported by the New York State Office of Mental Health. Scholle, Byron, and Morden work for the National Committee for Quality Assurance, a not-for-profit organization that develops and maintains quality measures. Neese-Todd was at Rutgers University at the time of this study and is now employed by the National Committee for Quality Assurance. The other authors have no financial relationships relevant to this article to disclose. Study concept and design were contributed by Finnerty, Neese-Todd, and Crystal, assisted by Scholle, Leckman-Westin, Horowitz, and Hoagwood. Scholle, Byron, Morden, and Hoagwood collected the data, and data interpretation was performed by Pritam, Bilder, Leckman-Westin, and Finnerty, with assistance from Scholle, Byron, Crystal, Kealey, and Neese-Todd. The manuscript was written by Leckman-Westin, Kealey, and Horowitz and revised by Layman, Crystal, Leckman-Westin, Finnerty, Scholle, Neese-Todd, and Horowitz, along with the other authors.
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Affiliation(s)
- Emily Leckman-Westin
- 1 New York State Office of Mental Health, Albany, New York, and State University of New York at Albany, School of Public Health, Rensselaer, New York
| | - Molly Finnerty
- 2 New York State Office of Mental Health, and New York University Langone Health, New York, New York
| | | | - Riti Pritam
- 4 New York State Office of Mental Health, Albany, New York
| | - Deborah Layman
- 4 New York State Office of Mental Health, Albany, New York
| | - Edith Kealey
- 4 New York State Office of Mental Health, Albany, New York
| | - Sepheen Byron
- 3 National Committee for Quality Assurance, Washington, DC
| | - Emily Morden
- 3 National Committee for Quality Assurance, Washington, DC
| | | | | | - Sarah Horwitz
- 6 New York University Langone Health, New York, New York
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Jerrell JM, McIntyre RS, Deroche CB. Pharmacotherapy effectiveness for clinical subgroups among children and adolescents with early onset schizophrenia. Hum Psychopharmacol 2017; 32. [PMID: 28370310 DOI: 10.1002/hup.2585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 11/27/2016] [Accepted: 03/03/2017] [Indexed: 01/07/2023]
Abstract
OBJECTIVE This study aims to determine the effectiveness of pharmacotherapies among children and adolescents diagnosed with early onset schizophrenia subgrouped according to their co-occurring psychiatric disorders. METHODS A retrospective cohort design was employed, using South Carolina's (USA) Medicaid claims dataset covering outpatient and inpatient medical services, between January, 1999 and December, 2013 to identify patients ≤17 years of age. Random effects regression analyses assessed differential changes in acute psychiatric service utilization over time across the 3 subgroups associated with antipsychotic, mood stabilizer, psychostimulant, or antidepressant pharmacotherapy. RESULTS For patients with schizophrenia and comorbid mood disorders or emotional dysregulation (Cluster 1), or schizophrenia and severe cognitive impairments (Cluster 2), those treated with monotherapy second-generation antipsychotics (SGAs) over time demonstrated consistently lower use of acute psychiatric treatment services as did those coprescribed mood stabilizers, primarily lithium, or anticonvulsants. In all clusters, including the relatively homogenous subgroup of patients with early onset schizophrenia and few comorbid disorders, acute psychiatric service utilization was significantly higher and more variable over time for those prescribed multiple SGAs. CONCLUSIONS Regardless of the specific constellation of symptoms and comorbid disorders targeted, the coprescription of multiple SGAs was not effective over time in stabilizing children and adolescents outside of acute care settings.
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Affiliation(s)
- Jeanette M Jerrell
- Department of Neuropsychiatry, University of South Carolina School of Medicine, Columbia, South Carolina, USA
| | - Roger S McIntyre
- Departments of Psychiatry and Pharmacology, University of Toronto, Toronto, Ontario, Canada
| | - Chelsea B Deroche
- Department of Health Management and Informatics Office of Research Biostatistics Research and Design Unit, University of Missouri School of Medicine, Columbia, Missouri, USA
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Malas N, Spital L, Fischer J, Kawai Y, Cruz D, Keefer P. National Survey on Pediatric Acute Agitation and Behavioral Escalation in Academic Inpatient Pediatric Care Settings. PSYCHOSOMATICS 2017; 58:299-306. [PMID: 28365002 DOI: 10.1016/j.psym.2017.01.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/23/2017] [Accepted: 01/23/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pediatric acute agitation and behavioral escalation (PAABE) is common and disruptive to pediatric inpatient health care. There is a paucity of literature on PAABE in noncritical care inpatient pediatric care settings with little consensus on its evaluation and management. METHODS In January 2016, a 34-question survey was e-mailed to pediatric hospitalists and consultation-liaison psychiatrists through their respective professional listservs. Excluded responses included incomplete surveys, and surveys from providers in community care settings. The survey consisted of multiple-choice questions, rating scales, and free-text responses relating to the identification, education, and evaluation and management of PAABE at the respondent's respective hospital. RESULTS Responses were obtained from 38 North American academic children's hospitals. Of the respondents, 69.3% were pediatric hospitalists and 30.7% were pediatric psychiatry consultants. Most respondents practice in urban areas (84.2%), and in hospitals with ≥100 beds (89.4%). Overall, 84.2% of the respondents encountered PAABE at least once a month and as frequently as every week. Most respondents (70.0%) rated PAABE as an 8 or higher on a 10-point Likert scale. Despite being highly important and common, 53.9% of respondents do not screen for risk factors for PAABE, 63.6% reported no formal process to facilitate caregiver involvement in managing PAABE, and 59.7% indicated no physician training in PAABE evaluation and management. CONCLUSION Many pediatric hospitals identify PAABE as a great concern, yet there is little training, screening, or standardization of care in PAABE. There is a need to consolidate existing knowledge regarding PAABE, while developing enhanced collaboration, training, and standardized practice in inpatient PAABE.
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Affiliation(s)
- Nasuh Malas
- Department of Pediatrics and Communicable Diseases, University of Michigan School of Medicine, Ann Arbor, MI.
| | - Linden Spital
- Department of Psychiatry, University of Michigan School of Medicine, Ann Arbor, MI
| | - Jason Fischer
- Department of Pediatrics and Communicable Diseases, University of Michigan School of Medicine, Ann Arbor, MI
| | - Yu Kawai
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - David Cruz
- C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI
| | - Patricia Keefer
- Department of Pediatrics and Communicable Diseases, University of Michigan School of Medicine, Ann Arbor, MI; Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI
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Kakko K, Pihlakoski L, Salmelin R, Keskinen P, Puura K, Tamminen T. Clinical use of second-generation antipsychotics in children. Scand J Child Adolesc Psychiatr Psychol 2017. [DOI: 10.21307/sjcapp-2017-009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Abstract
Background
The use of second-generation antipsychotic (SGA) medication among child and adolescent psychiatric patients has increased worldwide in recent years. The increase appears to have been more extensive in the USA than in European countries, but the tendency is similar. However, after a peak the use seems to have declined in the USA. Simultaneously with the increasing numbers, the duration of SGA use has lengthened, indications have broadened, and off-label use has increased. Despite existing follow-up recommendations and evidence for the metabolic adverse effects of SGAs in children, research evidence has not translated into clinical practice.
Objective
The aim of this study was to assess the clinical use and follow-up practices of SGA medication among child psychiatric patients of one university hospital in Finland.
Method
This retrospective patient report-based study was conducted at the Child Psychiatric Clinic of Tampere University Hospital, Finland. The study sample consisted of 133 patients who were younger than 13 years when initiating SGA treatment and had an ongoing SGA medication during the study period. The study sample was divided into two groups according to diagnosis to examine whether there were differences between patients with an autistic or a developmental disorder (F83-84) and patients with other psychiatric diagnoses.
Results:
This study showed that SGA use in children younger than 13 years was mainly off-label. Irrespective of diagnosis, the most common indication was aggression. Especially children with psychiatric diagnoses other than developmental disorders had multiple socio-demographic risk factors and adverse life experiences in their background. The follow-up practices were diverse and partly irregular.
Conclusions:
A need for systematic SGA monitoring practices and dialogue between the medical specialities treating children and their families is evident.
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Affiliation(s)
- Kirsi Kakko
- Department of Child Psychiatry, Tampere University Hospital, Faculty of Medicine and Life Sciences, University of Tampere , Finland Finland
| | - Leena Pihlakoski
- Department of Child Psychiatry, Tampere University Hospital, Faculty of Medicine and Life Sciences, University of Tampere , Finland Finland
| | - Raili Salmelin
- Department of Child Psychiatry, Tampere University Hospital, Faculty of Social Sciences/Health Sciences, University of Tampere , Finland Finland
| | - Päivi Keskinen
- Department of Pediatrics, Tampere University Hospital, Center for Child Health Research, University of Tampere , Finland Finland
| | - Kaija Puura
- Department of Child Psychiatry, Tampere University Hospital, Faculty of Medicine and Life Sciences, University of Tampere , Finland Finland
| | - Tuula Tamminen
- Faculty of Medicine and Life Sciences, University of Tampere , Finland Finland
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Xu S, Gullapalli RP, Frost DO. Olanzapine antipsychotic treatment of adolescent rats causes long term changes in glutamate and GABA levels in the nucleus accumbens. Schizophr Res 2015; 161:452-7. [PMID: 25487700 PMCID: PMC4308953 DOI: 10.1016/j.schres.2014.10.034] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Revised: 10/20/2014] [Accepted: 10/23/2014] [Indexed: 10/24/2022]
Abstract
Atypical antipsychotic drugs (AAPDs) are widely used in children and adolescents to treat a variety of psychiatric disorders. However, little is known about the long-term effects of AAPD treatment before the brain is fully developed. Indeed, we and others have previously reported that treatment of adolescent rats with olanzapine (OLA; a widely prescribed AAPD) on postnatal days 28-49, under dosing conditions that approximate those employed therapeutically in humans, causes long-term behavioral and neurobiological perturbations. We have begun to study the mechanisms of these effects. Dopamine (DA) and serotonin (5HT) regulate many neurodevelopmental processes. Currently approved AAPDs exert their therapeutic effects principally through their DAergic activities, although in schizophrenia (SZ) and some other diseases for which AAPDs are prescribed, DAergic dysfunction is accompanied by abnormalities of glutamatergic (GLUergic) and γ-aminobutyric acidergic (GABAergic) transmission. Here, we use proton magnetic resonance spectroscopy ((1)H MRS) to investigate the effects of adolescent OLA administration on GABA and GLU levels. We found that the treatment caused long-term reductions in the levels of both GLU and GABA in the nucleus accumbens (NAc) of adult rats treated with OLA during adolescence. The NAc is a key node in the brain's "reward" system, whose function is also disrupted in schizophrenia. Further research into potential, OLA-induced changes in the levels of GLU and GABA in the NAc and other brain areas, and the dynamics and mechanisms of those changes, are an essential step for devising new adjunct therapies for existing AAPDs and for designing new drugs that increase therapeutic effects and reduce long-term abnormalities when administered to pediatric patients.
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Affiliation(s)
- Su Xu
- Dept. of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Rao P Gullapalli
- Dept. of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Douglas O Frost
- Dept. of Pharmacology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; Dept. of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Rodday AM, Parsons SK, Correll CU, Robb AS, Zima BT, Saunders TS, Leslie LK. Child and adolescent psychiatrists' attitudes and practices prescribing second generation antipsychotics. J Child Adolesc Psychopharmacol 2014; 24:90-3. [PMID: 24679174 PMCID: PMC3967387 DOI: 10.1089/cap.2013.0133] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The purpose of this study was to examine psychiatrists' attitudes and practices in prescribing second-generation antipsychotics (SGA) to children and adolescents (referred to here as "children") and identify factors associated with off-label SGA use. METHODS A survey was mailed to a national, randomly selected sample of 1600 child and adolescent psychiatrists identified by the American Medical Association. Multivariable logistic regression was used to identify factors, including psychiatrists' characteristics, practice characteristics, and psychiatrists' attitudes, that are associated with off-label SGA use (i.e., SGAs used in children with attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder, conduct disorder, or nonbipolar mood disorders). RESULTS The final sample included 340 psychiatrists. Overall, respondents reported higher use and appropriateness of SGAs for United States Food and Drug Administration (FDA)-approved disorders, symptoms of aggression, and older child age. More than one third (36%) of respondents reported some off-label SGA use. Significant predictors of off-label use were: Practicing at inpatient/residential facilities (odds ratio [OR]=4.2, p=0.001); white/non-Hispanic race/ethnicity (OR=0.3, p<0.0001), agreeing that SGAs should be used for ADHD with aggression (OR=7.1, p<0.0001); and agreeing that SGAs should be used for severe delinquent behaviors (OR=1.9, p=0.03). CONCLUSIONS Psychiatrists' attitudes about prescribing SGAs to children exhibiting aggressive symptoms were associated with off-label SGA use. Research is needed to understand the construct of aggression, potential interaction effects of aggression with diagnostic criteria, and their impact on SGA use.
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Affiliation(s)
- Angie Mae Rodday
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
| | - Susan K. Parsons
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
- Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts
| | - Christoph U. Correll
- The Zucker Hillside Hospital, North Shore-LIJ Health System, Glen Oaks, New York
| | - Adelaide S. Robb
- Center for Clinical and Community Research, Children's National Medical Center, Washington, DC
| | - Bonnie T. Zima
- Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, Los Angeles, California
| | - Tully S. Saunders
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Laurel K. Leslie
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
- Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts
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Birnbaum ML, Saito E, Gerhard T, Winterstein A, Olfson M, Kane JM, Correll CU. Pharmacoepidemiology of antipsychotic use in youth with ADHD: trends and clinical implications. Curr Psychiatry Rep 2013; 15:382. [PMID: 23881713 PMCID: PMC4010184 DOI: 10.1007/s11920-013-0382-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although concern has been raised about antipsychotic prescribing to youth with attention-deficit/hyperactivity disorder (ADHD), the available database is limited to individual studies. Therefore, in order to provide a synthesis of prevalence and time trends, we conducted a systematic review and pooled analysis of pharmaco-epidemiologic data on antipsychotic use in ADHD youth. Of 1806 hits, 21 studies (N) were retained that reported analyzable data for three separate populations: 1) antipsychotic-treated youth (N = 15, n = 341,586); 2) ADHD youth (N = 9, n = 6,192,368), and 3) general population youth (N = 5, n = 14,284,916). Altogether, 30.5 ± 18.5% of antipsychotic-treated youth had ADHD. In longitudinal studies, this percentage increased over time (1998-2007) from 21.7 ± 7.1% to 27.7 ± 7.7%, ratio = 1.3 ± 0.4. Furthermore, 11.5 ± 17.5% of ADHD youth received antipsychotics. In longitudinal studies, this percentage also increased (1998-2006) from 5.5 ± 2.6% to 11.4 ± 6.7%, ratio = 2.1 ± 0.6. Finally, 0.12 ± 0.07% of youth in the general population were diagnosed with ADHD and received antipsychotics. Again, in longitudinal studies, this percentage increased over time (1993-2007): 0.13 ± 0.09% to 0.44 ± 0.49%, ratio = 3.1 ± 2.2. Taken together, these data indicate that antipsychotics are used by a clinically relevant and increasing number of youth with ADHD. Reasons for and risk/benefit ratios of this practice with little evidence base require further investigation.
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Affiliation(s)
- Michael L. Birnbaum
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA
| | - Ema Saito
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA, Hofstra North Shore LIJ School of Medicine, Hempstead, New York, USA
| | - Tobias Gerhard
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ,Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ
| | - Almut Winterstein
- Department of Pharmaceutical Outcomes and Policy and Department of Epidemiology, University of Florida
| | - Mark Olfson
- New York State Psychiatric Institute/Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, New York, USA
| | - John M. Kane
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA, Hofstra North Shore LIJ School of Medicine, Hempstead, New York, USA,The Feinstein Institute for Medical Research, Manhasset, New York, USA,Albert Einstein College of Medicine, Bronx, New York, USA
| | - Christoph U. Correll
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA, Hofstra North Shore LIJ School of Medicine, Hempstead, New York, USA,The Feinstein Institute for Medical Research, Manhasset, New York, USA,Albert Einstein College of Medicine, Bronx, New York, USA
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Olanzapine treatment of adolescent rats alters adult reward behaviour and nucleus accumbens function. Int J Neuropsychopharmacol 2013; 16:1599-609. [PMID: 23351612 PMCID: PMC5819604 DOI: 10.1017/s1461145712001642] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Antipsychotic drugs are increasingly used in children and adolescents to treat a variety of psychiatric disorders. However, little is known about the long-term effects of early life antipsychotic drug (APD) treatment. Most APDs are potent antagonists or partial agonists of dopamine (DA) D₂ receptors; atypical APDs also have multiple serotonergic activities. DA and serotonin regulate many neurodevelopmental processes. Thus, early life APD treatment can, potentially, perturb these processes, causing long-term behavioural and neurobiological sequelae. We treated adolescent, male rats with olanzapine (Ola) on post-natal days 28-49, under dosing conditions that approximate those employed therapeutically in humans. As adults, they exhibited enhanced conditioned place preference for amphetamine, as compared to vehicle-treated rats. In the nucleus accumbens core, DA D₁ receptor binding was reduced, D₂ binding was increased and DA release evoked by electrical stimulation of the ventral tegmental area was reduced. Thus, adolescent Ola treatment enduringly alters a key behavioural response to rewarding stimuli and modifies DAergic neurotransmission in the nucleus accumbens. The persistence of these changes suggests that even limited periods of early life Ola treatment may induce enduring changes in other reward-related behaviours and in behavioural and neurobiological responses to therapeutic and illicit psychotropic drugs. These results underscore the importance of improved understanding of the enduring sequelae of paediatric APD treatment as a basis for weighing the benefits and risks of adolescent APD therapy, especially prophylactic treatment in high-risk, asymptomatic patients.
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Baeza I, Correll CU, Saito E, Amanbekova D, Ramani M, Kapoor S, Chekuri R, De Hert M, Carbon M. Frequency, characteristics and management of adolescent inpatient aggression. J Child Adolesc Psychopharmacol 2013; 23:271-81. [PMID: 23647136 PMCID: PMC3657279 DOI: 10.1089/cap.2012.0116] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Inpatient aggression is a serious challenge in pediatric psychiatry. METHODS A chart review study in adolescent psychiatric inpatients consecutively admitted over 24 months was conducted, to describe aggressive events requiring an intervention (AERI) and to characterize their management. AERIs were identified based on specific institutional event forms and/or documentation of as-needed (STAT/PRN) medication administration for aggression, both recorded by nursing staff. RESULTS Among 408 adolescent inpatients (age: 15.2±1.6 years, 43.9% male), 1349 AERIs were recorded, with ≥1 AERI occurring in 28.4% (n=116; AERI+). However, the frequency of AERIs was highly skewed (median 4, range: 1-258). In a logistical regression model, the primary diagnosis at discharge of disruptive behavior disorders and bipolar disorders, history of previous inpatient treatment, length of hospitalization, and absence of a specific precipitant prior to admission were significantly associated with AERIs (R(2)=0.32; p<0.0001). The first line treatment of patients with AERIs (AERI+) was pharmacological in nature (95.6%). Seclusion or restraint (SRU) was used at least once in 59.4% of the AERI+ subgroup (i.e., in 16.9% of all patients; median within-group SRU frequency: 3). Treatment and discharge characteristics indicated a poorer prognosis in the AERI+ (discharge to residential care AERI+: 22.8%, AERI-: 5.6%, p<0.001) and a greater need for psychotropic polypharmacy (median number of psychotropic medications AERI+: 2; AERI-: 1, p<0.001). CONCLUSIONS Despite high rates of pharmacological interventions, SRU continue to be used in adolescent inpatient care. As both of these approaches lack a clear evidence base, and as adolescents with clinically significant inpatient aggression have increased illness acuity/severity and service needs, structured research into the most appropriate inpatient aggression management is sorely needed.
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Affiliation(s)
- Immaculada Baeza
- Child and Adolescent Psychiatry and Psychology Department, CIBERSAM IDIBAPS, Hospital Clinic i Universitari, Barcelona, Spain
| | - Christoph U. Correll
- The Zucker Hillside Hospital, Department of Psychiatry Research, North Shore-Long Island Jewish Health System, Glen Oaks, New York
- Hofstra North Shore Long Island Jewish School of Medicine, East Meadow, and Nassau County University Hospital, Hempstead, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Ema Saito
- The Zucker Hillside Hospital, Department of Psychiatry Research, North Shore-Long Island Jewish Health System, Glen Oaks, New York
| | - Dinara Amanbekova
- The Zucker Hillside Hospital, Department of Psychiatry Research, North Shore-Long Island Jewish Health System, Glen Oaks, New York
| | - Meena Ramani
- Hofstra North Shore Long Island Jewish School of Medicine, East Meadow, and Nassau County University Hospital, Hempstead, New York
| | - Sandeep Kapoor
- The Zucker Hillside Hospital, Department of Psychiatry Research, North Shore-Long Island Jewish Health System, Glen Oaks, New York
| | - Raja Chekuri
- The Zucker Hillside Hospital, Department of Psychiatry Research, North Shore-Long Island Jewish Health System, Glen Oaks, New York
| | - Marc De Hert
- University Psychiatric Center, Catholic University Leuven, Kortenberg, Belgium
| | - Maren Carbon
- The Zucker Hillside Hospital, Department of Psychiatry Research, North Shore-Long Island Jewish Health System, Glen Oaks, New York
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Milstein JA, Elnabawi A, Vinish M, Swanson T, Enos JK, Bailey AM, Kolb B, Frost DO. Olanzapine treatment of adolescent rats causes enduring specific memory impairments and alters cortical development and function. PLoS One 2013; 8:e57308. [PMID: 23437365 PMCID: PMC3577739 DOI: 10.1371/journal.pone.0057308] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 01/21/2013] [Indexed: 01/31/2023] Open
Abstract
Antipsychotic drugs are increasingly used in children and adolescents to treat a variety of psychiatric disorders. However, little is known about the long-term effects of early life antipsychotic drug treatment. Most antipsychotic drugs are potent antagonists or partial agonists of dopamine D2 receptors; atypical antipsychotic drugs also antagonize type 2A serotonin receptors. Dopamine and serotonin regulate many neurodevelopmental processes. Thus, early life antipsychotic drug treatment can, potentially, perturb these processes, causing long-term behavioral- and neurobiological impairments. Here, we treated adolescent, male rats with olanzapine on post-natal days 28-49. As adults, they exhibited impaired working memory, but normal spatial memory, as compared to vehicle-treated control rats. They also showed a deficit in extinction of fear conditioning. Measures of motor activity and skill, habituation to an open field, and affect were normal. In the orbital- and medial prefrontal cortices, parietal cortex, nucleus accumbens core and dentate gyrus, adolescent olanzapine treatment altered the developmental dynamics and mature values of dendritic spine density in a region-specific manner. Measures of motor activity and skill, habituation to an open field, and affect were normal. In the orbital- and medial prefrontal cortices, D1 binding was reduced and binding of GABA(A) receptors with open Cl(-) channels was increased. In medial prefrontal cortex, D2 binding was also increased. The persistence of these changes underscores the importance of improved understanding of the enduring sequelae of pediatric APD treatment as a basis for weighing the benefits and risks of adolescent antipsychotic drug therapy, especially prophylactic treatment in high risk, asymptomatic patients. The long-term changes in neurotransmitter receptor binding and neural circuitry induced by adolescent APD treatment may also cause enduring changes in behavioral- and neurobiological responses to other therapeutic- or illicit psychotropic drugs.
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Affiliation(s)
- Jean A. Milstein
- Dept. of Pharmacology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Ahmed Elnabawi
- Dept. of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Monika Vinish
- Dept. of Pharmacology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Thomas Swanson
- Dept. of Pharmacology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Jennifer K. Enos
- Dept. of Pharmacology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Aileen M. Bailey
- Dept. of Psychology, St. Mary's College of Maryland, St. Mary's, Maryland, United States of America
| | - Bryan Kolb
- University of Lethbridge, Canadian Center for Behavioral Neuroscience, Lethbridge, Alberta, Canada
| | - Douglas O. Frost
- Dept. of Pharmacology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Dept. of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Program in Neuroscience, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
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Buchmann A, Hohmann S, Brandeis D, Banaschewski T, Poustka L. Aggression in children and adolescents. Curr Top Behav Neurosci 2013; 17:421-42. [PMID: 24362971 DOI: 10.1007/7854_2013_261] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Aggressive behaviour is a common phenomenon during childhood and adolescence, but at the same time it is an important associated feature of many psychiatric disorders during this age period. Persistent aggression is related to a variety of negative outcomes in adulthood, including low socioeconomic status and unemployment, criminal behaviour and social isolation. The great heterogeneity of aggressive behaviour still hampers our understanding of causal mechanisms. Still, over the past years, the identification of specific subtypes of aggression has opened possibilities for new and individualized treatment approaches. This article provides information on different subtypes of aggression in children and adolescents, on individual differences that contribute to aggression during development and on possible underlying processes related to aggressive behaviour in young people. Current treatment approaches as well as new emerging treatment possibilities are discussed.
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Affiliation(s)
- Arlette Buchmann
- Medical Faculty Mannheim, Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Heidelberg University, J5, 68159, Mannheim, Germany
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Pringsheim T, Gorman D. Second-generation antipsychotics for the treatment of disruptive behaviour disorders in children: a systematic review. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2012; 57:722-7. [PMID: 23228230 DOI: 10.1177/070674371205701203] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The use of second-generation antipsychotics (SGAs) in youth has increased considerably. Increases are mainly attributable to treatment of disruptive behaviour disorders (DBDs). Our objective was to review the evidence regarding the efficacy of SGAs for DBDs in youth. METHOD We performed a systematic review of all randomized controlled trials (RCTs) of SGAs and placebo for the treatment of DBDs in youth, focusing on efficacy data. RESULTS Eight RCTs in youth with DBDs were included. Five RCTs evaluated the use of risperidone in youth with the combination of subaverage-borderline IQ and disruptive behaviour-aggression. Single RCTs evaluated the use of risperidone for treatment-resistant aggression in attention-deficit hyperactivity disorder and for the treatment of conduct disorder (CD), and a single RCT evaluated the use of quetiapine for adolescent CD. The efficacy results of each of these studies are described. CONCLUSION Four placebo-controlled studies support the short-term efficacy of low-dose risperidone in youth with a subaverage IQ. Placebo-controlled evidence is weak or nonexistent for SGAs other than risperidone, and is weak in youth with an average IQ. Multiple factors likely account for the disconnect between this limited evidence base and the frequent use of SGAs for DBDs in clinical practice. These include extrapolation from studies in youth with autism or a subaverage IQ to normally developing youth; ease of SGA titration and the mistaken perception that little monitoring is required; unavailability of psychosocial treatments; limited familiarity with other pharmacological options; clinical and cultural norms; and the influence of the pharmaceutical industry.
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Affiliation(s)
- Tamara Pringsheim
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.
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Scotto Rosato N, Correll CU, Pappadopulos E, Chait A, Crystal S, Jensen PS. Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management. Pediatrics 2012; 129:e1577-86. [PMID: 22641763 DOI: 10.1542/peds.2010-1361] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To develop guidelines for management and treatment of maladaptive aggression in youth in the areas of psychosocial interventions, medication treatments, and side-effect management. METHODS Evidence was assembled and evaluated in a multistep process, including systematic reviews of published literature; an expert survey of recommended practices; a consensus conference of researchers, policymakers, clinicians, and family advocates; and review by the steering committee of successive drafts of the recommendations. The Center for Education and Research on Mental Health Therapeutics Treatment of Maladaptive Aggression in Youth guidelines reflect a synthesis of the available evidence, based on this multistep process. RESULTS This article describes the content, rationale, and evidence for 11 recommendations. Key treatment principles include considering psychosocial interventions, such as evidence-based parent and child skills training as the first line of treatment; targeting the underlying disorder first following evidence-based guidelines; considering individual psychosocial and medical factors, including cardiovascular risk in the selection of agents if medication treatment (ideally with the best evidence base) is initiated; avoiding the use of multiple psychotropic medications simultaneously; and careful monitoring of treatment response, by using structured rating scales, as well as close medical monitoring for side effects, including metabolic changes. CONCLUSIONS Treatment of children with maladaptive aggression is a "moving target" requiring ongoing assimilation of new evidence as it emerges. Based on the existing evidence, the Treatment of Maladaptive Aggression in Youth guidelines provide a framework for management of maladaptive aggression in youth, appropriate for use by primary care clinicians and mental health providers.
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Affiliation(s)
- Nancy Scotto Rosato
- State of New Jersey, Department of Health and Senior Services, Trenton, New Jersey, USA
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