Factors Associated with Developmental Behavioral Pediatricians Prescribing Psychotropic Medication to Children with Autism Spectrum Disorder: A Study of Three DBPNet Sites

State of the Evidence for Use of Psychotropic Medications in School-Age Youth

Psychotropic medications are commonly prescribed to school-aged youth for the management of mental health concerns. This paper describes the current state of evidence for psychotropic medications in school-aged youth. More specifically, the following sections summarize relevant medication research trials and practice parameters pertaining to psychotropic medication prescribing as well as the specific medications indicated for a range of commonly presenting disorders and symptom clusters in school-aged youth. For each of these disorders and symptom clusters, key findings pertaining to the current state of science and practice are highlighted for the purpose of offering patients, clinicians, researchers, and policymakers with nuanced considerations for the role of psychopharmacology within the context of a larger "whole-child" approach to care that relies on the collaboration of providers and services across systems of care to promote optimal child and family health and wellness. The paper concludes with a discussion about supporting the use of medication treatments in schools, including considerations for ensuring effective family-school-health system collaboration to best meet youth mental health needs.

A Retrospective Chart Review of Factors Impacting Psychotropic Prescribing Patterns and Polypharmacy Rates in Youth with Autism Spectrum Disorder during the COVID-19 Pandemic

High but variable rates of psychotropic polypharmacy (PP) in youth with autism spectrum disorder (ASD) have been reported in previous studies. The effect of the COVID-19 pandemic on prescribing patterns has not been well described. This study aims to examine the factors associated with psychotropic prescribing patterns, including rates of PP and multiclass polypharmacy (MPP) in youth with ASD during the COVID-19 pandemic. We examined the prescription records and clinical characteristics of youth aged between 3−21 years with a clinical diagnosis of ASD who were followed at an urban tertiary autism center psychiatry clinic between 1 January 2019, and 31 December 2020. For study purposes, we treated 2019 as the pre-pandemic year and 2020 as the pandemic year and compared the clinical characteristics of the “total clinic cohort (n = 898)” across two years. We examined the clinical characteristics of patients seen in both years (“paired-sample,” n = 473) and those seen only in 219 (“not-paired sample,” n = 378) to identify factors associated with the likelihood of patients’ return to clinic in 2020. As the total clinic cohort was a naturalistic sample containing duplicate patients, we created a separate data set by randomly assigning duplicate patients to one of the years (“random unique sample,” n = 898) and examined the clinical characteristics across two years. We defined PP and MPP broadly as the use of ≥2 unique medications (PP) and ≥2 unique medication classes (MPP) within a calendar year in this study. In the total clinic cohort, increased rates of PP (71.6% to 75.6%), MPP (61.9% to 67.8%, p = 0.027), and antidepressant prescriptions (56.9% to 62.9%, p = 0.028) were noted, although only the latter two were nominally significant. The paired-sample had a higher proportion of teens (31.0% vs. 39.7%, p < 0.001 and persons who self-identified as non-Hispanic (77.8% vs. 85.4%, p = 0.016)), higher rates of anxiety (78.9% vs. 48.7%, p < 0.001), ADHD (71.0% vs. 44.4%, p < 0.001), depression (23.9% vs. 13.0%, p < 0.001) and disruptive behavior (63.3% vs. 33.3%, p < 0.001) diagnoses, higher rates of antidepressants (63.4% vs. 48.7%, p < 0.001), ADHD medications (72.5% vs. 59.8%, p < 0.001), and antipsychotics (36.8% vs. 26.2%, p < 0.001) prescribed, and higher rates of PP (81.6% vs. 59.0%, p < 0.001) and MPP (71.0% vs. 50.5%, p < 0.001) than the not-paired sample. In the random unique sample, the patient group assigned to 2020 had higher rates of anxiety (75.0% vs. 60.2%, p < 0.001), ADHD (69.9% vs. 54.6%, p < 0.001), and disruptive behavior (57.9% vs. 45.4%, p < 0.001) diagnoses but the PP and MPP rates did not differ across years. Overall, we found high rates of PP and MPP, likely due to the broader definition of PP and MPP used in this study than those in other studies as well as the study site being a tertiary clinic. While our study suggests a possible impact of the COVID-19 pandemic on comorbidity rates and prescribing patterns, a replication study is needed to confirm how pandemic-related factors impact prescribing patterns and polypharmacy rates in youth with ASD.

Understanding the Diversity of Pharmacotherapeutic Management of ADHD With Co-occurring Autism: An Australian Cross-Sectional Survey

OBJECTIVES

Attention deficit hyperactivity disorder (ADHD) frequently co-occurs with other neurodevelopmental diagnoses, such as autism spectrum disorder (autism), which can make clinical decision making around symptom management challenging for clinicians. There is a paucity of research examining pharmacotherapeutic management of children who have ADHD with co-occurring diagnoses. We aimed to report on the co-occurring diagnoses and symptom profile of children, and report on medication use, stratified by ADHD, autism and ADHD + autism diagnoses.

METHODS AND MATERIALS

Caregivers of 505 children (2-18 years) with ADHD (n = 239), autism (n = 117), and co-occurring ADHD + autism (n = 149) completed a questionnaire on current medication use and clinical rating scales about their child's symptoms, as part of a broader project investigating diagnosis and management of symptoms in children with ADHD or autism.

RESULTS

The parents of the ADHD group reported a higher proportion of their children had learning disorders (17.15%) and speech and language disorders (4.60%) compared to the parents of the autism and ADHD + autism groups. Parents of the ADHD + autism group reported higher proportions of intellectual disability (5.37%), oppositional defiant disorder (20.13%), anxiety (38.93%), depression (6.71%) and genetic conditions (3.36%) in their children, in comparison to the parents of the ADHD and autism groups. Children with ADHD were reported to be taking a higher proportion of psychotropic medication (90%), followed by ADHD + autism (86%) and autism (39%). The parents of children with ADHD + autism reported a higher proportion of non-stimulant ADHD medication (25.5%), antipsychotic (18.79%), antidepressant (22.15%) and melatonin (31.54%) use by their children, compared to the parents of the ADHD and autism groups.

CONCLUSIONS

A similar proportion of children with ADHD + autism and ADHD were reported to be taking medication. However, the types of medication taken were different, as expected with reported co-occurring diagnoses. The complexity of symptoms and diagnoses in ADHD + autism warrants targeted research to optimize management and therapeutic outcomes.

Psychotropic Medication Prescribing for Youth at a Regional Autism Center

Objectives: The Seattle Children's Autism Center (SCAC) serves youth throughout Washington state (WA). The authors examined (1) whether the ethnicity and race of patients seen at the SCAC aligned with the demographics reported in the WA census, and (2) whether psychotropic medication prescriptions were associated with patient factors, including age, sex, ethnicity, race, insurance, visit number, and diagnoses. Methods: The authors extracted demographic and prescription data from electronic medical records for all patients (3-21 years) seen at the SCAC in 2018 for psychiatric medication evaluation in the context of autism spectrum disorder (ASD) and/or other related neurodevelopmental disorder (n = 1112), and used binary logistic regression to ascertain the effects of patient factors on psychotropic prescriptions. Results: The SCAC study sample appeared to align well with the WA census. Older age and higher visit number were among the most significant factors associated with psychotropic prescriptions. Psychotropic prescriptions increased with age, across all categories, except attention-deficit/hyperactivity disorder medications. There were no sex differences in prescribing rates. There were differences in prescribing rates by ethnicity and race. There were also increased prescription rates among those with Medicaid insurance. Conclusion: These demographic differences in prescribing for youth with ASD provide more specificity than prior studies about sex, ethnic, racial, and insurance-related differences, and can serve as an impetus to examine the reasons for variance.

Weight outcomes in children with developmental disabilities from a multidisciplinary clinic

BACKGROUND

Children with developmental disabilities experience disparately high rates of obesity yet there are few reports detailing clinical outcomes for this population.

AIM

To describe outcomes of obesity treatment for children with developmental disabilities and a comparison group of children without developmental disabilities.

METHODS AND PROCEDURES

We examined weight outcomes of children with and without developmental disabilities seen in a family-centered, multidisciplinary treatment center over a ten-year period. We stratified by age and developmental disability diagnosis. We assessed whether intake demographic or health behavior data was associated with successful reduction of adiposity over six and twelve month follow-up periods, using a ≥5% absolute reduction in percent over the 95th percentile body mass index (BMIp95) as the primary outcome.

OUTCOMES AND RESULTS

Over a ten-year period, 148 of 556 children in the obesity clinic (27 %) had a developmental disability. In children <12 years of age, 36 % of children with developmental disabilities reduced their adiposity compared with 18 % of children without developmental disabilities at six months, p = .01. This pattern continued at twelve months. Active transport to school was associated with reduced adiposity for those without a disability. Older children with disabilities rarely had a significant reduction (2 of 26 children), and they took more medications with weight-related side effects.

CONCLUSIONS AND IMPLICATIONS

Younger children with developmental disabilities experienced relative success in reducing their adiposity. Challenges to addressing obesity in this population include structural barriers to physical activity and medications for behavioral management with weight-related side effects.

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.

Young Children with Attention-Deficit/Hyperactivity Disorder and/or Disruptive Behavior Disorders Are More Frequently Prescribed Alpha Agonists Than Stimulants

Objective: To examine medication prescribing patterns for preschool-aged children with diagnoses of attention-deficit/hyperactivity disorder (ADHD) and/or disruptive behavior disorder (DBD). Secondary objectives included determining if prescription patterns varied by gender, insurance type, or comorbid diagnosis of autism spectrum disorder (ASD). Methods: A retrospective, cross-sectional chart review was completed for children ages 2-5 years who were treated at an academic medical center between 2013 and 2016 with a diagnosis of ADHD and/or DBD. Data were analyzed by Fisher's exact and chi-square tests and Cochran-Armitage trend analysis. Results: Of the 966 children who met inclusion criteria, 343 (35.5%) were prescribed ADHD medications. For 2-, 3-, and 4-year olds, the most commonly prescribed medication was an alpha agonist (AA), while for 5-year olds, methylphenidate (MPH) was most commonly prescribed. With advancing age, an increasing number of children were prescribed a stimulant medication and a decreasing number of children were prescribed an AA (p < 0.001). Children were more often prescribed an MPH formulation (48.2%) compared with amphetamine-based stimulants (26.8%). Children without ASD were more likely to be prescribed a stimulant medication (72.1%) when compared with children with ASD (37.0%, p < 0.0001). Children with private insurance were more likely to be prescribed an extended-release stimulant medication when compared with Medicaid patients (34.3% vs. 17.2%, p = 0.004). Conclusion: Both stimulants and nonstimulants are being prescribed regularly in very young children, even before the age of four at an academic medical center. AAs were the most commonly prescribed medication for children 2, 3, and 4 years of age with diagnoses of ADHD, DBD, and ASD. Insurance type, comorbid diagnosis of ASD, and age of child were found to be significantly associated with prescribing a nonpreferred medication.

Community-based service use in preschool children with autism spectrum disorder and associations with insurance status

BACKGROUND

ASD-related services can improve outcomes for children, but less is known about service outside of school settings during preschool age. We aimed to describe amount and category of community-based service use among 3-5-year-old children with ASD and examine differences by health insurance.

METHODS

We used cross-sectional data on 792 children with ASD diagnoses in the Study to Explore Early Development, a community-based study of neurodevelopment with enrollment between 2012-2016. Mothers reported current child service use and insurance status at study entry. We used log-Poisson and logistic regression to compare service use by insurance group.

RESULTS

Nearly 40% of children were not receiving community-based services at study entry. Children with public insurance had fewer total services than children with private or both insurances. After adjustment for sociodemographic confounders, insurance status was not associated with types of different categories of community-based services. However, children with public insurance alone were least likely to receive community-based behavioral therapy and most likely to receive psychotropic medication compared to other insurances.

CONCLUSION

Many preschool-aged children do not receive community-based services, with receipt associated with insurance type. Increasing access and availability for evidence-based service, especially for beneficiaries of public insurance, may improve service use and outcomes.

Common Use of Stimulants and Alpha-2 Agonists to Treat Preschool Attention-Deficit Hyperactivity Disorder: A DBPNet Study

OBJECTIVE

To describe the use of stimulants and alpha-2 agonists (A2As) for the treatment of preschool-aged children with attention-deficit hyperactivity disorder (ADHD) at 2 Developmental-Behavioral Pediatrics Research Network sites.

METHODS

Demographic information, diagnoses, and medications prescribed by developmental-behavioral pediatricians (DBPs) were extracted from the electronic health record for all outpatient visits from January 1, 2010, to December 31, 2011. The subset of visits for children aged 2 to 5 years who had a diagnosis of ADHD was included in this analysis. Multivariable models were constructed to identify factors associated with prescribing stimulants and A2As.

RESULTS

Over the 2-year period, 984 children with a diagnosis of ADHD were seen at 1779 visits. Of the 984 children, 342 (34.8%) were prescribed a stimulant, and 243 (24.7%) were prescribed an A2A. Both medications were prescribed at the same visit at least once during the 2-year period for 97 children (9.9%). Alpha-2 agonists were prescribed more often at site 2 than site 1 (OR [odds ratio] = 1.62, p = 0.015). Stimulants were more likely to be prescribed for older preschool-aged children (OR = 1.66, p < 0.001), and A2As were more likely to be prescribed for younger children (OR = 0.82, p = 0.02). Both stimulants and A2As were more likely to be prescribed to children with ADHD and comorbid conditions.

CONCLUSION

Alpha-2 agonists are commonly used by some DBPs for preschool ADHD. Variation in the use of A2As across sites may indicate a lack of consensus on when to use these medications and suggests a need for comparative effectiveness research to better define the relative benefits and side effects of A2As and stimulants for the treatment of preschool ADHD.