Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management

PROTOCOL: The efficacy of nutritional interventions in reducing childhood/youth aggressive and antisocial behavior: A systematic review and meta-analysis

This is a protocol for a Campbell systematic review of intervention effectiveness. The goal of this systematic review is to answer the following questions based on the available empirical evidence: Are there nutritional interventions (dietary manipulation, fortification or supplementation) that can reduce excessive aggression towards others in children/youth? If yes, how strong is their effect and is there a difference among the three intervention types? Are there nutritional interventions that can reduce antisocial behaviors in children/youth? If yes, how strong is their effect and is there a difference among the intervention types? Are there nutritional interventions that can reduce violent offending in children/youth? If yes, how strong is their effect and is there a difference among the intervention types? Are there nutritional interventions that can reduce non-violent offending in children/youth? If yes, how strong is their effect and is there a difference among the intervention types? What implementation barriers and solutions to these exist in relation to the above nutritional interventions in children/youth?

Randomized controlled trial of individualized arousal-biofeedback for children and adolescents with disruptive behavior disorders (DBD)

Disruptive behavior disorders [including conduct disorder (CD) and oppositional defiant disorder (ODD)] are common childhood and adolescent psychiatric conditions often linked to altered arousal. The recommended first-line treatment is multi-modal therapy and includes psychosocial and behavioral interventions. Their modest effect sizes along with clinically and biologically heterogeneous phenotypes emphasize the need for innovative personalized treatment targeting impaired functions such as arousal dysregulation. A total of 37 children aged 8-14 years diagnosed with ODD/CD were randomized to 20 sessions of individualized arousal biofeedback using skin conductance levels (SCL-BF) or active treatment as usual (TAU) including psychoeducation and cognitive-behavioral elements. The primary outcome was the change in parents´ ratings of aggressive behavior measured by the Modified Overt Aggression Scale. Secondary outcome measures were subscales from the Child Behavior Checklist, the Inventory of Callous-Unemotional traits, and the Reactive-Proactive Aggression Questionnaire. The SCL-BF treatment was neither superior nor inferior to the active TAU. Both groups showed reduced aggression after treatment with small effects for the primary outcome and large effects for some secondary outcomes. Importantly, successful learning of SCL self-regulation was related to reduced aggression at post-assessment. Individualized SCL-BF was not inferior to active TAU for any treatment outcome with improvements in aggression. Further, participants were on average able to self-regulate their SCL, and those who best learned self-regulation showed the highest clinical improvement, pointing to specificity of SCL-BF regulation for improving aggression. Further studies with larger samples and improved methods, for example by developing BF for mobile use in ecologically more valid settings are warranted.

Virtual Collaborative Behavioral Health Model in a Community Pediatric Network: Two-Year Outcomes

Due to the pervasive shortage of behavioral health (BH) specialists, collaborative partnerships between pediatric primary care practitioners (PPCPs) and BH specialists can enhance provision of BH services by PPCPs. We aimed to create a new model of collaborative care that was mostly virtual, affordable, and scalable. The pilot program was implemented in 18 practices (48 PPCPs serving approximately 150 000 patients) in 2 consecutive cohorts. Outcomes were assessed by administering pre-program and post-program surveys. Across the 18 practices, PPCPs reported significantly increased confidence in their BH knowledge and skills, and significantly increased their provision of target BH services. Barriers to BH service provision (resources, time, and staff) were unchanged. This compact, mostly virtual model of BH collaboration appears to be beneficial to PPCPs while also offering convenience to patients and affordability and scalability to the practice network.

Antipsychotic-Related Prolactin Levels and Sexual Dysfunction in Mentally Ill Youth: A 3-Month Cohort Study

OBJECTIVE

Although these agents are used frequently, prospective data comparing serotonin/dopamine antagonists/partial agonists (SDAs) in youth regarding prolactin levels and sexual adverse effects (SeAEs) are scarce.

METHOD

Youth aged 4 to 17 years, SDA-naive (≤1 week exposure) or SDA-free for ≥4 weeks were followed for ≤12 weeks on clinician's-choice aripiprazole, olanzapine, quetiapine, or risperidone. Serum prolactin levels, SDA plasma levels, and rating scale-based SeAEs were assessed monthly.

RESULTS

Altogether, 396 youth (aged 14.0 ± 3.1 years, male participants = 55.1%, mood spectrum disorders = 56.3%, schizophrenia spectrum disorders = 24.0%, aggressive-behavior disorders = 19.7%; SDA-naive = 77.8%) were followed for 10.6 ± 3.5 weeks. Peak prolactin levels/any hyperprolactinemia/triple-upper-limit-of-normal-prolactin level were highest with risperidone (median = 56.1 ng/mL/incidence = 93.5%/44.5%), followed by olanzapine (median = 31.4 ng/mL/incidence = 42.7/76.4%/7.3%), quetiapine (median = 19.5 ng/mL/incidence = 39.7%/2.5%) and aripiprazole (median = 7.1 ng/mL/incidence = 5.8%/0.0%) (all p < .0001), with peak levels at 4 to 5 weeks for risperidone and olanzapine. Altogether, 26.8% had ≥1 newly incident SeAEs (risperidone = 29.4%, quetiapine = 29.0%, olanzapine = 25.5%, aripiprazole = 22.1%, p = .59). The most common SeAEs were menstrual disturbance = 28.0% (risperidone = 35.4%, olanzapine = 26.7%, quetiapine = 24.4% aripiprazole = 23.9%, p = .58), decreased erections = 14.8% (olanzapine = 18.5%, risperidone = 16.1%, quetiapine = 13.6%, aripiprazole = 10.8%, p = .91) and decreased libido = 8.6% (risperidone = 12.5%, olanzapine = 11.9%, quetiapine = 7.9%, aripiprazole = 2.4%, p = .082), with the least frequent being gynecomastia = 7.8% (quetiapine = 9.7%, risperidone = 9.2%, aripiprazole = 7.8%, olanzapine = 2.6%, p = 0.61), galactorrhea = 6.7% (risperidone = 18.8%, quetiapine = 2.4%, olanzapine = 0.0%, aripiprazole = 0.0%, p = .0008), and mastalgia = 5.8% (olanzapine = 7.3%, risperidone = 6.4%, aripiprazole = 5.7%, quetiapine = 3.9%, p = .84). Postpubertal status and female sex were significantly associated with prolactin levels and SeAEs. Serum prolactin levels were rarely associated with SeAEs (16.7% of all analyzed associations), except for the relationship between severe hyperprolactinemia and decreased libido (p = .013) and erectile dysfunction (p = .037) at week 4, and with galactorrhea at week 4 (p = .0040), week 12 (p = .013), and last visit (p < .001).

CONCLUSION

Risperidone, followed by olanzapine, was associated with the largest prolactin elevations, with little prolactin-elevating effects of quetiapine and, especially, aripiprazole. Except for risperidone-related galactorrhea, SeAEs did not differ significantly across SDAs, and only galactorrhea, decreased libido, and erectile dysfunction were associated with prolactin levels. In youth, SeAEs are not sensitive markers for significantly elevated prolactin levels.

Antipsychotic Medication Use In Medicaid-Insured Children Decreased Substantially Between 2008 And 2016

After the rapid growth of pediatric antipsychotic prescribing in the early 2000s, especially in the Medicaid population, concerns regarding the safety and appropriateness of such prescribing increased. Many states implemented policy and educational initiatives aimed at safer and more judicious antipsychotic use. Antipsychotic use leveled off in the late 2000s, but there have been no recent national estimates of trends in antipsychotic use in children enrolled in Medicaid, and it is unclear how use varied by race and ethnicity. This study observed a sizable decline in antipsychotic use among children ages 2-17 between 2008 and 2016. Although the magnitude of change varied, declines were observed across foster care status, age, sex, and racial and ethnic groups studied. The proportion of children with an antipsychotic prescription who received any diagnosis associated with a pediatric indication that was approved by the Food and Drug Administration increased from 38 percent in 2008 to 45 percent in 2016, which may indicate a trend toward more judicious prescribing.

Adherence to antipsychotic laboratory monitoring guidelines in children and youth: a population-based study

Background

In 2011, the Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA) published guidelines for the metabolic monitoring of antipsychotic-treated children and youth. Population-based studies examining adherence to these guidelines are needed to ensure the safe use of antipsychotics in children and youth.

Methods

We conducted a population-based study of all Ontario residents aged 0 to 24 who were newly dispensed an antipsychotic between April 1, 2018, and March 31, 2019. We estimated prevalence ratios (PRs) and 95% confidence intervals (CI) associating sociodemographic characteristics with the receipt of baseline and follow-up (3- and 6-month) laboratory testing using log-Poisson regression models.

Results

Overall, 6,505 of 27,718 (23.5%) children and youth newly dispensed an antipsychotic received at least one guideline-recommended baseline test. Monitoring was more prevalent among individuals aged 10 to 14 years (PR 1.20; 95% CI 1.04 to 1.38), 15 to 19 years (PR 1.60; 95% CI 1.41 to 1.82), and 20 to 24 years (PR 1.71; 95% CI 1.50 to 1.94) compared to children under the age of 10. Baseline monitoring was associated with mental health-related hospitalizations or emergency department visits in the year preceding therapy (PR 1.76; 95% CI 1.65 to 1.87), a prior diagnosis of schizophrenia (PR 1.20; 95% CI 1.14 to 1.26) or diabetes (PR 1.35; 95% CI 1.19 to 1.54), benzodiazepine use (PR 1.13; 95% CI 1.04 to 1.24), and receipt of a prescription from a child and adolescent psychiatrist or developmental pediatrician versus a family physician (PR 1.41; 95% CI 1.34 to 1.48). Conversely, monitoring was less frequent in individuals co-prescribed stimulants (PR 0.83; 95% CI 0.75 to 0.91). The prevalence of any 3- and 6-month follow-up monitoring among children and youth receiving continuous antipsychotic therapy at these time points was 13.0% (1,179 of 9,080) and 11.4% (597 of 5,261), respectively. Correlates of follow-up testing were similar to those of baseline monitoring.

Conclusion

Most children initiating antipsychotic therapy do not receive guideline-recommended metabolic laboratory monitoring. Further research is needed to understand reasons for poor guideline adherence and the role of clinician training and collaborative service models in promoting best monitoring practices.

Clinical Update: Collaborative Mental Health Care for Children and Adolescents in Pediatric Primary Care

OBJECTIVE

The objective of this Clinical Update is to review the principles, structures, processes, and outcomes of collaborative mental health care in the pediatric primary care setting.

METHOD

A search of the literature on this topic from 2001was conducted initially in 2016, yielding 2,279 English-language citations. These citations were supplemented by references suggested by topic experts and identified through Web searches, increasing the yield to 2,467 total citations, of which 1,962 were unduplicated. After sequential review by Update authors at title/abstract and then full-text levels, the citations were winnowed to 219 based on topic relevance. A follow-up search from 2016 was conducted in 2021, yielding 2 additional citations based on nonduplication from initial search and topic relevance.

RESULTS

The collaborative care approach, arising in the 1990s and gaining momentum in the 2000s, aims to extend behavioral health care to the primary care setting. The goal of collaborative care is to conserve the sparse specialty care workforce for severe and complex psychiatric disorders through shifting certain specialty mental health tasks (eg, assessment; patient self-management; brief psychosocial intervention; basic psychopharmacology; care coordination) to primary care. Collaborative care can be delivered on a spectrum ranging from coordinated to co-located to integrated care. Although each of these models has some empirical support, integrated care-a multidisciplinary team-based approach-has the strongest evidence base in improving clinical outcomes and patient satisfaction while constraining costs. Challenges to integrated care implementation include insufficient mental health education and insufficient specialist consultative and care coordination support for primary care practitioners; space, time, and reimbursement constraints in the primary care setting; discomfort among primary care practitioners in assuming mental health tasks previously undertaken by specialists; and continuing need for and unavailability of ongoing specialty mental health care for severe and complex cases. Essential supporting activities for effective collaborative care include patient and family engagement, professional education and training, evaluation/demonstration of impact, fiscal sustainability, and advocacy for model dissemination.

CONCLUSION

Health professionals who are educated in the collaborative care approach can improve access to and quality of behavioral health care for children and adolescents with behavioral health needs.

Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry

Introduction

Agitation in children and adolescents in the emergency department (ED) can be dangerous and distressing for patients, family and staff. We present consensus guidelines for management of agitation among pediatric patients in the ED, including non-pharmacologic methods and the use of immediate and as-needed medications.

Methods

Using the Delphi method of consensus, a workgroup comprised of 17 experts in emergency child and adolescent psychiatry and psychopharmacology from the the American Association for Emergency Psychiatry and the American Academy of Child and Adolescent Psychiatry Emergency Child Psychiatry Committee sought to create consensus guidelines for the management of acute agitation in children and adolescents in the ED.

Results

Consensus found that there should be a multimodal approach to managing agitation in the ED, and that etiology of agitation should drive choice of treatment. We describe general and specific recommendations for medication use.

Conclusion

These guidelines describing child and adolescent psychiatry expert consensus for the management of agitation in the ED may be of use to pediatricians and emergency physicians who are without immediate access to psychiatry consultation.Reprinted from West J Emerg Med 2019; 20:409-418, with permission from the authors. Copyright © 2019.

Characteristics and Correlates of Metabolic Syndrome in Adolescents with Unipolar and Bipolar Depression: Results from a Cross-National Inpatient Case-Control Study

Abstract Objectives: To assess characteristics and correlates of metabolic syndrome (MetS) in adolescents with major depressive disorder (MDD) or bipolar disorder-depressive episode (BP-d). Methods: Case-control study, using national inpatient sample data, including adolescents (age, 12-18 years) with a primary diagnosis of MDD or BP-d. Using propensity score matching (based on age, sex, and race/ethnicity), we extracted cases with MetS (≥3 of the following conditions: obesity, diabetes, hypercholesterolemia, and hypertension) and controls without MetS. We used a multivariable logistic regression model calculating adjusted odds ratios (aORs) for potential correlates of MetS, focusing on primary mood disorders and psychiatric comorbidities. Results: In 607 age-/sex-/race/ethnicity-matched adolescents (MDD = 83.5%, BP-d = 16.5%), comparing those with (N = 332) versus without MetS (N = 275), MetS was most prevalent in later-age adolescents (mean age 16.3 years), females (58.1%), Whites (40.3%), and Blacks (31.5%). MetS was characterized by obesity (84.9% vs. 3.6%), hypertension (81% vs. 1.8%), diabetes (72.8% vs. 9.1%), and hypercholesterolemia (67.2% vs. 3.6%) (all p < 0.001). MetS was associated with a primary diagnosis of BP-d versus MDD (aOR 2.42, 95% confidence interval [CI] 1.47-3.97) and comorbid disruptive behavior disorders (DBD) (aOR 4.45, 95% CI 1.55-12.78), while comorbid substance use disorder reduced MetS risk (aOR 0.31, 95% CI 0.19-0.50). Conclusion: In adolescents with MDD or BP-d, MetS was associated with a primary BP-d diagnosis, and comorbid DBD. MetS-related parameters should be screened for early in adolescents with depression-spectrum disorders aiming to prevent the development or effects of MetS.

Pediatric Off-Label Antipsychotic Use for Attention-Deficit/Hyperactivity Disorder

PURPOSE

Off-label antipsychotic use for behavioral symptoms in pediatric attention-deficit/hyperactivity disorder (ADHD) poses safety concerns, and evidence to support such use is limited. This study aims to investigate the risk of off-label antipsychotic use associated with comorbid disruptive behavior disorder (DBD) among a cohort of youth with ADHD.

METHODS

A cohort study was conducted using IQVIA PharMetrics Plus for Academics data from 2007 to 2020. Youth 5 to 15 years of age at the index ADHD visit were included in the cohort. The index ADHD visit meets at least 1 of the following criteria: (1) 1 inpatient ADHD visit, (2) 2 outpatient ADHD visits within 90 days, or (3) an ADHD medication prescription fill within 30 days of an outpatient ADHD visit. We excluded youth who had a diagnosis of DBD or a US Food and Drug Administration (FDA)-approved indication for antipsychotics at baseline. Youth were followed up until antipsychotic initiation or were censored at a loss of coverage, receipt of an FDA-indicated diagnosis, or end of the study. A Cox proportional hazards regression model with DBD as a time-varying covariate estimated the hazard of antipsychotic use after the index ADHD visit.

FINDINGS

Of 41,098 youth with ADHD who met the study criteria, 4557 were diagnosed with DBD during follow-up. The incidence of antipsychotic initiation was 19.6 (95% CI, 18.7- 20.5) per 1000 person-years. After adjustment for baseline covariates, the hazard ratio of antipsychotic initiation associated with DBD was 4.64 (95% CI, 4.15-5.18).

IMPLICATIONS

Antipsychotic use among youth with ADHD is more likely in the presence of DBD, suggesting that an off-label use is for behavior problems.

Updates in Pharmacologic Strategies for Emotional Dysregulation in Attention Deficit Hyperactivity Disorder

Emotional dysregulation (ED) manifesting as irritability or aggression produces appreciable impairment in children with attention deficit hyperactivity disorder and a main reason why they present for treatment. Central nervous system (CNS) stimulants seem to be a safe and tolerable treatment of most youth with these presentations. Optimization of CNS stimulants dose in combination with psychosocial interventions led to reductions in ED. Randomized controlled trials support that addition of risperidone further reduces aggression when these treatments are not sufficient. There is evidence for the efficacy of divalproex, molindone and selective serotonin reuptake inhibitor improve these outcomes when used as adjunct to CNS stimulants.

The Complexity of Psychotropic Medication Prescription and Treating Trauma Among Youth in Foster Care: Perspectives from the Lived Experience

Youth in the US foster care system are disproportionately prescribed antipsychotic and psychotropic medication compared to youth not involved with foster care. Research on the relationship between experiences of trauma, mental health symptoms, evidence-based treatment, and safe psychotropic prescribing practices for youth in foster care is limited. We explored stakeholders' perspectives of the relationship between psychotropic medications and trauma informed care (TIC) for youth in foster care. We conducted semi-structured individual and group interviews with foster caregivers, caseworkers, prescribing clinicians, and alumni of the foster care system. Data were recorded and transcribed verbatim, and analyzed using a directed content analysis approach. Five themes emerged across and within stakeholder groups: (1) acknowledging trauma; (2) role of psychotropic medication; (3) psychosocial resources; (4) additional supports; and, (5) training and education. Stakeholders identified TIC as an important component of mental health services for youth in foster care. There was not consensus around the role of psychotropic medication in treating trauma; however, most stakeholders felt that it was overused. Respondents suggested including additional supportive team members to help guide youth through the mental health treatment system, and emphasized the importance of support from individuals with common lived experiences. Results demonstrate the need for a system that emphasizes trauma-sensitive clinical interactions and psychosocial supports. Improving training and education for stakeholders, and providing additional sources of support for youth in foster care, could help better identify and treat the effects of trauma and the safe pharmacotherapy for youth in foster care.

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

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.

Implementation and evaluation of a curriculum on the assessment and treatment of disruptive behaviour disorders

Disruptive behaviour disorders (DBDs)—which can include or be comorbid with disorders such as attention-deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder and disruptive mood dysregulation disorder—are commonly seen in paediatric practice. Given increases in the prescribing of atypical antipsychotics for children and youth, it is imperative that paediatric trainees in Canada receive adequate education on the optimal treatment of DBDs. We describe the development, dissemination, and evaluation of a novel paediatric resident curriculum for the assessment and treatment of DBDs in children and adolescents. Pre–post-evaluation of the curriculum showed improved knowledge in participants.

Closing the gap: unmet needs of individuals with impulsive aggressive behavior observed in children and adolescents

Impulsive aggressive (IA, or impulsive aggression) behavior describes an aggregate set of maladaptive, aggressive behaviors occurring across multiple neuropsychiatric disorders. IA is reactive, eruptive, sudden, and unplanned; it provides information about the severity, but not the nature, of its associated primary disorder. IA in children and adolescents is of serious clinical concern for patients, families, and physicians, given the detrimental impact pediatric IA can have on development. Currently, the ability to properly identify, monitor, and treat IA behavior across clinical populations is hindered by two major roadblocks: (1) the lack of an assessment tool designed for and sensitive to the set of behaviors comprising IA, and (2) the absence of a treatment indicated for IA symptomatology. In this review, we discuss the clinical gaps in the approach to monitoring and treating IA behavior, and highlight emerging solutions that may improve clinical outcomes in patients with IA.

A Double-Blind, Randomized Study of Extended-Release Molindone for Impulsive Aggression in ADHD

Objective: To evaluate efficacy and safety of SPN-810 (extended-release molindone) in a Phase-2b, randomized, double-blind, placebo-controlled, dose-ranging study of children (6-12 years) with ADHD and persistent impulsive aggression (IA). Method: After lead-in, children were randomized to (a) placebo (N = 31); (b) low-dose (N = 29, 12/18 mg/day); (c) medium-dose (N = 30, 24/36 mg/day); and (4) high-dose (N = 31, 36/54 mg/day) groups. Treatment included ~2.5-week titration, 3-week maintenance, and 1-week tapering/conversion, alongside existing monotherapy (stimulants/nonstimulants) and behavioral therapy. The primary endpoint was change in Retrospective-Modified Overt Aggression Scale (R-MOAS) score at end of study, with safety monitored. Results: A total of 95 (78.5%) children completed the study. Aggression (R-MOAS) improved with low and medium doses (low dose: p = .031; medium dose: p = .024; high dose: p = .740). The most common adverse events were headache (10.0%), sedation (8.9%), and increased appetite (7.8%). Conclusion: These results suggest SPN-810 may be effective in reducing residual IA behaviors in children with ADHD. Research is still needed to support the benefit-risk profile of SPN-810 in pediatric populations.

Practitioner's review: medication for children and adolescents with autism spectrum disorder (ASD) and comorbid conditions

Alleviating the multiple problems of children with autism spectrum disorder (ASD) and its comorbid conditions presents major challenges for the affected children, parents, and therapists. Because of a complex psychopathology, structured therapy and parent training are not always sufficient, especially for those patients with intellectual disability (ID) and multiple comorbidities. Moreover, structured therapy is not available for a large number of patients, and pharmacological support is often needed, especially in those children with additional attention deficit/hyperactivity and oppositional defiant, conduct, and sleep disorders.

Five-Phase Replication of Behavioral Health Integration in Pediatric Primary Care

BACKGROUND AND OBJECTIVES

Because of severe and protracted shortages of pediatric behavioral health (BH) specialists, collaboration between pediatric primary care practitioners (PCPs) and BH specialists has the potential to increase access to BH services by expanding the BH workforce. In a previous study, we demonstrated that phase 1 of a behavioral health integration program (BHIP) enrolling 13 independently owned, community-based pediatric practices was associated with increased access to BH services while averting substantial cost increases and achieving high provider self-efficacy and professional satisfaction. The current study was undertaken to assess whether the initial access findings were replicated over 4 subsequent implementation phases and to explore the practicality of broad dissemination of the BHIP model.

METHODS

After phase 1, BHIP was extended over 4 subsequent phases in a stepped-wedge design to 46 additional pediatric practices, for a total cohort of 59 practices (354 PCPs serving >300 000 patients). Program components comprised BH education and consultation and support for integrated practice transformation; these components facilitated on-site BH services by an interprofessional BH team. Outcomes were assessed quarterly, preprogram and postprogram launch.

RESULTS

Across combined phases 1 to 5, BHIP was associated with increased primary care access to BH services (screening, psychotherapy, PCP BH visits, psychotropic prescribing) and performed well across 7 standard implementation outcome domains (acceptability, appropriateness, feasibility, fidelity, adoption, penetration, and sustainability). Emergency BH visits and attention-deficit/hyperactivity disorder prescribing were unchanged.

CONCLUSIONS

These findings provide further support for the potential of integrated care to increase access to BH services in pediatric primary care.

Trends in Antipsychotic Medication Use in Young Privately Insured Children

OBJECTIVE

To estimate trends of annual antipsychotic medication use by privately insured young children (aged 2-7 years) in the United States, and to describe the clinical and treatment characteristics of these children.

METHOD

The study population included young children from a nationwide commercial claims database (2007-2017). We estimated annual antipsychotic use by age and sex, defined as the number of children dispensed an antipsychotic per year divided by the number enrolled. We described clinical diagnoses and mental health service use in those with prescription antipsychotic use in 2009 and 2017.

RESULTS

Annual antipsychotic use in young children was 0.27% in 2007, peaked at 0.29% in 2009, and statistically significantly declined to 0.17% by 2017 (linear trend: -0.017% per year, 95% CI: -0.018 to -0.016). Antipsychotic use was higher in boys than in girls. A greater proportion of antipsychotic users received a mental disorder diagnosis in 2017 (89%) than in 2009 (86%, p < .01). The most common clinical diagnoses in antipsychotic users, under a hierarchical classification, were pervasive developmental disorder (2009 = 27%, 2017 = 38%, p < .01), conduct or disruptive behavior disorder (2009 = 15%, 2017 = 21%, p < .01), and attention-deficit/hyperactivity disorder (2009 = 24%, 2017 = 18%, p < .01). Among 2017 antipsychotic users, 32% had 4+ psychotherapy claims, 43% had a psychiatrist visit, and the majority used another psychotropic medication, most commonly a stimulant (boys = 57%, girls = 50%).

CONCLUSION

In privately insured young children, antipsychotic use declined from 2009 to 2017, with shifts toward indications with some supporting evidence. Nevertheless, a majority of use remains off label and for conditions lacking effectiveness and safety data. Improving antipsychotic prescribing in young children remains a challenge.

Psychopharmacology of Treating Explosive Behavior

Explosive and aggressive behavior in children can pose safety risks, disturb family functioning, and lead to significant impairments. Pharmacologic management should be based on the first-line treatment of the primary psychiatric diagnoses of the patient and initiated in combination with appropriate psychosocial interventions. Review of the literature suggests that risperidone has the most supporting evidence in the treatment of explosive behavior. Stimulants have been shown to be helpful in the treatment of explosive behavior in attention-deficit/hyperactivity disorder. Medication treatment can be associated with significant side effects and therefore the risks and benefits of medication management must be weighed carefully.

Efficacy and acceptability of pharmacological, psychosocial, and brain stimulation interventions in children and adolescents with mental disorders: an umbrella review

Top-tier evidence on the safety/tolerability of 80 medications in children/adolescents with mental disorders has recently been reviewed in this jour-nal. To guide clinical practice, such data must be combined with evidence on efficacy and acceptability. Besides medications, psychosocial inter-ventions and brain stimulation techniques are treatment options for children/adolescents with mental disorders. For this umbrella review, we systematically searched network meta-analyses (NMAs) and meta-analyses (MAs) of randomized controlled trials (RCTs) evaluating 48 medications, 20 psychosocial interventions, and four brain stimulation techniques in children/adolescents with 52 different mental disorders or groups of mental disorders, reporting on 20 different efficacy/acceptability outcomes. Co-primary outcomes were disease-specific symptom reduction and all-cause discontinuation ("acceptability"). We included 14 NMAs and 90 MAs, reporting on 15 mental disorders or groups of mental disorders. Overall, 21 medications outperformed placebo regarding the co-primary outcomes, and three psychosocial interventions did so (while seven outperformed waiting list/no treatment). Based on the meta-analytic evidence, the most convincing efficacy profile emerged for amphetamines, methylphenidate and, to a smaller extent, behavioral therapy in attention-deficit/hyperactivity disorder; aripiprazole, risperidone and several psychosocial interventions in autism; risperidone and behavioral interventions in disruptive behavior disorders; several antipsychotics in schizophrenia spectrum disorders; fluoxetine, the combination of fluoxetine and cognitive behavioral therapy (CBT), and interpersonal therapy in depression; aripiprazole in mania; fluoxetine and group CBT in anxiety disorders; fluoxetine/selective serotonin reuptake inhibitors, CBT, and behavioral therapy with exposure and response prevention in obsessive-compulsive disorder; CBT in post-traumatic stress disorder; imipramine and alarm behavioral intervention in enuresis; behavioral therapy in encopresis; and family therapy in anorexia nervosa. Results from this umbrella review of interventions for mental disorders in children/adolescents provide evidence-based information for clinical decision making.

Attention-Deficit Hyperactivity Disorder and the Dysregulation of Emotion Generation and Emotional Expression

Individuals with attention-deficit/hyperactivity disorder (ADHD) frequently experience strong reactions to emotionally evocative situations. Difficulties modulating anger and other upsets have clinically significant behavioral consequences. Those with ADHD may have anomalies in emotion generation, emotion expression, or both that predispose to these problems. The association between ADHD and emotion dysregulation raises Important clinical and research issues, including possible heterogeneity in the mechanisms by which they are related. Although first-line treatments for ADHD often help to resolve emotional dysregulation symptoms as well, the evidence base for widespread practice of combination pharmacotherapy remains sparse. Psychosocial treatments that engage processes underlying emotional dysregulation are in development.

Editorial: Why JAACAP Published an "Inconclusive" Trial: Optimize, Optimize, Optimize Psychostimulant Treatment

In this issue of the Journal, Blader et al.¹ report the results of a double-blind randomized controlled trial (RCT) aimed at assessing the comparative efficacy and tolerability of adjunctive risperidone (RISP), valproex sodium (DVPX), or placebo for aggressive behaviors in children (aged 6-12 years) with attention-deficit/hyperactivity disorder (ADHD) and comorbid oppositional defiant disorder (ODD) or conduct disorder (CD), as well as a prior history of psychostimulant treatment. Participants with aggressive symptoms persisting after an open-label optimization of psychostimulant medication entered the 8-week randomized phase. Weekly sessions of family-based behavioral treatment were offered during both the optimization and the randomized phases. Among the 151 participants who completed the optimization phase (175 were initially enrolled), an unexpected 63.6% met the study criteria for remission, that is, 3 consecutive weeks with subthreshold scores on the Retrospective-Modified Overt Aggression Scale (R-MOAS). Therefore, only 45 participants were eligible for randomization, and 40 (RISP: n = 17; DVPX: n = 14; placebo: n = 9) were included in the primary analysis. Why did JAACAP publish an inconclusive trial? Because, in our view, the lessons that can be learned from this RCT (in particular, from its optimization phase) are highly relevant for both clinicians and trialists in the field. We are confident that the Blader et al. study will contribute to make clinicians in the field more "optimizers" and trialists more "transparent."

Stepped Treatment for Attention-Deficit/Hyperactivity Disorder and Aggressive Behavior: A Randomized, Controlled Trial of Adjunctive Risperidone, Divalproex Sodium, or Placebo After Stimulant Medication Optimization

OBJECTIVE

Stimulant medications are the most prevalent first-line pharmacotherapy for attention-deficit/hyperactivity disorder, but children with aggressive behavior often receive multiagent treatment. There is sparse evidence for the benefits of adjunctive medications when stimulant monotherapy provides inadequate benefit for aggressive behavior, yet the adverse effects of common adjuncts are well established. This study compared the efficacy in reducing aggressive behavior of risperidone (RISP), divalproex sodium (DVPX), and placebo (PBO) added to stimulant medication among childrenwhose symptoms persisted after individually optimized stimulant treatment.

METHOD

This trial enrolled 6- to 12-year-old with attention-deficit/hyperactivity disorder, a disruptive disorder, significant aggressive behavior, and prior stimulant treatment. Open, systematically titrated stimulant treatment identified patients with inadequate reductions in aggressive behavior, who were then randomly assigned to receive adjunctive RISP, DVPX, or PBO under double-blinded conditions for 8 weeks. Family-based behavioral treatment was offered throughout the trial. The primary outcome was the parent-completed Retrospective Modified Overt Aggression Scale.

RESULTS

Participants included 175 children (mean [SD] age 9.48 [2.04] years, 19% female). Of participants, 151 completed the stimulant optimization phase, with aggression remitting among 96 (63%), and 45 were randomly assigned to adjunctive treatment groups. The adjunctive RISP group showed greater reductions in aggression ratings than the PBO group (least squares means difference [ΔLSM], -2.33; 95% CI, -3.83 to -0.82; effect size [ES], -1.32), as did the DVPX group (ΔLSM, -1.60; 95% CI, -3.18 to -0.03; ES, -0.91). Mean standardized body mass index scores increased more among RISP-treated participants than participants receiving PBO (ΔLSM, 1.54; 95% CI, 0.68 to 2.40; ES, 0.58).

CONCLUSION

High response rate during the trial's open stimulant optimization phase suggests that rigorous titration of stimulant medication and concurrent behavioral therapy may avert the need for additional medications. Among nonremitters, RISP and DVPX were efficacious adjunctive treatments, although RISP was associated with weight gain.

CLINICAL TRIAL REGISTRATION INFORMATION

Effectiveness of Combined Medication Treatment for Aggression in Children With Attention Deficit With Hyperactivity Disorder (The SPICY Study); https://www.clinicaltrials.gov; NCT00794625.

Systematic Review: System-wide Interventions to Monitor Pediatric Antipsychotic Prescribing and Promote Best Practice

OBJECTIVE

Rapid growth of antipsychotic use among children and adolescents at the turn of the 21st century led Medicaid programs to implement 3 types of system-wide interventions: antipsychotic monitoring programs, clinician prescribing supports, and delivery system enhancements. This systematic review assessed the available evidence base for and relative merits of these system-wide interventions that aim to improve antipsychotic treatment and management.

METHOD

Using PRISMA guidelines, eligible studies were written in English and evaluated system-wide interventions to monitor antipsychotic treatment or promote antipsychotic management among children and adolescents (0-21 years of age). Studies were identified through Ovid MEDLINE and PsychInfo (years 1990-2018) and an environmental scan. From an initial review of 824 publications, 17 studies met eligibility criteria. Two authors independently conducted quality assessments using the Crowe Critical Appraisal Tool. Findings were summarized descriptively.

RESULTS

Identified studies (n = 17) evaluated prior authorization programs (n = 10), drug utilization reviews (n = 2), quality improvement (n = 4), care coordination programs (n = 1), and multimodal initiatives (n = 2). Studies were predominantly pre-post analyses, without a comparison group. With the exception of care coordination and drug utilization reviews, more than half of the interventions in each category were associated with significant reduction in antipsychotic treatment or promotion of best practice parameters.

CONCLUSION

This evidence review concludes that evaluations of prior authorization programs demonstrate reductions in antipsychotic treatment, though evidence of impact of other system-wide interventions and other outcomes is limited. Additional research is necessary to investigate whether interventions influenced antipsychotic prescribing independent of secular trends, the comparative effectiveness and cost-effectiveness of interventions, the effect on functional outcomes, and the potential for unintended consequences.

Guideline Adherence of Monitoring Antipsychotic Use for Nonpsychotic Indications in Children and Adolescents: A Patient Record Review

BACKGROUND

Antipsychotics are frequently prescribed to children and adolescents for nonpsychotic indications. Guidelines recommend regularly assessing treatment response and adverse effects and the ongoing need for their use. We aimed to assess adherence to recommendations of available guidelines regarding monitoring antipsychotic use and to test the influence of children's age, sex, intelligence quotient, and diagnosis on adherence.

METHODS

We reviewed 426 medical records from 26 centers within 3 large Dutch child and adolescent psychiatry organizations, excluding children with schizophrenia, psychosis, mania, or an intelligence quotient below 70. We investigated whether there was regular assessment of treatment response, adverse events (physical and laboratory), and at least annual discussion of the need of continued use.

RESULTS

On average, treatment response was assessed in 69.3% of the recommended treatment periods, height in 25.6%, weight in 30.6%, blood pressure in 20.6%, evaluation of adverse events in 19.4%, and cardiometabolic measures in 13.7%; discontinuation and/or continued need was discussed at least annually in 36.2%. Extrapyramidal and prolactin-related adverse effects, waist circumference, glucose, and lipids were rarely investigated. Higher age was associated with lower rates of assessment of treatment response. Most antipsychotics were prescribed long-term. In those children with sufficient documentation of the course of treatment, 57.7% was still using an antipsychotic 3 years after initiation.

CONCLUSIONS

Our findings indicate insufficient adherence to guideline recommendations for monitoring antipsychotic use in children and adolescents, as well as long duration of use in the majority of children. Especially, older children are at higher risk of receiving suboptimal care.

A best-worst scaling experiment to identify patient-centered claims-based outcomes for evaluation of pediatric antipsychotic monitoring programs

Objective

This article employs a best‐worst scaling (BWS) experiment to identify the claims‐based outcomes that matter most to patients and other relevant parties when evaluating pediatric antipsychotic monitoring programs in the United States.

Data Sources

Patients and relevant parties, with pediatric antipsychotic oversight and treatment experience, completed a BWS experiment, including policymakers (n = 31), foster care alumni (n = 28), caseworkers (n = 23), prescribing clinicians (n = 32), and caregivers (n = 18).

Study Design

Respondents received surveys with a scenario on antipsychotic monitoring programs and ranked 11 candidate claims‐based outcomes as most and least important for program evaluation.

Data Analysis

Stratified by respondent group, best‐worst scores were calculated to identify the relative importance of the claims‐based outcomes. A conditional logit examined whether candidate outcomes for safety, quality, and unintended consequences were preferred over reduction in antipsychotic treatment, the outcome used most often to evaluate antipsychotic monitoring programs.

Principal Findings

Safety indicators (eg, antipsychotic co‐pharmacy, cross‐class polypharmacy, higher than recommended doses) ranked among the top three candidate outcomes across respondent groups and were an important complement to antipsychotic treatment reduction. Foster care alumni prioritized “antipsychotic treatment reduction” and “increased psychosocial treatment.” Caseworkers, prescribers, and caregivers prioritized “increased follow‐up after treatment initiation.” Potential unintended consequences of an antipsychotic monitoring program ranked lowest, including increased use of other psychotropic medication classes (as a substitute), increased psychiatric hospital stays, and increased emergency room utilization. Results of the conditional logit model found only caregivers significantly preferred other indicators over antipsychotic treatment reduction, preferring improvements in follow‐up care (5.78) and psychosocial treatment (4.53) and reduction in prescriptions of higher than recommended doses (3.64).

Conclusions

The BWS experiment supported rank ordering of candidate claims‐based outcomes demonstrating the opportunity for future studies to align outcomes used in antipsychotic monitoring program evaluations with community preferences, specifically by diversifying metrics to include safety and quality indicators.

Competency of Future Pediatricians Caring for Children With Behavioral and Mental Health Problems

BACKGROUND AND OBJECTIVES

There is an urgent need to prepare pediatricians to care for children with behavioral and mental health (B/MH) conditions. In this study, we evaluate the perceived competence of pediatric residents and recent graduates in the assessment and treatment of B/MH conditions, characterize variation in competence across residency programs, and identify program characteristics associated with high competence.

METHODS

Cross-sectional survey of applicants for the initial certifying examination in pediatrics. Questions were focused on (1) who should be competent in B/MH skills, (2) institutional support around B/MH training, and (3) perceived competence in 7 B/MH assessment skills and 9 treatment skills. Competence was rated on a 5-point scale, and high levels of assessment and treatment competence were defined as scores of ≥4. Composite measures for B/MH assessment and treatment were calculated as mean scores for each domain. We examined variation in residents' self-reported competence across programs and used linear regression to identify factors associated with high levels of competence at the program level.

RESULTS

Of applicants, 62.3% responded to the survey (n = 2086). Of these, 32.8% (n = 595) reported high competence in assessment skills and 18.9% (n = 337) in treatment skills. There were large variations in reported competence across programs. Respondents from smaller programs (<30 trainees) reported higher competence in assessment and treatment than those from large programs (P < .001).

CONCLUSIONS

Current and recent pediatric trainees do not report high levels of perceived competence in the assessment and treatment of children with B/MH conditions. The substantial variation across programs indicates that the pediatric community should create standards for B/MH training.

Prescribing antipsychotics in child and adolescent psychiatry: guideline adherence

Antipsychotics are often prescribed to children and adolescents, mostly off-label. We aimed to assess adherence to recommendations of guidelines for antipsychotic prescription. We reviewed 436 medical records from 155 clinicians from 26 clinics within three Dutch child and adolescent psychiatry organizations (n = 398 outpatient, n = 38 inpatient care). We assessed target symptoms, diagnostic process, prior and concomitant treatment, and consideration of contra-indications. Multiple logistic regression assessed the role of age, sex, and psychiatric diagnosis on adherence to three main recommendations: to (1) prescribe antipsychotics only after other treatments proved insufficient, (2) always combine antipsychotics with psychosocial interventions, and (3) not prescribe multiple antipsychotics simultaneously. Most patients received off-label antipsychotics. Main target symptoms were inattention/hyperactivity (25%), aggression (24%), and other disruptive behaviors (41%). Most patients underwent diagnostic evaluation before the first prescription; however, screening of contra-indications was low (0.2-19%). About 84% had previously received psychosocial treatment and 48% other psychoactive medication, but 9% had not received any treatment. Notably, only 37% continuously received concomitant psychosocial treatment. Simultaneous use of multiple antipsychotics occurred in 3.2%. Younger children were at higher risk of non-adherence to guideline recommendations regarding prior and concomitant treatment, children with autism spectrum disorder or attention-deficit/hyperactivity disorder more likely not to receive concomitant psychosocial treatment. Sex did not significantly affect adherence. Our findings implicate insufficient adherence to important recommendations regarding antipsychotic use in children and adolescents. Especially younger children are at higher risk of receiving suboptimal care. There is an urgency to consistently offer psychosocial interventions during antipsychotic treatment.

Screening for drugs to reduce zebrafish aggression identifies caffeine and sildenafil

Although aggression is a common symptom of psychiatric disorders the drugs available to treat it are non-specific and can have unwanted side effects. In this study we have used a behavioural platform in a phenotypic screen to identify drugs that can reduce zebrafish aggression without affecting locomotion. In a three tier screen of ninety-four drugs we discovered that caffeine and sildenafil can selectively reduce aggression. Caffeine also decreased attention and increased impulsivity in the 5-choice serial reaction time task whereas sildenafil showed the opposite effect. Imaging studies revealed that both caffeine and sildenafil are active in the zebrafish brain, with prominent activation of the thalamus and cerebellum evident. They also interact with 5-HT neurotransmitter signalling. In summary, we have demonstrated that juvenile zebrafish are a suitable model to screen for novel drugs to reduce aggression, with the potential to uncover the neural circuits and signalling pathways that mediate such behavioural effects.

Understanding Chronic Aggression and Its Treatment in Children and Adolescents

PURPOSE OF REVIEW

Youth aggression is common and has a significant burden on individuals, families, and society. However, its treatment is often a challenge for clinicians. Thus, this review will examine the current understanding of youth aggression, conceptualize aggression as a symptom rather than its own disorder, and provide an overview of treatment strategies.

RECENT FINDINGS

Youth aggression is associated with complex genetic, neurobiological, and environmental risks. Prevention strategies are of the utmost importance for at-risk families and youth. Psychosocial interventions are the first line treatment. But if not fully effective, then pharmacologic interventions-including psychostimulants, alpha-2 agonists, atomoxetine, and risperidone-have shown benefits. Other medications, such as SSRIs, can be useful in certain scenarios. It is important to conceptualize youth aggression as being a trans-diagnostic symptom in psychopathology. Determining the underlying cause of aggression will help to guide treatment.

Mental Health Competencies for Pediatric Practice

Pediatricians have unique opportunities and an increasing sense of responsibility to promote healthy social-emotional development of children and to prevent and address their mental health and substance use conditions. In this report, the American Academy of Pediatrics updates its 2009 policy statement, which proposed competencies for providing mental health care to children in primary care settings and recommended steps toward achieving them. This 2019 policy statement affirms the 2009 statement and expands competencies in response to science and policy that have emerged since: the impact of adverse childhood experiences and social determinants on mental health, trauma-informed practice, and team-based care. Importantly, it also recognizes ways in which the competencies are pertinent to pediatric subspecialty practice. Proposed mental health competencies include foundational communication skills, capacity to incorporate mental health content and tools into health promotion and primary and secondary preventive care, skills in the psychosocial assessment and care of children with mental health conditions, knowledge and skills of evidence-based psychosocial therapy and psychopharmacologic therapy, skills to function as a team member and comanager with mental health specialists, and commitment to embrace mental health practice as integral to pediatric care. Achievement of these competencies will necessarily be incremental, requiring partnership with fellow advocates, system changes, new payment mechanisms, practice enhancements, and decision support for pediatricians in their expanded scope of practice.

Maladaptive Aggression: With a Focus on Impulsive Aggression in Children and Adolescents

Objective: Aggressive behavior is among the most common reasons for referral to psychiatric clinics and confers significant burden on individuals. Aggression remains poorly defined; there is currently no consensus on the best ways to recognize, diagnose, and treat aggression in clinical settings. In this review, we synthesize the available literature on aggression in children and adolescents and propose the concept of impulsive aggression (IA) as an important construct associated with diverse and enduring psychopathology. Methods: Articles were identified and screened from online repositories, including PubMed, PsychInfo, the Cochrane Database, EMBase, and relevant book chapters, using combinations of search terms such as "aggression," "aggressive behavio(u)r," "maladaptive aggression," "juvenile," and "developmental trajectory." These were evaluated for quality of research before being incorporated into the article. The final report references 142 sources, published from 1987 to 2019. Results: Aggression can be either adaptive or maladaptive in nature, and the latter may require psychosocial and biomedical interventions when it occurs in the context of central nervous system psychopathology. Aggression can be categorized into various subtypes, including reactive/proactive, overt/covert, relational, and IA. IA in psychiatric or neurological disorders is reviewed along with current treatments, and an algorithm for systematic evaluation of aggression in the clinical setting is proposed. Conclusions: IA is a treatable form of maladaptive aggression that is distinct from other aggression subtypes. It occurs across diverse psychiatric and neurological diagnoses and affects a substantial subpopulation. IA can serve as an important construct in clinical practice and has considerable potential to advance research.

Antipsychotic Treatment Among Youths With Attention-Deficit/Hyperactivity Disorder

IMPORTANCE

Significant concern exists over treating youths with attention-deficit/hyperactivity disorder (ADHD) with antipsychotic medications, yet little is known about the factors associated with antipsychotic treatment.

OBJECTIVES

To describe the percentage of youths who fill antipsychotic prescriptions in the year following a new diagnosis of ADHD and characterize the clinical and demographic factors associated with antipsychotic initiation.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective longitudinal cohort analysis of antipsychotic treatment was performed in 187 563 youths, aged 3 to 24 years, with a new diagnosis of ADHD (without recent diagnosis of any US Food and Drug Administration [FDA]-indicated conditions for antipsychotic treatment). The sample was derived from the 2010 to 2015 MarketScan Commercial Database, with the analysis completed between November 1, 2018, and May 30, 2019.

MAIN OUTCOMES AND MEASURES

The percentage of youths prescribed an antipsychotic in the first year following a new diagnosis of ADHD. Among those prescribed antipsychotic medications, the percentage who received a diagnosis of conduct disorder, oppositional defiant disorder, or a disorder for which 1 or more antipsychotic medication has received an indication for use in youths from the FDA (schizophrenia, bipolar disorder, and Tourette disorder) and the percentage that filled an antipsychotic prescription before filling a stimulant prescription (methylphenidate or amphetamine derivative).

RESULTS

Of the 187 563 youths included in the study, 114 305 (60.9%) were male with a mean (SD) age of 13.74 (5.61) years. In the year following a new ADHD diagnosis, 4869 youths (2.6%; 95% CI, 2.5%-2.7%) with ADHD were prescribed an antipsychotic. Youths treated with antipsychotics with ADHD were more likely than their peers who were not receiving an antipsychotic to have recently received diagnoses of self-harm and/or suicidal ideation (adjusted odds ratio [aOR], 7.5; 95% CI, 5.9-9.6), oppositional defiant disorder (aOR, 4.4; 95% CI, 3.9-4.9), and substance use disorder (aOR, 4.0; 95% CI, 3.6-4.5). The youths who received antipsychotics were also more likely to have received inpatient treatment (aOR, 7.9; 95% CI, 6.7-9.3). During the year following the new ADHD diagnosis, 52.7% (95% CI, 51.3%-54.1%) of youths treated with antipsychotics received a diagnosis for which antipsychotics have either an FDA or evidence-supported indication for their use. Among youths who initiated antipsychotic medications, 47.9% (95% CI, 46.5%-49.3%) did not receive a stimulant prescription between their ADHD diagnosis and antipsychotic initiation. Antipsychotic prescribing was proportionally highest for preschool-aged children (4.3%) and associated with neurodevelopmental disorders (aOR, 3.9; 95% CI, 1.3-11.2) and recent inpatient mental health treatment (aOR, 8.9; 95% CI, 1.7-45.8).

CONCLUSIONS AND RELEVANCE

Approximately half of youths with a new ADHD diagnosis may have an evidence-supported indication for an antipsychotic medication. Less than half of these youths received a stimulant; the evidence-supported first line treatment for ADHD, before the antipsychotic was initiated. Use of antipsychotic prescribing appears to be associated with high levels of psychiatric comorbidity.

Five-Year Outcomes of Behavioral Health Integration in Pediatric Primary Care

BACKGROUND AND OBJECTIVES

In the context of protracted shortages of pediatric behavioral health (BH) specialists, BH integration in pediatric primary care can increase access to BH services. The objectives of this study were to assess the structure and process of pediatric BH integration and outcomes in patient experience (access and quality), cost, and provider satisfaction.

METHODS

In 2013, we launched a multicomponent, transdiagnostic integrated BH model (Behavioral Health Integration Program [BHIP]) in a large pediatric primary care network in Massachusetts. Study participants comprised the first 13 practices to enroll in BHIP (Phase-1). Phase-1 practices are distributed across Greater Boston, with ∼105 primary care practitioners serving ∼114 000 patients. Intervention components comprised in-depth BH education, on-demand psychiatric consultation, operational support for integrated practice transformation, and on-site clinical BH service.

RESULTS

Over 5 years, BHIP was associated with increased practice-level BH integration (P < .001), psychotherapy (P < .001), and medical (P = .04) BH visits and guideline-congruent medication prescriptions for anxiety and depression (P = .05) and attention-deficit/hyperactivity disorder (P = .05). Total ambulatory BH spending increased by 8% in constant dollars over 5 years, mainly attributable to task-shifting from specialty to primary care. Although an initial decline in emergency BH visits from BHIP practices was not sustained, total emergency BH spending decreased by 19%. BHIP providers reported high BH self-efficacy and professional satisfaction from BHIP participation.

CONCLUSIONS

Findings from this study suggest that integrating BH in the pediatric setting can increase access to quality BH services while engendering provider confidence and satisfaction and averting substantial increases in cost.

Depression in Maltreated Children and Adolescents

Maltreatment affects 9.1 to 17.1 of every 1000 US children and adolescents. Maltreated youth are at high risk for depression. Clinicians should screen young patients for maltreatment history. Depressed maltreated youth are at high risk for treatment resistance. Combination treatment with selective serotonin reuptake inhibitors and cognitive behavior therapy (CBT) with a trauma-informed approach should be considered for depressed maltreated youth. Behavioral management can be integrated with trauma-focused CBT to treat the externalizing disorders that commonly occur in maltreated depressed youth. If one approach is unsuccessful, a change to another medication or type of evidence-based psychotherapy or intervention is indicated.

Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry

Introduction

Agitation in children and adolescents in the emergency department (ED) can be dangerous and distressing for patients, family and staff. We present consensus guidelines for management of agitation among pediatric patients in the ED, including non-pharmacologic methods and the use of immediate and as-needed medications.

Methods

Using the Delphi method of consensus, a workgroup comprised of 17 experts in emergency child and adolescent psychiatry and psychopharmacology from the the American Association for Emergency Psychiatry and the American Academy of Child and Adolescent Psychiatry Emergency Child Psychiatry Committee sought to create consensus guidelines for the management of acute agitation in children and adolescents in the ED.

Results

Consensus found that there should be a multimodal approach to managing agitation in the ED, and that etiology of agitation should drive choice of treatment. We describe general and specific recommendations for medication use.

Conclusion

These guidelines describing child and adolescent psychiatry expert consensus for the management of agitation in the ED may be of use to pediatricians and emergency physicians who are without immediate access to psychiatry consultation.

A proposed anti-maladaptive aggression agent classification: improving our approach to treating impulsive aggression

Proper drug categorization enables clinicians to readily identify the agents most appropriate for patients in need. Currently, patients with maladaptive aggression do not all always fall into a single existing diagnostic or treatment category. Such is the case for those with impulsive aggression (IA). IA is an associated feature of numerous neuropsychiatric disorders, and can be described as eruptive, aggressive behavior or a 'short fuse'. Although agents from a broad spectrum of drug classes have been used to treat maladaptive aggression, few have been tested distinctly in patients with IA, and there is no drug specifically indicated by the US Food and Drug Administration (US FDA) for IA. Further, current treatments often fail to sufficiently treat IA symptomatology. These issues create an unclear and inadequate treatment path for patients. Here we will propose the establishment of a class of anti-maladaptive aggression agents to begin addressing this clinical issue. The development of such a class would unify the various drugs currently used to treat maladaptive aggression and streamline the treatment approach towards IA. As an important case example of the range of candidate drugs that could fit into a new anti-maladaptive aggression agent category, we will review an investigational IA pharmacotherapy. SPN-810 (extended-release molindone) is currently being investigated as a novel treatment for children with IA and ADHD. Based on these studies we will review how SPN-810 may be well suited for a new, anti-maladaptive aggression drug class and more precisely, a proposed subgroup of IA modulators. The goal of this review is to begin improving the identification of and therapeutic approach for maladaptive aggression as well as IA through more precise anti-maladaptive aggression agent categorization.

In vitro pharmacological characterization of SPN-810M (molindone)

Background

Impulsive aggression (IA) is considered a maladaptive form of aggression that is reactive and overt and occurs outside of the acceptable social context. Many children and adolescents with attention-deficit/hyperactivity disorder (ADHD) display clinically significant aggression, with the predominant subtype being IA. However, there is currently no Food and Drug Administration-approved medication specifically to treat IA. The pathophysiology of IA is not fully understood, although it has been suggested to include the dopamine, norepinephrine, and serotonin systems.

Methods

SPN-810 (extended-release molindone) is being developed for the novel indication of IA and is currently being studied in patients treated for ADHD. Molindone is an indole derivative and a dopamine D₂ receptor antagonist.

Results

The in vitro pharmacological studies described in the current manuscript demonstrate that the active substance molindone (SPN-810M) is a potent antagonist for the dopamine receptors, D_2S and D_2L, and the serotonin receptor, 5-HT_2B, at therapeutic concentrations. The in vitro studies further demonstrate that the antagonist effect of SPN-810M is due to the parent drug and not the metabolites, and that the antagonism is not affected by the presence of norepinephrine or dopamine neurotransmitters. In addition, studies investigating the potential differential effects of the enantiomers of SPN-810M have demonstrated that the R(−) enantiomer is more potent than S(+), showing greater regulatory effect on D_2S and D_2L receptors.

Conclusion

Overall, the results of the in vitro SPN-810M pharmacological studies provide some insight into how SPN-810M modulates the serotonin and dopamine pathways that play a role in IA.

Evidence-based psychosocial treatments of conduct problems in children and adolescents: an overview

The aims of the present study were to identify empirically supported psychosocial intervention programs for young people with conduct problems and to evaluate the underpinnings, techniques and outcomes of these treatments. We analyzed reviews and meta-analyses published between 1982 and 2016 concerning psychosocial intervention programs for children aged 3 to 12 years with conduct problems. Parent training should be considered the first-line approach to dealing with young children, whereas cognitive-behavioral approaches have a greater effect on older youths. Family interventions have shown greater efficacy in older youths, whereas multi-component and multimodal treatment approaches have yielded moderate effects in both childhood and adolescence. Some limitations were found, especially regarding the evaluation of effects. To date, no single program has emerged as the best. However, it emerges that the choice of intervention should be age-specific and should take into account developmental differences in cognitive, behavioral, affective and communicative abilities.

Psychotropic Polypharmacy Among Children and Youth Receiving Medicaid, 2012-2015

BACKGROUND

The rates of mental health diagnoses in children have increased. Children in poverty have the highest rates. The use of psychotropic medication for children has been increasing, which is concerning because of the unknown long-term effects and the increased burden on the health care system. The state of Kentucky ranks among the highest in the United States for children with mental health problems, children living in poverty, and children receiving psychotropic medication.

OBJECTIVE

To examine recent trends and determinants of interclass psychotropic polypharmacy (PP) use for children and youth receiving Medicaid to inform intervention development.

METHODS

A retrospective cohort study was conducted using 2012-2015 Kentucky Medicaid claims for children aged 0-17 years, with continuous enrollment for ≥ 90 days with at least 1 behavioral health diagnosis (N = 237,393). Interclass PP was defined as the presence of at least 2 psychotropic medication prescription fills for at least 2 different classes of medication that, if taken as directed, would be used concurrently for at least 90 consecutive days (allowing for a single 15-day lag). The outcome variables were the presence of any interclass PP and the number of months a child received interclass PP. We conducted a descriptive analysis and developed 2 separate generalized linear regression models to test for associations between individual characteristics of children treated with psychotropic medication for ≥ 90 days (n = 75,639) and each outcome of interest.

RESULTS

For the sample of children with at least 90 days of psychotropic medication treatment, 38% had at least 3 covered months of PP over the 4 years studied. Children in foster care received alpha agonists (116 vs. 69 per 1,000 children) or antidepressants (225 vs. 176 per 1,000) at a higher rate than other children receiving Medicaid but received stimulants at a lower rate (403 vs. 638 per 1,000). The primary 2-drug class combinations were stimulants with either alpha agonists or antidepressants. Children in foster care (OR = 1.7, 95% CI = 1.58, 1.84, P < 0.001), with a bipolar disorder (OR = 2.24, 95% CI = 2.10, 2.38, P < 0.001), mood disorder not otherwise specified (OR = 1.11, 95% CI = 1.04, 1.17, P < 0.001), or autism spectrum disorders (OR = 1.17, 95% CI = 1.08, 1.26, P < 0.001) had increased the odds of ever receiving PP. Black children had lower odds (OR = 0.72, 95% CI = 0.67, 0.77, P < 0.001) of ever receiving PP. Children aged 6-11 years (beta = 3.08, 95% CI = 2.87, 3.29) and 12-17 years (beta = 1.61, 95% CI = 1.38, 1.83) had more covered months with PP compared with those aged 0-5 years. Black children had fewer covered months of PP compared with white children (beta = -1.36, 95% CI = -1.61, -1.11]. Children in foster care (beta = 1.83, 95% CI = 1.53, 2.13) had more covered months with PP. Children residing in nonurban areas had fewer months with PP (beta = -0.4, 95% CI = -0.54, -0.26) compared with those residing in urban areas, as did those children with depression (beta = -3.32, 95% CI = -3.55, -3.1), impulse control disorder (beta = -2.07, 95% CI = -2.28, -1.85), and conduct disorder (beta = -1.34, 95% CI = -1.64, -1.05). Children with bipolar disorder (beta = 3.62, 95% CI = 3.38, 3.86) and autism (beta = 2.04, 95% CI = 1.75, 2.33) had more covered months with PP. As comorbidity increased, the duration of PP treatment increased (beta = 2.49, 95% CI = 2.36, 2.62).

CONCLUSIONS

The rates of PP are concerning, especially for children in foster care and children aged 6-11 years. Efforts to safeguard medication use are needed, as well as future exploration of racial differences in PP.

DISCLOSURES

This project was supported by the Kentucky Cabinet for Health and Family Services, Department for Medicaid; Norton Healthcare; and the School of Medicine, Department of Pediatrics; School of Public Health and Information Sciences; and Kent School of Social Work at the University of Louisville. Kentucky Medicaid approved the use of the data and granted permission to publish but played no role in the interpretation of data. Lui is employed by Kentucky Medicaid. The other authors report no potential conflicts of interest. An earlier version of this study was presented at the Pediatric Academic Societies' Annual Meeting in Baltimore, MD, on April 30-May 3, 2016. A poster presentation was given at the Society for Developmental and Behavioral Pediatrics in Cleveland, OH, on October 14-16, 2017.

Pharmacologic Management of Agitation and Aggression in a Pediatric Emergency Department - A Retrospective Cohort Study

BACKGROUND

Benzodiazepine and antipsychotic use for acute management of agitation and aggression in the pediatric emergency department (ED) setting has not been well described.

OBJECTIVES

To describe medication utilization in the management of agitation and aggression in a pediatric ED and to assess the safety of their use.

METHODS

This was a retrospective observational study. Patients less than 20 years of age who presented to our pediatric ED and had agitation or aggression as part of their chief complaint were included if they received at least 1 dose of benzodiazepine or antipsychotic. Outcomes included frequency of benzodiazepine and antipsychotic use, dosing of medications, and reported adverse events.

RESULTS

During the 5-year study period, there were 128 visits of 120 patients who met the inclusion criteria. Lorazepam was most commonly given (70%), followed by chlorpromazine (20%). Most patients (82%) required a single dose of medication. Intoxication was associated with needing more than 1 dose of medication. Patients with autism or Asperger syndrome were more likely to receive an antipsychotic medication compared to not having these conditions (75% vs. 28%, respectively). Adverse events were documented in 6 visits: oxygen desaturation (n = 1), dizziness and nausea (n = 2), dizziness (n = 1), and paradoxical excitation (n = 2). The Naranjo Score indicated a probable adverse drug reaction for the cases of paradoxical excitation.

CONCLUSIONS

Benzodiazepine and antipsychotic drug therapy for acute agitation and aggression in children appears to be safe and well tolerated when used as a single agent and at the recommended doses in this setting.

Screening for drugs to reduce aggression in zebrafish

Aggression is a common symptom of several human psychiatric disorders. However, the drugs available to treat aggression are non-specific and can have unwanted side effects. The zebrafish is an ideal model for behavioural pharmacology. They are small, aggression can be measured reliably, and drugs can be applied by immersion in the tank water. The ability to visualise and manipulate circuits in the intact brain represents an excellent opportunity to understand how chemical compounds modify the signalling pathways that control this behaviour. This review discusses protocols to measure zebrafish aggression, the neural circuits that control this behaviour and how pharmacological studies can inform us about environmental toxicology and the development of therapeutic drugs for humans. This article is part of the Special Issue entitled 'Current status of the neurobiology of aggression and impulsivity'.

Parsing cyclothymic disorder and other specified bipolar spectrum disorders in youth

OBJECTIVE

Most studies of pediatric bipolar disorder (BP) combine youth who have manic symptoms, but do not meet criteria for BP I/II, into one "not otherwise specified" (NOS) group. Consequently, little is known about how youth with cyclothymic disorder (CycD) differ from youth with BP NOS. The objective of this study was to determine whether youth with a research diagnosis of CycD (RDCyc) differ from youth with operationalized BP NOS.

METHOD

Participants from the Course and Outcome of Bipolar Youth study were evaluated to determine whether they met RDCyc criteria. Characteristics of RDCyc youth and BP NOS youth were compared at baseline, and over eight-years follow-up.

RESULTS

Of 154 youth (average age 11.96 (3.3), 42% female), 29 met RDCyc criteria. RDCyc youth were younger (p = .04) at baseline. Over follow-up, RDCyc youth were more likely to have a disruptive behavior disorder (p = .01), and were more likely to experience irritability (p = .03), mood reactivity (p = .02), and rejection sensitivity (p = .03). BP NOS youth were more likely to develop hypomania (p = .02), or depression (p = .02), and tended to have mood episodes earlier in the eight-year follow-up period.

LIMITATIONS

RDCyc diagnoses were made retrospectively and followed stringent criteria, which may highlight differences that, under typical clinical conditions and more vague criteria, would not be evident.

CONCLUSION

There were few differences between RDCyc and BP NOS youth. However, the ways in which the groups diverged could have implications; chronic subsyndromal mood symptoms may portend a severe, but ultimately non-bipolar, course. Longer follow-up is necessary to determine the trajectory and outcomes of CycD symptoms.

Diagnosis and Use of Psychotherapy Among Children and Adolescents Prescribed Antipsychotics

OBJECTIVE

To examine the diagnoses, demographics, and prevalence of psychotherapy use among children and adolescents prescribed antipsychotics by psychiatric providers in a community setting.

METHODS

Medical records from 1127 children aged 0 to 17 years who were prescribed antipsychotics in 2014-2015 at Pine Rest Christian Mental Health Services (PRCMHS) outpatient network were analyzed. Antipsychotics, diagnosis codes, demographics, and number of psychotherapy sessions during this time frame were analyzed using χ and logistic regression analyses.

RESULTS

During this year, 50.8% of the patients attended psychotherapy, and 35.6% attended 5 or more sessions of psychotherapy. The most prevalent primary diagnosis was bipolar disorder (37.1%), followed by attention-deficit/hyperactivity disorder (19.7%). Females being treated with antipsychotics were significantly more likely to attend psychotherapy than their male peers (55.7% vs. 47.9%, P=0.01). In the fully adjusted models, patients with diagnoses of bipolar disorder or disorders first diagnosed in infancy, childhood, or adolescence were less than half as likely to attend psychotherapy as patients with depressive disorders, with adjusted odds ratios of 0.41 and 0.42, respectively.

CONCLUSIONS

Approximately half of the child and adolescent patients prescribed antipsychotics in this community sample did not attend psychotherapy, and 39% of the patients did not have a diagnosis of bipolar disorder, psychotic disorder, or autistic disorder.

Enhancing Pediatricians' Behavioral Health Competencies Through Child Psychiatry Consultation and Education

The objective of this study was to assess feasibility, utilization, perceived value, and targeted behavioral health (BH) treatment self-efficacy associated with a collaborative child and adolescent psychiatry (CAP) consultation and BH education program for pediatric primary care practitioners (PCPs). Eighty-one PCPs from 41 member practices of a statewide pediatric practice association affiliated with an academic medical center participated in a program comprising on-demand telephonic CAP consultation supported by an extensive BH learning community. Findings after 2 years of implementation suggest that the program was feasible for large-scale implementation, was highly utilized and valued by PCPs, and was attributed by PCPs with enhancing their BH treatment self-efficacy and the quality of their BH care. After participation in the program, nearly all PCPs believed that mild to moderate presentations of common BH problems can be effectively managed in the primary care setting, and PCP consultation utilization was congruent with that belief.